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An analysis of Indonesia’s primaryhealth care supply-side readiness

Is IndonesiaReady to Serve ?

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An analysis of Indonesia’s primary health care supply-side readinessIs Indonesia Ready to Serve ?

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Is Indonesia ready to serve?

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Acknowledgements

This report was prepared by Vikram Rajan (Senior Health Specialist), Anchita Patil (Consultant), Eko Setyo Pambudi (Research Analyst), and Junedi (Consultant) of the World Bank (WB). The team would also like to thank WB colleagues Puti Marzoeki (Senior Health Specialist), and Pandu Harimurti (Senior Health Specialist), who provided valuable inputs on program-related aspects. The team also received substantive inputs during the review process from peer reviewers: Mickey Chopra (Lead Health Specialist, GHNDR), Jeremy Henri Maurice Veillard (Senior Health Specialist, GHNGE), and Ajay Tandon (Lead Health Economist, GHN06). The team would like to thank Christina Sukmawati (Program Assistant, WB, Indonesia Country Office) for formatting the report. The report was edited by Chris Stewart. The layout was done by Indra Irnawan.

The Quantitative Service Delivery Survey (QSDS) was designed by Wei Aun Yap (Consultant WB) and Eko Setyo Pambudi and was conducted by SurveyMeter (Wayan Suriastini and team) and Center for Health Policy and Management, Faculty of Medicine, Gadjah Mada University (Laksono Trisnantoro and team).

The team would also like to thank Rodrigo A. Chaves (Country Director, EACIF), and Toomas Palu (Practice Manager, East Asia and Pacific Health, Nutrition and Population) for their overall

guidance. This report and the survey received cofinancing from the Public Financial Management Multi Donor Trust Fund (supported by Canada, European Union and Switzerland). Other sources of financing for the survey were:

• The Gender Trust Fund (supported by the Department of Foreign Affairs and Trade (DFAT) (Australia); Royal Ministry of Foreign Affairs (Denmark); Gesellschaft Fur Internationale Zusammenarbeit (GIZ) (Germany); Ministry of Foreign Affairs (Iceland); Minister for Foreign Trade and Development Cooperation (Netherlands); Ministry of Foreign Affairs (Norway); Swedish International Development Cooperation Agency (Sida) (Sweden); Swiss Agency for Development and Cooperation (SDC); Department for International Development (DFID) (United Kingdom); and United States Agency for International Development (USAID);

• The Indonesia Integrating Donor-Funded Health Programs, Multi-Donor Trust Fund (supported by DFAT and Bill and Melinda Gates Foundation);

• The PNPM Generasi Trust Fund (supported DFAT; Royal Ministry of Foreign Affairs (Denmark); Commission of the European Communities (European Union); Millennium Challenge Account Indonesia; Minister for Foreign Trade and Development Cooperation (Netherlands); and DFID (United Kingdom).

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Acknowledgments v

Abbreviations and Acronyms viii

EXECUTIVE SUMMARY x

CHAPTER 1. INTRODUCTION 1

Country and Sectoral Background 2

The Need, Scope and Methodology for the Quantitative Service Delivery Survey (QSDS 2016) 7

CHAPTER 2. SERVICE AVAILABILITY AND UTILIZATION 9

Outpatient Services 11

Inpatient Services 12

Specific Services 13

Communicable Diseases 22

Non-communicable Diseases (NCDs) 30

CHAPTER 3. SERVICE READINESS 31

General Services 32

Specific Services 41

Understanding Temporal Trends: Comparison of QSDS 2016 with Rifaskes 2011 45

CHAPTER 4. HUMAN RESOURCES FOR HEALTH 53

Staff Availability 54

Staff Training 59

CHAPTER 5. FINANCING OF PUSKESMAS 63

Health Financing Landscape 64

JKN Program 65

Puskesmas Revenue 71

Puskesmas Expenditure 72

Contents

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CHAPTER 6. MANAGEMENT OF HEALTH FACILITIES 73

Governance for the Health Sector 74

Availability of Operational Guidelines 75

Monitoring and Evaluation 76

Health Information System 79

CHAPTER 7. SUMMARY OF FINDINGS AND KEY ISSUES TO BE ADDRESSED 81

Findings 82

Issues of Concern 88

Appendix 1: A Brief Description of GoI’s Health Program 93

Appendix 2: Indicators for Measuring General Service Readiness of Health Facilities 94

Appendix 3: Indicators for Measuring Specific Service Readiness of Health Facilities 96

Appendix 4: QSDS Sampling and Analytical Methodology 100

Appendix 5: Factsheets for General Service Readiness 106

Appendix 6: Specific Services’ Readiness Index 118

REFERENCES 144

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Abbreviations and Acronyms

AD Auto-disableAEFI Adverse Effects Following

ImmunizationAIDS Acquired Immuno-Deficiency

SyndromeANC Antenatal CareAPBD Anggaran Pendapatan dan Belanja

Daerah (Regional Budget)API Annual Parasite IndexARI Acute Respiratory InfectionART Antiretroviral TherapyATMI HIV and AIDS, Tuberculosis, Malaria

and ImmunizationATT Antitubercular TreatmentBCG Bacillus Calmette-Guérin (vaccine

against tuberculosis)BEmONC Basic Emergency Obstetric and

Neonatal CareBKKBN Badan Kependudukan dan Keluarga

Berencana Nasional (National Family Planning and Population Board)

BOK Bantuan Operasional Kesehatan (Health Operational Assistance)

BOR Bed Occupancy RateBPJS Badan Penyelenggara Jaminan Sosial

(Social Security Agency)CI Confidence intervalCVD Cardiovascular diseaseCST Care, Support and Treatment (for HIV)DAK Dana Alokasi Khusus (Special

Allocation Funds)DAU Dana Alokasi Umum (General

Allocation Funds)DHO District Health OfficeDinkes Dinas Kesehatan (District Health

Office)DM Diabetes Mellitus

DOTS Directly Observed Treatment Short-course

DPT Diphtheria Pertussis TetanusEPI Expanded Program on Immunization FDC Fixed-dose CombinationGDP Gross Domestic ProductGoI Government of IndonesiaGP General practitionerHCT HIV counseling and testingHDI Human Development IndexHep-B Hepatitis BHiB Hemophilus influenzae BHIV Human Immunodeficiency VirusHRH Human Resources for HealthIDHS Indonesia Demographic and Health

SurveyIDR Indonesian RupiahIFA Iron and Folic AcidIMCI Integrated Management of Childhood

IllnessIMNCI Integrated Management of Neonatal

and Childhood IllnessINA-CBG Indonesia Case-based GroupIPT Intermittent Preventive Treatment (for

malaria)IPV Inactivated Poliomyelitis VaccineIYCF Infant and Young Child FeedingKAFKTP Komisi Akreditasi Fasilitas Kesehatan

Tingkat Primer (Primary Care Accreditation Commission)

KAP Key Affected PopulationLG Local GovernmentLLIN Long-lasting Insecticidal NetLMIS Logistics Management Information

SystemMCH Maternal and child healthMDR-TB Multi-drug Resistant Tuberculosis

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MMR Maternal Mortality RatioMoF Ministry of FinanceMoH Ministry of HealthMoHA Ministry of Home AffairsMP-ASI Makanan Pendamping Air Susu Ibu

(Complementary food)MSS Minimum Service StandardsMUAC Mid upper arm circumferenceNCD Noncommunicable diseaseNTT Nusa Tenggara Timur (East Nusa

Tenggara)OOP Out-of-Pocket (Expenditure)OPD Outpatient DepartmentOPV Oral Polio VaccineORS Oral Rehydration SolutionPHBS Perilaku Hidup Bersih Sehat (Clean

and Healthy Life Behavior)PHC Primary Health CarePHE Public Health ExpenditurePKK Pembinaan Kesejahteraan Keluarga

(Family Welfare Program)PMTCT Prevention of Mother-to-Child

TransmissionPolindes Pos Bersalin Desa (Village Maternity

Post)PONED Pelayanan Obstetri Neonatal

Emergensi Dasar (Basic Emergency Neonatal and Obstetric Service)

Poskesdes Pos Kesehatan Desa (Village Health Post)

Posyandu Pos Pelayanan Terpadu (Integrated Service Post)

PPH Post-partum HemorrhagePuskesmas Pusat Kesehatan Masyarakat

(Community Health Center)Pustu Puskesmas Pembantu (Auxiliary

Puskesmas)

QSDS Quantitative Service Delivery SurveyRDT Rapid diagnostic testRifaskes Riset Fasilitas Kesehatan (Health

facility survey)RMNCH Reproductive Maternal Newborn and

Child HealthSARA Service Availability and Readiness

AssessmentSBA Skilled Birth Attendant/AttendanceSDITK Stimulasi, Deteksi dan Intervensi

Dini Tumbuh Kembang (Stimulation, Early Detection and Growth Intervention)

SHI Social Health InsuranceSP2TP Sistem Pencatatan Pelaporan Terpadu

Puskesmas (Puskesmas Integrated Reporting and Recording System)

STI Sexually Transmitted infectionTB TuberculosisTHE Total Health ExpenditureTT Tetanus ToxoidU5MR Under-five Mortality RateUHC Universal Health CoverageUKBM Usaha Kesehatan Bersama

Masyarakat (Community-based Health Services)

VCT Voluntary counseling and testingWHO World Health Organization

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Executive Summary

This report brings out key findings from a Quantitative Service Delivery Study (2016) of public and private primary health care providers in Indonesia. The report analyzes primary health care supply-side readiness across public and private facilities, rural and urban facilities, private facilities empaneled by the national social health insurance agency (Badan Penyelenggara Jaminan Sosial – BPJS) versus those who have not, amongst others. It also compares temporal changes in public-sector primary health care supply-side readiness since the last facility census, the Rifaskes (2011). The primary aim of the report is to present findings from the survey that can inform policy choices to improve primary health care service readiness as part of Indonesia’s path towards achieving Universal Health Coverage (UHC).

