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1.  Recent changes in human resources for health and health facilities at the district level in Indonesia: evidence from 3 districts in Java 
There is continuing discussion in Indonesia about the need for improved information on human resources for health at the district level where programs are actually delivered. This is particularly the case after a central government decision to offer doctors, nurses and midwives on contract the chance to convert to permanent civil service status. Our objective here is to report changes between 2006 and 2008 in numbers and employment status of health staff in three districts following the central government decision.
Information was derived from records at the district health office and, where necessary for clarification, discussions with district officials.
Across the three districts and all public sector provider categories there was an increase of almost 680 providers between 2006 and 2008 - more than 300 nurses, more than 300 midwives and 25 doctors. The increases for permanent public servants were proportionately much greater (43%) than the total (16%). The increase in those who are permanent civil servants was greatest for nurses (51%) and midwives (35%) with corresponding decreases in the proportion of staff on contract. There was considerable variation between the three districts.
There has been a significant increase in the number of healthcare providers in the 3 districts surveyed and the proportion now permanent public servants has increased even more than the increase in total numbers. The changes have the effect of increasing the proportion of total public expenditure allocated to salaries and reducing the flexibility of the districts in managing their own budgets. Because public servants are allowed private practice outside office hours there has also been an increase in the number of private practice facilities offering health care. These changes illustrate the need for a much improved human resources information system and a coherent policy to guide actions on human resources for health at the national, provincial and district levels.
PMCID: PMC3049179  PMID: 21314986
2.  Current situation of midwives in indonesia: Evidence from 3 districts in West Java Province 
BMC Research Notes  2010;3:287.
The village midwife is a central element of Indonesia's strategy to improve maternal and child health and family planning services. Recently there has been concern that the midwives were not present in the villages to which they had been assigned. To determine the extent to which this was the case we conducted a field-based census and survey of village midwives in three districts in West Java Province, Indonesia.
In June 2009 we interviewed a random sample of village midwives from three districts - Ciamis, Garut and Sukabumi - in West Java Province. Trained interviewers visited all villages represented in the sample to interview the midwives. We also obtained information about the midwives and their professional activities in the last year.
Thirty percent of village midwives had moved to another location in the 12 months between the end of 2008, when the sampling frame was constructed, and December 2009 when the survey was conducted; most had moved to a government health center or another village. Of those who were present, there was considerable variation between districts in age distribution and qualifications. The total number of services provided was modest, also with considerable variation between districts. The median number of deliveries assisted in the last year was 64; the amount and mix of family planning services provided varied between districts and were dominated by temporary methods.
Compared to an earlier survey in an adjacent province, the village midwives in these three districts were younger, had spent less time in the village and a higher proportion were permanent civil servants. A high proportion had moved in the previous year with most moving to a health center or another village. The decision to move, as well as the mix of services offered, seems to be largely driven by opportunities to increase their private practice income. These opportunities are greater in urban areas. As urbanization procedes the forces drawing village midwives away from the village are certain to strengthen. This will require a reassessment of the original service model embodied in the village midwife concept and a new approach to reducing maternal mortality.
PMCID: PMC2992543
3.  Health facilities at the district level in Indonesia 
At Independence the Government of Indonesia inherited a weak and unevenly distributed health system to which much of the population had only limited access. In response, the government decided to increase the number of facilities and to locate them closer to the people. To staff these health facilities the government introduced obligatory government service for all new graduates in medicine, nursing and midwifery. Most of these staff also established private practices in the areas in which they were located. The health information system contains little information on the health care facilities established for private practice by these staff. This article reports on the results of enumerating all health facilities in 15 districts in Java.
We enumerated all healthcare facilities, public and private, by type in each of 15 districts in Java.
The enumeration showed a much higher number of healthcare facilities in each district than is shown in most reports and in the health information system which concentrates on public, multi-provider facilities. Across the 15 districts: 86% of facilities were solo-provider facilities for outpatient services; 13% were multi-provider facilities for outpatient services; and 1% were multi-provider facilities offering both outpatient and inpatient services.
