Development of the publicly funded portion of the health system in post-Independence Indonesia was achieved essentially through the creation of a new facility, the health center, and then locating these facilities at the sub-district level throughout the country. At the same time a public hospital was established in districts in which there was no public hospital previously. These facilities were staffed with doctors, nurses and midwives through a period of obligatory service for all new graduates who were assigned to specific facilities. To supplement their incomes the government granted doctors and midwives rights to private practice; although nurses were not granted these rights, most of them established practices after hours as well and for the same reasons, their incomes were low too. The private practices of these public sector employees, together with an increasing number of private practitioners who do not work for the government, constitute the solo-provider facilities – in essence, the provider is the facility; these facilities, all of them private, account for 86% of facilities (Table ). In addition, private hospitals and maternity clinics have also been established, often owned and staffed by public sector employees with the result that 90% of all facilities are private.
Thus, the common pattern of health facilities in most districts on Java includes a public hospital, one or two (usually smaller) private hospitals and three or four small private facilities offering inpatient and outpatient obstetric services to women and their young children. At the district level there are also private outpatient treatment clinics and numerous solo-provider private facilities for outpatient services; the providers are various, including doctors, nurses and midwives, some of whom are full-time private practitioners and others part-time in addition to their public sector roles.
At the sub district level there is a public health center, the associated auxiliary health centers, and a much larger number of solo-provider outpatient facilities through which doctors, nurses and midwives operate their after-hours private practices. Village midwives located in many villages also operate private practices.
This distribution of facilities and providers means that within each sub-district there is a range of facility types (multi-provider, solo-provider); a range of provider types in the facilities (doctors, nurse and midwives); a range of facility locations, some close to, even in the village, others in the sub-district headquarters. Some facilities are public, others private; some are free, at others there is a charge for the service. This distribution allows consumers to exercise some choice of facility and/or provider. In exercising this choice, many consumers choose the solo-provider facilities even though the public facilities at the health center, sub-center and district hospital are nominally free and they have to pay out-of-pocket at the private practice of the doctor, nurse and midwife. The lower fees of the nurse and midwife mean that they are often the preferred choice of the poor.
An extraordinary characteristic of the Indonesian system is that the most numerous of the solo-provider facilities – that staffed by nurses – is illegal and, therefore, seldom discussed. However, it is widely acknowledged that they do have private practice. Because it is not legal for them to provide treatment the government does not collect information about the solo-provider facilities of nurses and the nurses themselves are unwilling to acknowledge their own activities for fear of the law. In this study we assume that 60% of nurses have a private practice in which they offer treatment. Discussions with health authorities at the provincial and district levels indicate that this estimate may be conservative. Using this estimate, the solo-provider facilities of nurses are the largest single group of facilities (40% of all facilities and 46% of single provider facilities), much higher than village midwives who constitute a quarter of all facilities. Further, two-thirds of all nurses in a district are located at the sub-district level in the health center [9
]; their private practice is most likely to be in the same locality meaning that these practices are quite widely distributed throughout the district. Despite constituting such a high proportion of all facilities, the system continues to act as if solo-provider facilities of nurses do not exist. If the past is any guide, enforcement of the law on private practice of nurses is unlikely to occur. So why not recognize reality and change the law? Attempts to do so have been vigorously opposed by both doctors and midwives in the past as they protect their vested interests and are likely to be opposed in the future, particularly if the government continues to take an ambivalent stance on the issue. It seems that the only option for nurses is to continue to operate outside the law until the government provides the leadership necessary to change the relevant legislation.
One category of facility about which very little is known is the private treatment clinic, usually found at the district level. They are usually staffed by nurses working outside their hours in public hospitals and health centers. These facilities operate within the law as the nurses are, on paper, under the supervision of a doctor. The supervision is usually very nominal and at a distance. Private treatment clinics are potentially an important source of outpatient care, particularly in urban areas. Indeed, across these 15 districts they are almost as numerous as the health centers. Little attention is paid to these facilities by the government in terms of either supervision or as a potentially innovative service delivery model.
There is one more element to the solo-provider facilities situation. That is the increasing number of solo-private providers who have no employment with the government and are usually located in the vicinity of the district capital. This is particularly true for doctors – in 6 of the districts studied more than one-third of the doctors are in private practice and do not receive a salary from the government; in 2 districts these private practitioners constitute more than half the doctors. This trend is also increasingly apparent for midwives (in 6 of the districts studied here more than 10% of the midwives were in private practice and did not receive a salary from the government; in 2 districts the proportion was as high as one-third) [9
These private practitioners operate with minimal government supervision. Regulation and accreditation of facilities at which health services are provided is not well developed – to the extent that it occurs it concentrates on multiple-provider facilities. There is practically no supervision or accreditation of solo-provider facilities where the majority of outpatient services are provided.