Indonesia, the fourth most populous country in the world, has taken great strides in reduction of poverty and improvement of health indicators. Life expectancy has increased from 67 in 2002 to 69 in 2015 and under-five mortality has declined from 46 per 1,000 live births in 2002 to 32 per 1,000 live births in 2017, however, there are remaining challenges to be tackled. For example, the maternal mortality ratio (MMR), at 126 maternal deaths for every 100,000 live births, is high compared to countries with a similar economic status and childhood malnutrition, as reflected by a stunting rate of 37 percent, continues to be a problem. The change in the population structure due to the demographic transition is resulting in an epidemiological transition wherein the burden of noncommunicable diseases (NCDs) is increasing in the face of a persistent load of communicable diseases leading to double burden of disease.

Health financing in Indonesia is marked by low public health expenditures (PHE), high out-of-pocket (OOP) expenditures and a complex and fragmented intergovernmental fiscal transfer system. Central government has

1 Puskesmas: Pusat Kesehatan Masyarakat (Primary public health care center).

underutilized levers to direct service-delivery improvement at the local level. The majority of intergovernmental transfers are unconditional, and those transfers that are conditional have weak performance orientation. There are multifaceted and competing mixtures of central and subnational regulations governing authority over key decisions which complicates health service delivery. Another complication following decentralization in the health sector has been the disruption to, and varying quality of, monitoring, reporting, and data systems.

Indonesia has a mixed model of public-private provision of health care services. The public primary health care system is decentralized to the district level–with about 9,750 puskesmas1 forming the backbone of the country’s health system. A similar number of private primary care clinics have been empaneled by BPJS; many nonempaneled private clinics exist too, the count of which is not known. BPJS runs JKN–one of the largest single-payer social health insurance (SHI) programs in the world–under which health insurance coverage rates have increased from about 27 percent in 2004 and to about 70 percent in 2016.

Despite this large network of primary health care facilities, health service delivery is challenging. Indonesia has over 6,000 inhabited islands, resulting in large geographical inequities in access to health services and health outcomes. While JKN was designed to improve access to health services by the poor by making health care more affordable, income-related inequities continue to abound as JKN is facing a number of implementation challenges such as: (i) lack of clarity in institutional roles; (ii) poor coverage of the “nonpoor” working in the informal sector; (iii) a nonexplicit benefits package; and (iv) weak strategic purchasing of services. The JKN is also poorly integrated with supply-side financing to improve public sector supply-side readiness and is also being underused to harness private-sector provision.

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The last survey of health facilities–Rifaskes, which was conducted in 2011–was a census of only public-sector health facilities and measured service availability and readiness. Rifaskes 2011 found gaps in multiple areas for general service readiness (such as some basic equipment, health care waste management and patient safety systems) as well as for specific services (such as availability of guidelines and training, medicines and commodities and diagnostics). Since Rifaskes 2011, the Government of Indonesia (GoI) has put in substantive efforts to improve the availability of health services. This includes introduction and expansion of the JKN, increased availability of supply-side financing through special allocation funds (Dana Alokasi Khusus – DAK) to provinces and districts for improving supply-side readiness, expanding access to health facilities in remote, lagging and border areas, as well as quality improvement and accreditation of primary health care facilities.

The current study, the Quantitative Service Delivery Survey (QSDS) 2016, was conceptualized to address the need to assess changes in the health service availability and readiness in the last five years since Rifaskes–it has these specific objectives:

• To provide a baseline for the JKN in terms of its ability to improve supply-side readiness

• To include private-sector primary health care supply-side readiness, that is an important provider of services but was not covered in Rifaskes 2011

• To measure urban-rural differences• To measure factors that affect service

delivery at the facility level–such as governance, health and health financing (but not costing information)

• To measure any changes in supply-side readiness from Rifaskes 2011 given the increased investments in supply-side readiness.

The QSDS focused on the availability at, and readiness of, the facility of not just general health care services but also services in specific health care domains like maternal and child health (MCH), communicable diseases like HIV and AIDS,2 TB and malaria as well as NCDs. While the availability of services was assessed at all the sampled facilities (the only exception being family planning and maternal health services),3 the readiness of the facility to provide the services was examined in only those facilities where the services were reported to be available. The survey also collected data regarding health-system issues related to primary health care delivery like financing, governance and management as well as human resources for health (HRH).

Recent studies (such as Leslie et al. 2017) have shown that availability of resources in facilities for provision of services (service readiness), is not sufficient to improve quality of care outcomes by itself. Quality of care outcomes improve as a result of several other clinical process improvements, including systems to increase adherence to standard protocols by the facility staff. The availability of key inputs such as necessary infrastructure, equipment, diagnostics, and human resources are, however, necessary prerequisites to the provision of quality care. The results of this study should not, therefore, be interpreted as a study on quality of care outcomes at the public and private-sector primary health care facilities in Indonesia but as a measure of supply-side readiness as a necessary, but not sufficient, prerequisite to improve quality of care.

This report primarily reflects data analysis on the service availability and readiness components at the puskesmas and private-sector clinics, along with additional analysis on governance, HRH and financing, for the nationally representative sample. Information on provider ability and patient satisfaction have been covered in thematic reports such as for maternal health and will be covered in a forthcoming report on HRH.4

2 HIV: Human Immunodeficiency Virus; AIDS: Acquired Immunodeficiency Syndrome.3 Family planning and maternal health services were not assessed in the private clinics, as the national sample did not cover private

maternity clinics which are the main providers of these services in the private sector.4 Detailed results on various thematic service-delivery areas such as maternal health, HIV/AIDS, TB, immunization, and nutrition are

available or forthcoming in the following reports: (i) Revealing the missing link: Private Sector Supply Side Readiness for Primary Maternal Health Services in Indonesia (2017); (ii) Transitioning from Donor Funded Health Programs in Indonesia: Issues and Priorities (2018); (iii) Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia – Descriptive Analysis of QSDS (2018); and (iv) a chapter in a forthcoming book on nutrition (2018).

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THE KEY FINDINGS FROM THIS REPORT ARE:

A. The public-sector facilities (the puskesmas) were readier to provide both general and specific primary health care services when compared to the private general practitioner (GP) clinics. To assess the facilities’ readiness for provision of general health care services, this report analyzed the availability of about 34 components– including basic amenities, equipment, diagnostics, and essential medicines. On average, the puskesmas had 26 components available compared to private GP clinics that had only 20 components (Figure 1). While the puskesmas outscored private clinics on all subdomains of general service readiness, the difference was particularly stark in terms of availability of general diagnostics–with the sampled puskesmas on average having about four of the five items asked for, compared to less than two at the private clinics. 5

For all the specific services, the puskesmas were better prepared than the private clinics to offer services. The difference between the public and private sector varied across these specific services. The survey had no questions on the availability (and readiness) of maternal health and services related to facility planning in the private clinics, as maternity homes that provide such services were not included in the national sample. A separate sample was used for private maternity homes (see Yap et al. 2017). Puskesmas were the main providers of childhood immunization services. Only 15 percent of the sampled private clinics provided any immunization services. Even the few that provided immunization services, were found to be less “ready” than the puskesmas (Figure 2). In addition, unlike the puskesmas, very few private clinics provided outreach services. Newer vaccines like the rotavirus vaccine, the pneumococcal vaccine and even the injectable polio vaccine were, however, provided almost exclusively by the private sector.

5 Details about the availability of individual items, as well as the subdomain scores, can be found in the main report in Appendix 5.

Figure 1. General Service Readiness (Availability of Components in Puskesmas and Private GP Clinics)

Note : vertical solid line=mean; vertical dash line=medianComparing 34 component measured in both type of facility

05

1015

Percentage

0 2 6 10 14 18 22 26 30 34

Number of Component

Puskesmas

Private GP/Clinic

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Figure 2. Immunization Service Readiness (Availability of Components in Puskesmas and Private GP Clinics)

Note : vertical solid line=mean; vertical dash line=medianNumber of component = 12

010

2030

0 2 4 6 8 10 12

Puskesmas

Private GP/Clinic

Percentage

Number of Component

Similarly, provision of care for diagnosis and management of communicable diseases like malaria, TB and HIV was found primarily in the puskesmas with significantly fewer private-sector clinics providing these services. In the private clinics that did provide these services, the quality of care in terms of adherence to standards was circumspect. For example, for both malaria and TB, the private clinics relied on clinical symptoms instead of laboratory tests to make a diagnosis before initiating treatment. Additionally, most of the private clinics neither prescribed fixed dose combinations nor did they adhere to Directly Observed Treatment Short-course (DOTS) for management of TB.