The relatively good distribution of health facilities in Indonesia was achieved through establishing public health centers at the sub-district level and staffing them through a system of compulsory service for doctors, nurses and midwives. Subsequently, these public sector staff also established solo-provider facilities for their own private practice; these solo-provider facilities, of which those for nurses are almost half, comprise the largest category of outpatient care facilities, most are not included in official statistics. Now that Indonesia no longer has mandatory service for newly graduated doctors, nurses and midwives, it will have difficulty maintaining the distribution of facilities and providers established through the 1980s. The current challenge is to envision a new health system that responds to the changing disease patterns as well as the changes in distribution of health facilities.
PMCID: PMC2689868  PMID: 19445728
4.  Public funding of health at the district level in Indonesia after decentralization – sources, flows and contradictions 
During the Suharto era public funding of health in Indonesia was low and the health services were tightly controlled by the central government; district health staff had practically no discretion over expenditure. Following the downfall of President Suharto there was a radical political, administrative and fiscal decentralization with delivery of services becoming the responsibility of district governments. In addition, public funding for health services more than doubled between 2001 and 2006. It was widely expected that services would improve as district governments now had both more adequate funds and the responsibility for services. To date there has been little improvement in services. Understanding why services have not improved requires careful study of what is happening at the district level.
We collected information on public expenditure on health services for the fiscal year 2006 in 15 districts in Java, Indonesia from the district health offices and district hospitals. Data obtained in the districts were collected by three teams, one for each province. Information on district government revenues were obtained from district public expenditure databases maintained by the World Bank using data from the Ministry of Finance.
The public expenditure information collected in 15 districts as part of this study indicates district governments are reliant on the central government for as much as 90% of their revenue; that approximately half public expenditure on health is at the district level; that at least 40% of district level public expenditure on health is for personnel, almost all of them permanent civil servants; and that districts may have discretion over less than one-third of district public expenditure on health; the extent of discretion over spending is much higher in district hospitals than in the district health office and health centers. There is considerable variation between districts.
In contrast to the promise of decentralization there has been little increase in the potential for discretion at the district level in managing public funds for health – this is likely to be an important reason for the lack of improvement in publicly funded health services. Key decisions about money are still made by the central government, and no one is held accountable for the performance of the sector – the district blames the center and the central ministries (and their ministers) are not accountable to district populations.
PMCID: PMC2678112  PMID: 19371410
5.  Human resources for health at the district level in Indonesia: the smoke and mirrors of decentralization 
In 2001 Indonesia embarked on a rapid decentralization of government finances and functions to district governments. One of the results is that government has less information about its most valuable resource, the people who provide the services. The objective of the work reported here is to determine the stock of human resources for health in 15 districts, their service status and primary place of work. It also assesses the effect of decentralization on management of human resources and the implications for the future.
We enumerated all health care providers (doctors, nurses and midwives), including information on their employment status and primary place of work, in each of 15 districts in Java. Data were collected by three teams, one for each province.
Provider density (number of doctors, nurses and midwives/1000 population) was low by international standards – 11 out of 15 districts had provider densities less than 1.0. Approximately half of all three professional groups were permanent public servants. Contractual employment was also important for both nurses and midwives. The private sector as the primary source of employment is most important for doctors (37% overall) and increasingly so for midwives (10%). For those employed in the public sector, two-thirds of doctors and nurses work in health centres, while most midwives are located at village-level health facilities.
In the health system established after Independence, the facilities established were staffed through a period of obligatory service for all new graduates in medicine, nursing and midwifery. The last elements of that staffing system ended in 2007 and the government has not been able to replace it. The private sector is expanding and, despite the fact that it will be of increasing importance in the coming decades, government information about providers in private practice is decreasing. Despite the promise of decentralization to increase sectoral "decision space" at the district level, the central government now has control over essentially all public sector health staff at the district level, marking a return to the situation of 20 years ago. At the same time, Indonesia has changed dramatically. The challenge now is to envision a new health system that takes account of these changes. Envisioning the new system is a crucial first step for development of a human resources policy which, in turn, will require more information about health care providers, public and private, and increased capacity for human resource planning.
PMCID: PMC2662783  PMID: 19192269

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