The quality of services provided by all three professional groups is sub-optimal. Measuring quality in terms of knowledge about clinical guidelines, Barber et al showed low knowledge of evidence-based practices in all professional groups, particularly for prenatal and adult curative care [16
]. Physicians had the highest scores. Nurses had lower scores than midwives and physicians. Whilst this work underscores that all three groups scored poorly, the most important point is that nurses, the largest single group of solo-provider facilities scored the lowest but attempts to improve their skills are opposed on the grounds that their private practice is illegal. Yet improving the quality of care provided by nurses in solo-provider facilities, where the low tariff makes them the facility of choice for many of the poor, may be one of the most important avenues for improving quality of outpatient care, especially for those with low incomes.
In terms of the contribution to seeing patients, each group-provider facility, because it houses a number of providers, has the capacity to see many more patients in a day than a solo-provider facility. Whether this is reflected in actual patients seen is not known as there is essentially no information on the characteristics of the solo-provider facilities, the number of patients they see in a day, the setting in which the services are provided, details of the actual services offered. What we do know is that 55% of ambulatory care is provided by private providers [14
]. Further, informal observations and anecdotes indicate that many solo-provider practices regularly see more patients in a day than are routinely seen per provider per day at the health center, the most common group-provider facility. And because the number of solo-provider facilities is much larger than the number of group-provider facilities the total number of patients seen by all the solo-provider facilities is potentially similar to, if not larger than, that seen by all the group-provider facilities. What is clear is that we need much better information about the contribution this group makes to outpatient care.
Indonesia's health information system concentrates mostly on obtaining information about the public sector. The results of this study indicate just how partial is the picture provided by the concentrating on the public sector in this way. Across the 15 districts studied here 90% of the health facilities are in the private sector and most are not systematically and regularly included in the health information system, either as facilities that provide health care and therefore are a part of the whole health system, or as facilities that see patients and should be included in disease reporting systems and interventions to improve overall service quality.
Overall, Indonesia's approach to the development of health services achieved a wide distribution of health facilities and staff. Although perhaps unintended by those who devised the Bandung Plan, the vast majority of the health facilities (86%) are solo-provider facilities in which the provider and the facility are synonymous. Most of the facilities in a district are at the sub-district level and below. Through the village midwife and nurses these solo facilities were distributed more widely than health centers and even sub-centers. At the same time, and continuing to this day, there are centripetal forces working to contract the distribution of facilities and providers. The concentration of doctors in urban areas was documented in the 1990s [8
] and is only likely to have intensified since. Further, doctors assigned to health centers have always found opportunities to be away including, in some cases, spending most of their time at private practices in urban areas. District health officials report that midwives have tended to move to health centers from the villages and there are widespread anecdotes (but no quantitative evidence) from health sector administrators indicating that many village midwives spend little time in the village to which they have been assigned. Many, if not most, young graduates in all professional groups have a preference for urban areas for family and lifestyle reasons. The result of these preferences is a high rate of absenteeism from the public multi-provider facilities, particularly health centers, as well as the solo-provider facilities staffed by the village midwife – an independent multi-country survey found absenteeism rates of 40% in the health sector in Indonesia, the highest of all countries surveyed [17
Nevertheless, for a period Indonesia was able to distribute facilities more evenly by locating health centers at the sub-district level and conscripting staff to work there. Conscription is no longer an option for the government. The challenge now is to determine the level of distribution of facilities and providers the government should aim for and identify the ways in which this can be achieved. No matter how much we would like it to be the case, it seems clear that the level of distribution achieved in the 1980s is not possible now – the centripetal forces are winning.
As the various levels of government consider the future direction of the health system the distribution of facilities is a critical question, and the role of the health center, central to the distribution achieved so far, in that new system is important. The question is how to re-define the health center (its role, staffing and financing) in such a way that the distribution of facilities and staff makes a more effective health system for the Indonesia of the 21st century – an Indonesia in which there is no coercion of health staff, in which the road infrastructure, though still needing much improvement, is a great deal better than 40 years ago so that patient mobility is much improved, an Indonesia in which the population has higher levels of income, disease patterns are changing, and the consumer prefers different types of services than was the case in the 1970s and 1980s.
A new vision is needed for the health sector, a vision which addresses the questions of the types, roles and distribution of health facilities and providers needed to tackle the health problems of the next 50 years. There are important issues to be addressed in the health sector. Can the government rise to meet the challenge?