B. Facilities located in urban areas perform better on the service-readiness index than rural facilities. The urban-rural divide in service availability and readiness was seen in both the public and private-sector facilities across general services and most of the specific services. There were a few specific domains, however, where the availability of related services was higher in rural facilities compared to urban ones. For example, only 58 percent of the urban puskesmas provided normal delivery care compared to 87 percent of the rural ones (the plausible reason for this was not explored as part of this survey). Similarly, 95 percent of the rural puskesmas provided malaria-related services compared to only 79 percent of the urban ones. The picture was, however, different for the private clinics where a marginally higher proportion of urban clinics provided malaria services compared to the rural ones. In addition, there were certain specific service domains like childhood immunization, child health care and services for TB diagnosis and management where no difference was observed between the urban and rural puskesmas, although there were differences observed between urban and private GP clinics.

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Figure 3. General Service Readiness (Availability of Components in Urban and Rural Puskesmas)


05

1015

20

0 4 8 12 16 20 24 28 32 36 40 44

Urban

Rural

Percentage

Number of Component

Of all the facilities that provided a certain kind of service, the urban facilities fared better than the rural ones for service readiness but the magnitude of the urban-rural difference varied with the type of service domain (or subdomain) that was being assessed and by the type of facility. For example, on average, an urban puskesmas had about four additional components related to general service readiness available in its facility compared to its rural counterpart (Figure 3). On the other hand, the difference between an urban and rural private clinic was only of two such components (Figure 4). Generally, the urban-rural difference was less stark for the private clinics compared to the puskesmas, probably because of the low overall service readiness at the private clinics, leaving less room for the differences to show up.

C. Within the private sector, the clinics that were empaneled with BPJS were more likely to offer a wider spectrum of services and be service-delivery ready than those that were not empaneled. This suggests that linking the private sector with government programs and provision of capitation payments for service provision can be a key strategy to strengthen private-sector engagement. The one exception to this was the availability of Sexually Transmitted Infection (STI) services where the nonempaneled private clinics were slightly more likely (67 percent) to provide STI-related services compared to the ones working under the BPJS umbrella (64 percent). The service-readiness index was also higher for the BPJS private clinics compared to the nonempaneled ones. For example, as can be seen in Figure 5, the empaneled clinics had about 22 of the 34 components related to general service readiness available in their clinics compared to only 18.5 components in the nonempaneled ones. Only 43 percent of the sampled private-sector providers were empaneled; the primary reason for nonempanelment was lack of interest from the providers, which may be secondary to inadequate capitation fees that was cited by other nonempaneled providers.

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Figure 4. General Service Readiness (Availability of Components in Urban and Rural Private GP Clinics)


05

1015

0 2 6 10 14 18 22 26 30 34

Urban

Rural

Percentage

Number of Component

Figure 5. General Service Readiness (Availability of Components in the BPJS-empaneled and Nonempaneled Private GP Clinics)


05

1015

0 2 6 10 14 18 22 26 30 34

EmpaneledNot empaneled

Percentage

Number of Component

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D. When compared to Rifaskes 2011, most of the health services show an improvement in QSDS 2016. There were, however, some areas that also saw regressions from Rifaskes 2011, such as availability of vaccines and training and guidelines for the malaria and TB program that are a cause of concern. While interpreting the results, it must be borne in mind that the two surveys had key methodological differences. First, the Rifaskes was a census of public-sector facilities, while QSDS is a sample-based survey that captured only the primary health care facilities. In addition to the puskesmas, QSDS also sampled the private-sector GP clinics that were providing primary health care services. Given the different sample spreads, only data for the puskesmas on commonly measured indicators are comparable between the two surveys.

The data shows that, in terms of general service readiness, the mean readiness index rose from 71 percent to 78 percent in the five years following Rifaskes 2011. While some components of general services readiness such as the availability of basic amenities and adherence to standard precautions show a major positive shift of about 9 percent or more, there was not much change in the availability of medicines and needed equipment in the facility. In both surveys, lack of availability of basic diagnostics was a cause of concern. None of the facilities met all the indicators for general service readiness in both surveys. For specific services, the areas where puskesmas were performing well under the Rifaskes 2011, continued to do so even under the QSDS 2016. This included the availability of equipment for family planning or immunization services, however, the actual availability of commodities (vaccines) for immunization services dropped from 95 percent to 84 percent, showing that the progress has not been uniform.

E. The availability of specific health care services was very variable across domains, and the lack of availability of certain specific services was a cause of concern. For example, while almost all the puskesmas provided antenatal care (ANC) services, only three of four puskesmas provided services for normal delivery, and this proportion reduced further to just half when it came to the provision of basic emergency obstetric and neonatal care (BEmONC)–the latter being a key to reducing maternal mortality.

Similarly, the lack of availability of HIV-related services is a cause of concern. Only two-thirds of the puskesmas and one-quarter of the private clinics provided these services. HIV counseling and testing (HCT) services, both for the general population as well as for pregnant women as part of the Prevention of Mother-to-Child Transmission (PMTCT) program were primarily available in the puskesmas, while most of the private clinics referred these cases to public hospitals and/or the puskesmas that were offering these services. Provisions for special target groups such as needle exchange and methadone maintenance programs for injecting drug users were available in even fewer facilities. Availability of Antiretroviral Therapy (ART) for HIV-positive pregnant women and their newborn and people living with HIV was dismally low in the public sector and almost absent in the private-sector primary care facilities.

F. The logistics management information system (LMIS) of most facilities was not functioning optimally–leading to frequent stock-outs of drugs and commodities. QSDS 2016 data revealed that the puskesmas had a system to manage drug and diagnostics’ stock, which included having a person assigned for this job and having systems to calculate requirements on a periodic basis. Almost all the facilities, however, had stock-out of at least one drug and/or diagnostic (like rapid diagnostic test – RDT – kits) for malaria and syphilis) in the month prior to the survey, suggesting inefficiencies in the system. The reasons provided by the facility for the stock-outs could provide certain solutions for improvement. The private clinics also had frequent stock-outs, however, unlike the puskesmas, these clinics did not have a formal LMIS, indicating the need to develop one through the BPJS–especially for ensuring availability of life-saving drugs, diagnostics and other commodities.

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Some other important findings that need to be considered by GoI to improve health service availability and readiness are:

• The increase in the number of puskesmas has, on an average, kept pace with the growing population in Indonesia, however, there is inequitable access to primary care, with wide variations in not only the population size served by the puskesmas (from less than 2,000 to about 98,000), but also a five-fold difference in the minimum and maximum “time-to-reach care”.

• Almost all puskesmas had at least one functioning emergency transport vehicle for referral but only one-third (33 percent) of the private clinics had such facilities, with single-provider run clinics being far less likely to have such a referral transport system ready, which indicates a need for a more systematic ambulance system to be introduced for timely referrals.

• About one-half of sampled facilities in both the public and private sector were not adhering to waste segregation guidelines for infectious medical waste. Storage of sharp waste material too was an issue with the private sector.

• Lack of privacy in the clinics for provider-patient interaction, was a cause for concern, especially in the puskesmas. This was of greater concern in the facilities offering HCT services, where less than one-half of these facilities had these amenities.

• When compared to the norms set by GoI, there was an overall lack of nonmedical staff such as the pharmacist and nutritionist at the puskesmas. In contrast, the private-sector clinics, especially the single-provider ones, were overly dependent on the doctors and had significantly fewer nursing, administrative and other support staff. Lack of staff was also the main reason for the facilities receiving less than the mandated maximum capitation fee per member as their staff strength did not meet the norms set by BPJS.

• There was a positive correlation that is statistically significant (at p<0.05) for doctors/nonclinical staff and outpatient visits at the puskesmas but not for nurses/midwives and outpatient visits.

• While staff at the puskesmas were more likely to be trained in the various technical guidelines than the private-sector staff, there were many facilities where none of the staff had received training (on the multiple themes enquired about) in the two years preceding the survey.

• The maximum capitation fee per registered member provided to a puskesmas was IDR6 6,000, whereas it was IDR 10,000 for the private facilities as puskesmas also receive other government budgetary financing. Some 43 percent of puskesmas and 46 percent of the private clinics received less than the maximum capitation fee, the primary reason for the same being lack of staff as mandated by BPJS. There was no significant difference observed between puskesmas that received maximum capitation versus those that did not in terms of supply-side readiness for child care, diabetes and cardiovascular disease. There was a significant difference observed (p<0.05), however, in the empaneled private clinics that received maximum capitation versus those that did not in terms of supply-side readiness for child care, diabetes and cardiovascular disease. This indicates that JKN is a key instrument that can be used to influence supply-side readiness for the private sector.

• About one-half of puskesmas revenue was spent on providing monetary incentives to staff, with relatively little being spent on drugs and consumables. There was a significant difference observed (at p<0.05) between puskesmas that fully utilized JKN funds versus those that did not and supply-side readiness for child care but not for diabetes and cardiovascular disease.

• No clear link of increased operational expenditures with supply-side readiness was observed. There was no significant difference observed between puskesmas that retained all revenue versus those that did not and supply-side readiness for general services.

6 IDR: Indonesian Rupiah. US$1 = approximately IDR 13,000.

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7 SP2TP: Puskesmas Integrated Reporting and Recording System.

• While regular monitoring visits from the District Health Office (DHO) to the puskesmas and by the puskesmas staff to the posyandu were being performed, the system of providing written feedback needs improvement. There was no significant difference between puskesmas that received regular monitoring and supervision versus those that did not for supply-side readiness in various specific health care areas.

• Both the public and private-sector facilities were using the SP2TP7 for recording and reporting health information. While the public-sector facilities were using computers to maintain these records, the private sector was more dependent on a paper-based system.

It is important that these findings are addressed through key policy and implementation actions related to health financing, service delivery and governance. While this report itself does not cover these recommendations, many of these have been covered by other publications and will be covered in forthcoming work. As mentioned earlier, supply-side readiness improvement is necessary, but not sufficient, to improve service-delivery access and outcomes. There needs to be a package of policy interventions to improve performance and quality of primary health care quality, including strengthening performance monitoring and accountability, ensuring supply-side readiness verification and improving managerial capacity as well as strengthening adherence to clinical processes through accreditation, incentivizing local governments and providers to achieve results by linking supply-side (DAK) and demand-side (JKN) financial transfers to performance, strengthening human resource skills and competencies, enabling better distribution of human resources as well as introducing innovations for better service delivery by frontline providers.

1

Introduction

2


Indonesia, the fourth most populous country (approximately 250 million) in the world, has made significant gains in economic growth and poverty reduction. Relatively strong economic growth (5.5 percent per year since 2000) has been accompanied by a sustained decline in poverty rates: about 31 percent and 6.8 percent of the population lived on US$3.10 a day and US$1.90 a day, respectively, in 2016, down from 82 percent and 48 percent (respectively) in 1998 (World Bank 2017). With a Gross Domestic Product (GDP) per capita of US$3,603 in 2016, Indonesia is currently classified as a lower-middle-income country and will transition to an upper-middle-income country with continued economic growth. Its human capital indicators also show impressive gains, with adult literacy at almost 95 percent, gross enrolment of 100 percent, 83 percent, and 32 percent in primary, secondary and tertiary education, respectively, with the share of female enrolment exceeding that of males at each level.

Health outputs and outcomes in Indonesia have improved in recent years. Life expectancy has increased from 67 years in 2002 to 69 years in 2015 (World Bank 2017) and the under-five mortality rate (U5MR) has declined from 46 per 1,000 live births in 2002 to 32 per 1,000 live births in 2017 (Statistics Indonesia et al. 2013). The share of pregnant women receiving four or more antenatal care (ANC) visits8 has also increased–from 64 percent in 2002 to 77 percent in 2017. The percentage of moderately/severely underweight children under five years of age has decreased from 23 percent in 2002 to 19.6 percent in 2013. Landmark legislation in 2004 and 2011 has helped realize a potential pathway to Universal Health Coverage (UHC). Indonesia has one of the largest single-payer social health insurance (SHI) programs–Jaminan Kesehatan Nasional (JKN)–in the world. Health insurance coverage rates in Indonesia

have increased significantly in recent years: from approximately 27 percent in 2004 to approximately 73 percent in 2017. By 2019, everyone in Indonesia should have coverage under the JKN.

Key challenges remain, including slow progress on addressing inequalities in health outcomes, and access to primary and secondary health care. The national maternal mortality ratio (MMR) is 126 per 100,000 live births, closer to low-income countries (World Bank 2017), while the MMR in Eastern Indonesia is even higher (above 200 per 100,000 live births). Post-partum hemorrhage (PPH), eclampsia and infections are the key causes of maternal death with underlying factors including: (i) lack of continuum of care; (ii) adolescent pregnancies; (iii) unsafe abortions; and (iv) a stagnating family planning program. Similarly, the U5MR in the Eastern Indonesian provinces of East Nusa Tenggara (Nusa Tenggara Timur – NTT) and Maluku is close to 60 per 1,000 live births, much higher than the national average of 40 per 1,000.9

Large regional and income-related inequalities10 remain across the country, with the Infant Mortality Rate in the poorest households being more than double that in the richest. Chronic malnutrition or stunting rates remain very high at 37 percent at the national level (Riskesdas 2013) and are even higher in Eastern Indonesia. While overall coverage rates of key maternal health services are high,11 it varies widely across regions and income: there is a two-fold difference in skilled birth attendance (SBA) across some provinces and home delivery rates are six times higher among women in the lowest income quintile compared to the richest income quintile (Statistics Indonesia et al. 2013).

Indonesia is facing a double burden of disease, with new challenges rapidly emerging due to a demographic (ageing

Country and Sectoral Background

8 At least one visit in first trimester, at least one visit in second trimester and at least two visits in third trimester.9 IDHS 2012 is used to compare between regional and national estimates as this data are not yet available for IDHS 2017. 10 The consumption Gini index (a measure of income inequality) grew from 30 (2003) to 40 (2016).11 The 2012 Demographic and Health Surveys (IDHS) shows the following: 4 ANC visits – 88 percent, SBA – 83 percent and post-natal

care (PNC) at 80 percent. Institutional delivery is low at 63 percent (17 percent public; 46 percent private).

3

population) and epidemiological transition (persistent communicable diseases with rising prevalence of noncommunicable diseases (NCDs)). Indonesia is among a few countries in the world that reported an increase of Human Immunodeficiency Virus (HIV) incidence among key affected population (KAP) groups (World Bank 2018). Although the epidemic is concentrated in KAP groups, there is a generalized HIV epidemic in Papua and West Papua. Indonesia has the second highest tuberculosis (TB) burden in the world–with the disease being the second most common cause of premature deaths in Indonesia–and only one-third of the cases being detected (WHO 2017). In addition, new challenges such as Multi-drug Resistant TB (MDR-TB) have emerged, with the annual incidence now estimated to be 30,000 cases, which poses a significant financial burden and program management challenge.12 Malaria

remains endemic in some regions, including Papua. At 66 percent, NCDs now account for the largest share of the burden of disease in Indonesia, almost doubling since 1990 (Institute of Health Metrics and Evaluation Metric Evaluation –IHME 2017).

Indonesia has a mixed model of public-private provision of health care services (Figure 1.1). Service delivery at all levels is challenging as Indonesia has over 6,000 inhabited islands. The public sector is more dominant in provision of inpatient services, especially in rural areas. Two-thirds of outpatient care (for the poor and general population), about one-half of inpatient care for the general population and one-third of inpatient care for the poor are provided by the private sector. There are approximately 2,400 hospitals in Indonesia–of which about two-thirds are private.

Figure 1.1 Organization of Service Delivery in Indonesia

12 Only 1,848 cases of MDR-TB are currently receiving treatment.13 Puskesmas are public-sector primary health centers that cover a population of about 25,000-30,000, with almost one-third having

inpatient beds.

Hierarchical

Regulation

Central government

andparliament

Ministryof

HomeAffairs

Provincial government

andparliament

Districtgovernment

andparliament

SocialSecurity

Management Agency

Ministryof Health

Provincialhospitals

ProvincialHealthOffice

Districthospitals

DistrictHealth Office

BPJS

Central hospitals

Publicprimary

carefacilities

Privateclinics

andpractice

Source: Asia Pacific Observatory and WHO 2015.

4


The public health care system is decentralized to the district level with about 9,760 puskesmas13 forming the backbone of the country’s health system. A similar number of private primary care clinics have been empaneled by the Social Security Agency (Badan Penyelenggara Jaminan Sosial – BPJS Health). There is, however, no systematic information on the entire private-sector health system. The public primary care system also includes 23,000 auxiliary puskesmas (pustu) for outreach activities in remote regions; village-level delivery posts (polindes, often the home of the village midwife) and village health posts (poskesdes). Frontline service delivery at approximately 75,000 villages is also undertaken through posyandu14 and by village midwives (who are formally part of the health system). Volunteer Kader15 are not part of the formal health system and do not get paid other than a minimal transport allowance.

Many Indonesians face significant physical and time barriers to accessing health care, especially in Eastern Indonesia. Although the median distance to a health facility in Indonesia is only five kilometers, the median distance in provinces such as West Papua, Papua, and Maluku is over 30 kilometers. Widely divergent geographic accessibility is correlated with the time taken to reach public health facilities. According to Riskesdas 2013, while about 18 percent of Indonesians took more than one hour to reach a public hospital (using any travel means), over 40 percent of people in West Sulawesi, Maluku, and West Kalimantan faced this barrier to access. Measured in time, puskesmas were more accessible, as only two percent of the national population took more than one hour to reach a puskesmas, but the proportion of the population facing this travel time was much higher in Papua (28 percent) and NTT (11 percent).16

Rifaskes 2011 indicated wide variations in health facility service readiness to provide good quality health care services. Rifaskes was the last survey that was conducted to study

supply-side readiness of health facilities. It was a census of all public-sector health facilities and service delivery points (from posyandu to puskesmas and up to the public-sector hospitals), and a sample of private-sector hospitals. The survey revealed that not even one puskesmas had met all the 38 tracer indicators. There was significant variation observed across districts; while almost all puskesmas in Central Java met at least 80 percent of the readiness indicators, only one-half of puskesmas in Papua and Maluku met this benchmark. Only 39 percent of public hospitals and 3 percent of the 30 private hospitals surveyed maintained all 23 basic obstetric care tracer items. Twenty percent of public hospitals and none of the sampled private hospitals maintained all six blood transfusion tracer items, with a four-fold variation between districts. A large majority of provinces (25 out of 33) had less than 30 percent of public hospitals with all tracer items, including eight provinces where no hospitals reached this target.

Despite having attained the minimum World Health Organization (WHO) norm, Human Resources for Health (HRH) remains a key challenge for Indonesia’s health sector, further impeding the ability to provide equitable access to good quality health care services. The HRH-to-population ratio in 2013 was estimated at 2.3 per 1,000,17 equal to the minimum recommended by WHO as necessary to attain an 80 percent SBA rate. Multiple HRH-related issues remain, however, including inequitable geographical distribution of health personnel, a shortage of specialists, and inadequately skilled HRH. The physician-to-population ratio in Maluku-NTT-Papua is one-third of that in the Java-Bali region, while the ratio for specialists is even worse than for general physicians (Indonesia Health Profile 2016). The shortage of nurses is especially acute in public facilities. Studies show that financial resources are often not enough to attract HRH in remote areas; good management and better facilities have been found to be equally important (Efendi et al. 2015).

14 Posyandu is a monthly event manned by at least five types of community health workers who cater to the five essential services: registration, weighing and monitoring children’s growth, recording of child growth in health cards, counseling and education; immunization and ANC as part of outreach services of primary health care centers (puskesmas).

15 Kader is a volunteer health worker organized under the Family Welfare Program (Pembinaan Kesejahteraan Keluarga - PKK) that is administered by Ministry of Home Affairs (MoHA). PKK is responsible for supporting kader technical training and ongoing capacity building.

16 The time to walk to a private health facility or drug outlet to access affordable essential drugs on a sustainable basis is a key indicator used for MDG tracking, with one hour identified as the benchmark. See United Nations (2003).

5

Some of the key issues that need to be addressed to improve the performance, including quality, of primary health care are related to governance and accountability, service-delivery capacity, and low-performance orientation of health financing:

a. Lack of performance monitoring and accountability in a decentralized setting. Since 2001, decentralization has been accompanied by increased complexity in fiscal transfers, diffuse governance and accountability mechanisms, and a fragmentation of monitoring systems. Most frontline health workers and local government staff managing subnational health systems report to local governments–not to the Ministry of Health (MoH). This has led to big variations in subnational capacity and the performance of local governments in delivering health services, especially at the primary-care level. It has also made it difficult for the MoH, or provincial and local leaders and citizens, to know how the system is performing and proactively address problems.

b. Underdeveloped ability to enforce clinical and managerial standards at the facility and district level. The MoH has comprehensive standards and guidelines that both districts and facilities must comply with to conduct health outreach, manage facilities, provide clinical care and run the subnational system. Standardization and compliance with managerial and health care guidelines and processes is weak at the district and the facility level.

c. Weak performance orientation of intergovernmental fiscal transfers and JKN. Special allocation funds (Dana Alokasi Khusus – DAK) and the JKN are neither well coordinated nor strongly oriented towards incentivizing performance at the facility level. The DAK–the largest conditional transfer to districts–currently offers an important lever to influence subnational service-delivery outcomes.

The Indonesian health financing system and the governance landscape, relevant to the Indonesian health sector, are described in Chapters 5 and 6, respectively. Appendix 1 briefly describes the main GoI program to achieve UHC.

An opportunity to improve the performance of primary care has recently emerged with the establishment of a primary care accreditation commission (Komisi Akreditasi Fasilitas Kesehatan Tingkat Primer – KAFKTP) that is based on the two decades of experience in hospital accreditation. Accreditation will improve quality of services by ensuring that not only the necessary inputs (such as infrastructure, equipment and human resources) are in place but also certifies that both clinical and managerial processes are improved. Accreditation involves a hands-on process of expert mentoring of facilities to improve their managerial processes and primary health care (PHC) (clinical care and community health) standards. It also provides follow-up support for facilities to address recommendations for continual quality improvement. The requirement to be reaccredited every three years provides an incentive to maintain standards. This is enhanced by Ministry of Health (MoH) policy that makes accreditation of PHC facilities by 2021 a prerequisite for empanelment by BPJS-Health as a JKN provider. While accreditation does not lead to improved clinical outcomes by itself, it is an important part of a “package” of interventions that would improve PHC performance. In addition to building capacity in the primary-care facilities, it also provides a governance framework for the sector, directing investments, and signaling managerial and clinical competence to beneficiaries and payers.

17 The rate of 2.3 HRH workers per 1,000 population included physicians (0.5), nurses (1.3), and midwives (0.5). The WHO target is 4.45 health workers per 1,000 population by the year 2030 to respond to the rising rates of NCDs.

6


For accreditation to work, however, the credibility of the KAFKTP and its processes need to be strengthened. Accreditation of PHC facilities began in 2015, with the enactment of Minister of Health Regulation No. 46/2015, and the establishment of the KAFKTP. While its current capacity is limited (owing to its nascent stage), the vision is to expand its capacity, become fully independent, cover both the public and private sector, and eventually get accredited by the International Society for Quality in Health Care (ISQua).18 It is also important that the commission develops credible quality assurance and validation mechanisms, as well as making its standards and results transparent.

18 International Society for Quality in Healthcare – an accreditor of accreditation agencies.

There are four levels of accreditation for PHC facilities, namely dasar (basic), madya (medium), utama (excellent), and paripurna (perfect), based on the scores achieved across nine major standard areas. For the public sector, plans for accreditation of puskesmas include a staggered approach, where at least one puskesmas in each of 5,600 subdistricts is to be accredited by 2019. As per MoH, approximately 4,200 puskesmas have been accredited as of December 2017, of which 30 percent have received accreditation at dasar level and 58.5 percent at madya level. While MoH has been focused on increasing coverage, from 2018 it will shift attention to increasing the proportion of puskesmas that achieve higher levels of accreditation. This is very important as higher levels of accreditation require more stringent adherence to outreach, managerial and clinical standards which are challenging to reach.

7

Given this background context, the Indonesia QSDS 2016 was envisioned as a PHC facility and services survey, with a specific focus on nutrition, maternal and child (MCH), communicable diseases (particularly HIV and AIDS, TB, and malaria), and NCD services. The survey captured information based on the WHO Service Availability and Readiness Assessment (SARA) conceptual framework and was adjusted per national guidelines. In addition, QSDS also included modules on governance, HRH indicators, health financing (without costing information), provider ability, and patient satisfaction. Instruments were developed to survery various PHC facilities (including puskesmas and polindes/poskesdes in the public sector, and private clinics and maternal health providers in the private sector), district health offices (dinkes), health workers, and conduct patient exit interviews in DKI Jakarta.

This report primarily reflects data analysis on the service availability and readiness components at the puskesmas and private-sector clinics, along with additional analysis on governance, HRH19 and financing, for the nationally representative sample. Information on provider ability and patient satisfaction have been covered in thematic reports such as for maternal health and will be covered in a forthcoming report on HRH. Appendixes 2 and 3 present in a fact sheet / tabular form the key indicators used to measure service readiness.

The Need, Scope and Methodology for the Quantitative Service Delivery Survey (QSDS 2016)

The main objectives for conducting this survey were as follows:

a. To provide a baseline for the JKN in terms of its ability to improve supply-side readiness;

b. To include private-sector PHC supply-side readiness, that is an important provider of services but was not covered in the Rifaskes 2011;

c. To measure urban-rural differences; d. To measure factors that affect service

delivery at the facility level–such as governance, health and health financing (but not costing information);

e. To measure any changes in supply-side readiness from the Rifaskes 2011 given the increased investments in supply-side readiness.

This report is not a study on quality of health care outcomes in Indonesia but rather a study on an important prerequisite for improved quality of care, namely supply-side readiness. Recent studies (such as Leslie et al. 2017) have shown that availability of resources in facilities for provision of services (service readiness), is not sufficient to improve quality of care outcomes by itself. Quality of care outcomes improve because of several other clinical process improvements, including systems to increase adherence to standard protocols by the facility staff. The availability of key inputs such as necessary infrastructure, equipment, diagnostics, and human resources are, however, a necessary prerequisite to providing quality care. The results of this study should not, therefore, be interpreted as a study on quality of care outcomes at the public and private sector primary health care facilities in Indonesia but as a measure of supply-side readiness as a necessary, but not sufficient, prerequisite to improve quality of care.

19 Detailed results on various thematic service-delivery areas such as maternal health, HIV/AIDS, TB, immunization, and nutrition are available or forthcoming in the following reports: (i) Revealing the missing link: Private Sector Supply Side Readiness for Primary Maternal Health Services in Indonesia (2017); (ii) Transitioning from Donor Funded Health Programs in Indonesia: Issues and Priorities (2018); (iii) Assessing HIV, TB, Malaria and Childhood Immunization Supply-Side Readiness in Indonesia – Descriptive Analysis of QSDS (2018); and (iv) a chapter in a forthcoming book on nutrition (2018).

20 Maternal health and family planning services were not measured at private clinics in the nationally representative sample, as private-sector maternity homes were not included in this sample but were reserved for the maternal health study

8


The QSDS 2016 had nationally representative sample sizes and instruments to measure general and specific clinical services supply-side readiness for both the puskesmas and the private clinics (the exception being maternal health and family planning services).20 Details of the final sample are presented in Table 1.1 and the detailed sampling and analytical methodology, with the trade-offs in sampling design, is discussed in Appendix 4.

In addition to data from the QSDS 2016, secondary data on service utilization and infrastructure availability in this report has been sourced from Rifaskes 2011, Indonesia Health Profiles21 (MoH 2014; MoH 2016; MoH 2017), and IDHS 2012 (Statistics Indonesia et al. 2013) for correlation and comparison purposes. Unless specified otherwise, the analysis referred to in the document is based on the QSDS 2016 survey. Changes in supply-side readiness between the QSDS 2016 (sample survey) and the Rifaskes 2011 (census) are presented only for the national-level estimates for puskesmas-related indicators to ensure comparability. A comparison of the key findings between these surveys is presented in Chapter 3 (Service Readiness), Chapter 7 (Summary of Key Findings), and in Appendixes 5 and 6.

Table 1.1 The National PHC Facility Sample Used in QSDS 2016

Type of FacilityAll Urban Rural

N % N % N %Puskesmas

With bed 149 56 48 43 101 65Without bed 119 44 64 57 55 35

Total 268 100 112 100 156 100

Private FacilityGP Clinic, single provider (including GP in private practice) 14 5% 13 6% 1 2%Clinic, multiple providers 151 52% 129 57% 22 36%GP clinic, home-based 124 43% 85 37% 39 62%

Total 289 100% 227 100% 62 100%

Source: Indonesia QSDS 2016.

As mentioned above, in addition to this report, two other reports focused on maternal health as well as HIV and AIDS, TB, malaria and immunization (ATMI) will also be published with this report. These other reports use QSDS 2016 sample and instruments focused on priority program districts across public and private sectors. In addition, there is separate policy brief covering nutrition and community-related service delivery through the posyandu.

The remainder of this report is structured as follows:

• Chapter 2 covers overall service availability and utilization of primary care services;

• Chapter 3 covers service readiness–both general and specific services at puskesmas and private primary care providers. This chapter also shares the comparison in the key findings between Rifaskes 2011 and QSDS 2016;

• Chapter 4 focuses on availability of HRH as well as training;

• Chapters 5 and 6 focus on financing and governance of PHC facilities, respectively;

• Chapter 7 summarizes the key findings from the report and lists down areas of concern that need attention from key policy makers.

21 The Indonesia Health Profile reports are based on administrative data that captures various types of public-sector facilities, including puskesmas, hospitals, and community-level/outreach health services (Usaha Kesehatan Bersama Masyarakat - UKBM), however, it does not capture private-sector data.

9

Service Availability and Utilization

This chapter analyzes the availability of general and specific health care services in both the public and private sector based on the data from QSDS 2016. This data has then been compared with appropriate service utilization data from other data sources, wherever available, to the demand-side perspective into the analysis. Service utilization information is based on secondary data sources such as the Indonesia health profiles and the Riskesdas, and not on QSDS 2016 as the latter was a supply-side survey.

10


The number of puskesmas has been increasing over the years, from 8,737 in 2009 to 9,767 in 2016 (Figure 2.1). The ratio of puskesmas per 30,000 population has remained stable, ranging from 1.13 to 1.17, indicating that the increase in the number of puskesmas has kept pace with overall population growth, however, there is wide variation in this ratio between provinces (from 0.57 to 5.07). Provinces in Java have a relatively low puskesmas-to-population ratio compared to provinces in Eastern Indonesia which can be explained by the difference in population density between these provinces.

The QSDS 2016 reveals a wide variation in the population served by each puskesmas. Data captured for multiple years saw approximately a 50-fold difference between the minimum and maximum population catered to by a puskesmas in both 2013 (3,937 to 181,976), and 2015 (1,889 to 97,890). Similarly, while the average number of villages served by a puskesmas was about 10, there was a wide variation from just one village to as many as 95 villages served by one puskesmas. The rural puskesmas, on average, served about one-half of the population of what an urban puskesmas covered (21,699 for rural versus 40,378 for urban).

The most common form of transport used by people to reach a puskesmas was a motorbike (87 percent), and the median time to reach a puskesmas using this means was 15 minutes. At the aggregate level, this is a good average “time to care”, as many medical emergencies can be handled within this time frame. When measuring the time taken to reach the facility from the farthest village, the national average time doubled to about 32 minutes, however, where the average time taken by a person to reach some puskesmas was five times longer. It took about double the time to reach a rural puskesmas (41 minutes) compared to an urban puskesmas (23 minutes) from the farthest village. Comparative data was not asked for from the private-sector clinics as they do not have a defined catchment area, nor do they have information on means of transport used by patients visiting their facilities.

The QSDS 2016 indicates that each puskesmas had an average of about 33 posyandu in its catchment area, which translates to over 3.5 posyandu per village. This is very similar to the Risfaskes 2011 data, indicating that the increase in the number of posyandu has kept pace with the increasing numbers of puskesmas. Almost all the posyandus were “active”.22 These posyandu are managed by the village kaders (community-based workers). On average, there were about 17523 kaders working in the catchment area of one puskesmas, which translates to about 18 kaders per village, or one such worker per about 170 people.

Each puskesmas had about five polindes or poskesdes24 in their catchment area. While these facilities are supposed to offer obstetric care services, they are mainly used for ANC services and are managed by the village midwives. There were, however, quite a few facilities (48 of the 268 sampled puskesmas, most of which were in urban areas) which did not have any polindes or poskesdes in their geographical catchment area. Given this situation, it probable that antenatal and basic obstetric care services, including delivery, in such areas take place either at home, in puskesmas, or private facilities. The QSDS 2016 also showed that there were about nine midwives on average in each puskesmas’ area, or about one in each village.

Figure 2.1 Number of Puskesmas in Indonesia (2009–16)

Source: MoH 2014; MoH 2016; MoH 2017.

8.737

9.005

9.321

9.510 9.655

9.731 9.754 9.767

2009 2010 2011 2012 2013 2014 2015 2016

22 “Active” posyandu, as defined by the GoI. 23 While 175 is the arithmetic mean, the median was 145 kaders per puskesmas.24 Village birthing house but usually used for ANC as service readiness for normal delivery is not up to standards (Yap et al. 2017).

11

Table 2.1 Availability of Services at the Public and Private-sector Health Facilities

Opening ArrangementsPuskesmas Private Clinic/GP

All Urban Rural All Urban Rural

Average days/week 6.5 6.4 6.6 6.3 6.2 6.5

Average hours/day 4.7 4.6 4.8 6.9 7.0 6.5

Facilities open 24x7 (%) 53 41 61 20 19 22


Both public and private facilities reported functioning almost seven days a week, with the private sector operating for a greater number of hours per day (Table 2.1). In comparison with the private-sector clinics, more than twice the proportion of the puskesmas were functioning 24 hours per day, 7 days per week.

According to the QSDS 2016, all the sampled puskesmas offer outpatient services and over one-half also offered inpatient services. According to the Indonesia Health Profile 2015 data (MoH 2016), of the 9,754 puskesmas, about two-thirds (6,358 puskesmas) had only outpatient facilities and the other one-third (3,396 puskesmas) also had inpatient care facilities (Figure 2.2). The proportion of puskesmas offering inpatient services compared to the total number of puskesmas has been steadily increasing. In the QSDS 2016, while all sampled puskesmas offered outpatient services, over one-half of the sampled puskesmas also had inpatient facilities.25 About 43 percent of the urban puskesmas, and almost two-thirds (65 percent) of the rural puskesmas offered inpatient services.

Outpatient Services

25 The difference between the Indonesia Health Profile and the QSDS numbers on outpatient and outpatient availability is likely due to the difference in methodology. The Indonesia Health Profile is a self-reported census whereas the QSDS is a sample survey based on actual visits to the puskesmas.

2.704 2.920 3.019 3.152 3.317 3.378 3.396

6.033 6.085 6.302 6.358 6.338 6.353 6.358

2009 2010 2011 2012 2013 2014 2015

Number of Puskesmas

Inpatient Non-Inpatient

Source: MoH 2014; MoH 2016.

Figure 2.2 Inpatient and Outpatient Puskesmas (2009-15)

12


26 For this question, only 205 of the 268 sampled puskesmas shared the Outpatient Department (OPD) attendance data for the year 2015.27 The calculations have been done assuming one month has 26 working days on average.

The QSDS 2016 showed that while all private-sector primary care facilities offered outpatient services, only 13 percent had inpatient facilities compared to about 50 percent for puskesmas. For both the puskesmas and the private clinics, the proportion of facilities offering inpatient services was higher for rural centers than urban ones–65 percent versus 43 percent for the puskesmas and 23 percent versus 10 percent for private clinics. As this survey is focused on primary care facilities, there is very little data available on inpatient services.

QSDS data shows that, while the average number of beds in urban facilities offering inpatient care was more than in the rural facilities (11 versus eight beds for puskesmas and 10 versus eight beds for private clinics), the bed occupancy rates (BOR) were higher in the rural areas. For puskesmas, the BOR was 74 percent and 53 percent for rural and urban facilities respectively, with an overall average of 68 percent; while it was 64 percent and 49 percent for private clinics respectively, averaging an overall rate of 55 percent.

Inpatient ServicesQSDS data in 2016 shows that the sampled26 puskesmas had an average monthly outpatient attendance of over 2,300 patients (or 90 patients a day),27 with a very wide range (Figure 2.3). For example, in the year 2014, the annual outpatient attendance varied from just 70 patients (or less than six patients in a month), to over 330,000 patients (monthly attendance of nearly 28,000 patients), which means that the outpatient load in such puskesmas on any given day was much higher than what some other puskesmas were attending to in the whole year. Attendance in urban facilities was found to be much higher than those located in rural areas. For example, in the year 2015, the median annual outpatient count in urban puskesmas was about three times than that of a rural puskesmas (28,467 for urban puskesmas versus about 10,956 for rural puskesmas). Possible explanations for this variation in OPD attendance include variable population density in the catchment area, a higher population-to-puskesmas ratio in urban areas, geographical access, time taken to reach the facility, and community perception of quality of care available at the facility.

Figure 2.3 Annual Outpatient Attendance at Puskesmas (by Location)


50

106.027

21.451

70

337.508

21.552

80

189.765

23.051

2013 2014 2015

All Urban Rural

min max median

5.448

106.027

27.243

3.537

337.508

28.467

3.605

189.765

28.337

2013 2014 2015

50

77.538

12.195

70

87.374

10.856

80

93.597

10.956

2013 2014 2015

13

The availability of services matches the mix of contraceptive use methods found in different surveys. Within the basket of contraceptive methods, hormonal methods like oral contraceptive pills, injectables and implants were the most common methods available in almost all (more than 97 percent) of the puskesmas. Both urban and rural puskesmas had negligible differences in service availability for these services except for the intra-uterine contraceptive device (IUD), which was available in 100 percent of the urban puskesmas but in only 78 percent of the rural puskesmas.

Male sterilization services were conspicuous by their absence, with only 1 percent (three of 268 sampled puskesmas) offering this method. Only one sampled puskesmas in each of Lhokseumawe, Pesisir Selatan and Banjar offered this service and all three facilities were in rural areas. Most of the sampled districts and municipalities in this survey offered a wide range of contraceptive choice in one or more of their facilities. One district that stood out as an exception was Yalimo (in Papua province), where the three sampled facilities offered male sterilization and condoms, and one offered oral pills too, but none of these three facilities offered injectables, implants or IUDs, thus severely limiting contraceptive choice availability in this district.

FAMILY PLANNING SERVICES Family planning is an important intervention that not only helps women, men and couples achieve their reproductive goals, but is also instrumental in improving maternal, neonatal and child health. More than 80 percent of couples use hormonal methods for women (injectable, oral pills and implants) to fulfil their contraceptive needs (Figure 2.4). The uptake of male sterilization was found to be less than 1 percent, with female sterilization being higher at 3.5 percent (BKKBN28 2016). As per Riskesdas 2013, almost 60 percent of married women in the reproductive age group use some modern method of contraception.

The QSDS 2016 shows that there was almost universal availability of family planning services in all the puskesmas (Figure 2.5).29 Of the 22 districts that were included in the sample, only one of the 14 sampled facilities in one district (Tapanuli Selatan in North Sumatra Province) did not have any family planning services available. More than three-quarters of puskesmas offered these services on all the days (six or seven days in a week) that the facility was open.

Specific Services

28 BKKBN: Badan Kependudukan dan Keluarga Berencana Nasional (National Family Planning and Population Board).29 Only puskesmas were covered for family planning services in the national sample.

Figure 2.4 Contraceptive Methods in “Active” Family Planning Users (2015)

Source: BKKBN 2016.

Pill; 23,6%

Implant; 10,6%

IUD; 10,7%

Condom; 3,2 %

Female sterilization; 3,5% Male sterilization; 0,7%

Injection; 47,8%

Figure 2.5 Availability of Different Contraceptive Methods in Puskesmas


3%

1%

97%

94%

99%

87%

98%

99%

1%

0%

100%

95%

99%

100%

99%

100%

5%

2%

94%

93%

99%

78%

98%

99%

Otherservices

Malesterilization

Implantcontraceptives

Malecondoms

Injectablecontraceptives

Insertion ofIUD/AKDR

Pillcontraceptives

Familyplanning

service

Rural

Urban

All

14


ANC SERVICES All sampled puskesmas (except one in Semarang district) offered some ANC services, and about three-quarters (72 percent) of the puskesmas offered ANC on all reported working days of the week (that is, 6-7 days a week). Most of the elements of ANC were available in the majority of puskesmas (Figure 2.6). Services that required relatively less skill and equipment such as weighing the pregnant woman or measuring her height were provided almost universally. The same was the case with abdominal examination (measuring fundal height, assessing the lie and presentation of the baby, and counting fetal heart rate) as well as administration of preventive care such as Iron and Folic Acid (IFA) supplements and Tetanus Toxoid (TT) vaccine.

Basic laboratory tests like hemoglobin estimation, blood grouping, estimation of blood sugar levels to rule out gestational diabetes and testing the urine for proteins to rule out pre-

41%

100%

98%

99%

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99%

98%

99%

99%

98%

86%

90%

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100%

Intermittent preventive treatment for…

Weight measurement

Height measurement

MUAC measurement

Blood pressure measurement

Fundal height measurement

Fetal heart rate monitoring

Fetal presentation

Tetanus Toxoid (TT)

Iron-folate supplementation

Blood Typing

Hemoglobin

Urine protein

Blood sugar

Malaria

Syphilis

HIV

TB

Antenatal Care Service (ANC)

Rural

Urban

All

Figure 2.6 ANC Service Availability in Puskesmas (by Urban-Rural Areas)

Source: Indonesia QSDS 2016.Note: MUAC: Mid-upper arm circumference.

eclampsia were, however, provided in fewer sampled puskesmas (84-91 percent) (Figure 2.6). While this is not a major cause of concern as they are on the higher side, averages hide regional variations. Provision of these laboratory tests was higher in urban puskesmas compared to rural puskesmas. For example, blood grouping was available in 97 percent of the urban puskesmas compared to just 77 percent of the rural puskesmas. This geographical variation is a cause of concern–in some districts within the sample, some of these laboratory facilities were almost absent. For example, none of the three sampled puskesmas in district Yalimo (in Papua province), and only one of the 13 sampled facilities in Tapanuli Selatan were performing blood grouping. Given that hemorrhage continues to be one of the leading causes of maternal mortality in Indonesia, there is a need for this simple laboratory test (as a necessary precursor for a blood transfusion) to be available–should a transfusion be needed to save the mother’s life.

15

Among all the elements of ANC surveyed under QSDS, the ones with the least availability were tests to detect concomitant diseases which are important to manage to prevent an adverse effect on the fetus. Only about one-half (51 percent) of the surveyed puskesmas conducted tests to screen the pregnant woman for HIV, and the numbers were even lower (40 percent) when it came to screening for syphilis. As per the national guidelines, these tests only need to be provided in high-risk areas, however, and this could explain the low availability. The only disease for which screening tests were being provided by a majority of puskesmas (93 percent) was TB. The main reasons given for the lack of these laboratory services was the unavailability of equipment and infrastructure as well as the lack of trained staff for this purpose. Another reason cited was that they did not have the service available because no client had ever requested it.

There was no significant urban-rural differences in the availability of ANC. There is no concomitant data for the private-sector clinics as private maternity homes–which are the key private sector facilities providing obstetric care–were not included in the QSDS national sample. There was a different survey instrument under the QSDS that was used for private maternity homes, data for which has been analyzed and presented as a separate report (Yap et al. 2017).

BASIC OBSTETRIC AND NEONATAL CARE SERVICESThe QSDS 2016 shows that three out of four puskesmas were providing normal delivery services (Figure 2.7). This translates to over 7,000 puskesmas in the country offering normal delivery care services. The proportion of puskesmas providing delivery care was higher in rural areas (87 percent), and in those under a district administration (80 percent) compared to urban areas (58 percent), and areas administered by the municipality (50 percent), respectively. Those that were not offering normal delivery services or basic obstetric care services cited lack of infrastructure, equipment and medicines as the common reasons for the facility not providing these services.

Most puskesmas providing delivery care also performed basic obstetric and newborn care functions related to a normal delivery. Routine care required for a normal delivery, such as monitoring labor using a partograph, or administering oxytocin immediately after birth to prevent PPH, was provided by almost all the facilities (97 percent and 99 percent respectively) providing delivery care. In addition, elements of essential newborn care such as early initiation of breastfeeding, thermal care (keeping the baby warm) to prevent hypothermia and care of the umbilical cord were also available in 95 percent to 98 percent of puskesmas (Figure 2.8). Encouragingly, all the puskesmas that offered normal delivery care also provided assisted vaginal delivery services. There were no significant urban-rural differences in the provision of various elements of institutional delivery and newborn care.

Figure 2.7 Availability of Normal Delivery Care (Left) and Assisted Vaginal Deliveries at Puskesmas (Right)


100%100%100%Assisted vaginal

delivery

99%98%99%Administration of

oxytocin injection

97%97%97%Monitoring and management

of labor using partograph

98%96%

99%Immediatebreastfeeding

95%91%

98%Hygieniccord care

98%97%99%Thermal

protection

75%

58%

87%

All Urban Rural

Puskesmas location

Rural

Urban

All

16


Seventy five of the 268 puskesmas (28 percent) identified themselves as Basic Emergency Obstetric and Neonatal Care (BEmONC) facilities or PONED.30 One-half of the sampled puskesmas reported that they provide BEmONC services, however, which means that facilities beyond those officially labelled as PONED reported that they provide BEmONC services.

While over one-half of the sampled puskesmas reported that they provide BEmONC services, the nonavailability of all the BEmONC signal functions31 in these puskesmas was a cause of concern (Figure 2.8). For example, while 93 percent of the puskesmas providing BEmONC services gave a uterotonic drug in case a woman develops PPH,

removal of retained products was offered in only 48 percent of such BEmONC puskesmas, which means that if PPH is due to retained placental fragments, the required management would not be available in over one-half (52 percent) of the BEmONC puskesmas. Emergency care services which were the most conspicuous by their absence were administration of corticosteroids to the mother in preterm labor (17 percent) and provision of injectable antibiotics to a child with neonatal sepsis (12 percent). The administration of corticosteroids is a relatively new recommendation from WHO and is not yet part of the national guidelines on obstetric care. Unlike normal delivery care, there was an urban-rural difference in the availability of various elements of BEmONC, which varied across these elements.

51%

93%

73%

84%

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57%

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Parenteral administration of antibiotics(IV or IM) for mothers

Parenteral administration of oxytocic fortreatment of post-partum hemorrhage (IV or IM)

Parenteral administration of magnesium sulphate formanagement of preeclampsia and eclampsia (IV or IM)

Manual removal of placenta

Removal of retained products of conception

Neonatal resuscitation with bag and mask

Antibiotics for preterm or prolonged PROM(premature rupture of membranes) to prevent infection

Corticosteroids in preterm labor

KMC (Kangaroo) mother care forpremature/very small babies

Injectable antibiotics for neonatal sepsis

Bimanual compression for post-partum hemorrhage

Rural

Urban

All

30 PONED: Pelayanan Obstetri Neonatal Emergensi Dasar (Basic Emergency Neonatal and Obstetric Service)–puskesmas designated to provide Basic Emergency Obstetric Care services.

31 Signal functions indicate emergency lifesaving management of common obstetric complications.

Figure 2.8 Availability of BEmONC Signal Functions at Puskesmas


17

IMMUNIZATION SERVICESWhile almost all (98 percent) of the sampled puskesmas provided immunization services, only 15 percent of the private facilities did. Within the private network, those registered under the National Health Insurance Agency or BPJS network were more likely to provide these services than other private facilities (28 percent versus 6 percent). Similarly, a greater proportion of multiprovider private facilities were providing immunization services compared to single-provider private facilities (27 percent versus 2 percent).

There was a wide variation in the frequency of immunization sessions within the facilities, from daily to weekly to even monthly; in addition, some facilities did not have a fixed schedule for the sessions (Figure 2.9). About two-thirds of the puskesmas offered the services within their premises at least once a week, including 27 percent of the puskesmas that provide it daily. The urban puskesmas appeared to provide these services

on a more frequent basis, with about 82 percent of the urban puskesmas providing immunization services on a daily or weekly basis compared to 55 percent for rural puskesmas. The frequency of immunization services provided across facilities was very variable. As very few private clinics had immunization services available, the percentages shown in (Figure 2.10) should be interpreted with caution.

Outreach sessions for immunization were primarily organized by puskesmas. Outreach sessions for the puskesmas are typically done through posyandus, which are organized monthly. While almost all the puskesmas held outreach sessions for immunization–almost two-thirds of the puskesmas hold such sessions monthly–less than 15 percent of the private-sector facilities organized such sessions. This is not surprising given that the public sector also focusses on delivery of preventive and promotive programs, for delivery of public goods like immunization, and have a delivery system (through outreach workers) in place for the same.

27%17%

34%29% 29% 25%

40% 65%21% 33% 31%

54%

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All(N=265)

Urban(N=157)

Rural(N=108)

All(N=41)

Urban(N=36)

Rural(N=5)

Puskesmas Private

Daily At least once a week At least once a month Not regular Others

Figure 2.9 Frequency of Immunization Sessions at Puskesmas and Private GPs


18


0 20 40 60 80 100

Japanese encephalitis

Rubella

Rotavirus

Pneumococcus

Measles

DTP-HepB-HiB(Pentravalent)

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Polio SUntik(IPV)

Polio Oral(OPV)

BCG

HepB zero

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RuralUrbanAll

percent

Almost all facilities (99 percent of the puskesmas and 99 percent of the private sector) where immunization services were available provided the basic vaccines that contain the six antigens that are part of the original list of WHO’s Expanded Program on Immunization (EPI) (Figure 2.10). These include Bacillus Calmette-Guérin (BCG), Polio (Bivalent Oral Polio Vaccine - OPV) and Inactivated Polio Vaccine (IPV), Diphtheria-Tetanus-Pertussis (DTP/DPT) and measles. DPT is now incorporated within either the tetravalent (with Hep-B added to the mix) or the pentavalent (HiB also added to the mix) vaccines. Of the two variants, the current survey found that while 96 percent of the puskesmas provided pentavalent, only 44 percent had the tetravalent vaccine. There was no such difference in availability of these two variants in the private sector.

Despite such high availability of basic EPI vaccines through the public health sector, the complete immunization32 rate for children aged 12-23 months was only 66 percent according to IDHS 2012 (Statistics Indonesia et al. 2013). This had increased substantially, however, from only 59 percent in the previous IDHS in 2007. Specifically, the measles vaccination rates for children at one year of age was 80 percent. The

GoI has expanded the immunization program to also include four doses of Hep-B vaccine into the complete immunization package. When Hep-B is also added to the mix in data analysis, complete immunization rates dropped to only 37 percent according to the IDHS 2012 data. The IDHS results pointed out that the real challenge lay in the high drop-out rates between the first and third doses of DPT (from 88 percent to 71 percent) and OPV (91 percent to 75 percent). As many as 8 percent of the children aged 12-23 months had not received any vaccine, which was a cause of concern.

While significantly fewer private-sector facilities had immunization services available, those that did, also provided the newer vaccines like IPV, and vaccines against rotavirus, pneumococcus, rubella and Japanese Encephalitis. In contrast, these vaccines were conspicuous by their near absence from the puskesmas. The limited number of puskesmas where these were available were almost all located in urban areas. This variation between the public and private sector is probably because most of these vaccines (exception for IPV) are not yet included under the national immunization program and have to be paid out of pocket by the clients who wish to avail these services.

32 Complete immunization means that the child has received one dose of BCG, three doses of DPT and OPV and one dose of the measles vaccine.

Figure 2.10 Availability of Different Vaccines (as a Proportion of Those Providing any Immunization Services)


19

Almost all the facilities that provided immunization also counseled clients on the relevant aspects like the potential side-effects and their management, and the follow-up schedule for the next doses (Table 2.2). Depending on the question, there was a variation in spontaneous responses33 - from about one-half to three-quarters of these facilities. The commonest spontaneous response was counseling the parents on the potential side-effects of immunization (76 percent of the public-sector facilities and 83 percent

of the private clinics that offer immunization), and the management of these side-effects. Spontaneous responses on counseling people about the next due date for immunization or the overall benefits of immunization were far less. The rate of spontaneous responses from the public-sector facilities compared to the private sector ones varied from question to question. These apparent differences need to be interpreted with caution, however, because of the significantly fewer numbers of private clinics offering immunization services.

Table 2.2 Counseling Provided With Immunization Services

Information provided during counseling Puskesmas (%) Private (%)

Possible adverse effect of vaccines

Spontaneous 76 83

Promted 22 16

No 2 1

Don’t know 0 1

How to manage side effects at home

Spontaneous 64 73

Promted 36 25

No 0 0

Don’t know 0 1

Next immunization schedule

Spontaneous 52 34

Promted 45 64

No 3 1

Don’t know 0 1

Benefit of immunization

Spontaneous 66 34

Promted 34 65

No 1 1

Don’t know 0 1

Others

Spontaneous 22 15

Promted 6 0

No 71 85

Don’t know 0 0


33 In such questions, a spontaneous response generally reflects a practice that is routinely followed by the respondent/health provider. On the other hand, a prompted response may be something that the provider is knowledgable about but is less likely to practice routinely.

20


CHILD HEALTH SERVICESThe QSDS 2016 showed that all the puskesmas, and more than 90 percent of the private-sector facilities provided some preventive and curative services for children under five years of age (Figure 2.11). There was not much difference in the provision of child care between single providers (90 percent) and multiple provider (93 percent) private clinics, however, there was some difference between those within the BPJS network (96 percent) versus those not in the BPJS network (88 percent). There was wide variation in terms of the spectrum of services available at different facility types (Figure 2.11).

Diarrhea and pneumonia continue to be the primary causes of child morbidity and mortality. According to IDHS 2012, 5 percent of children under five years of age had symptoms suggestive of acute respiratory infection (ARI) in the two weeks preceding the survey. Of those who had these symptoms, 75 percent sought medical help at a health facility or from a health provider, but only 39 percent were given antibiotics as part of the treatment. Similarly, 14 percent of children under five years of age suffered from diarrhea in the two weeks preceding the IDHS 2012 survey, however, only 65 percent of these children were taken to a health facility or provider for care. As part of the

management, almost one-half of mothers had given either prepackaged oral rehydration solution (ORS) or recommended home fluids. While many medicines were also added to the treatment mix, including antibiotics and antimotility drugs, only 1 percent were given zinc supplements along with ORS.

More than 90 percent of puskesmas but only 75 percent of the private-sector facilities that provided child health-related services included services for management of pneumonia, including administration of co-trimoxazole, and management of diarrhea with ORS and Zinc (Figure 2.12). There were fewer facilities offering Zinc supplementation for management of diarrhea compared to those that offer ORS; while the difference was insignificant for the puskesmas–99 percent versus 100 percent–it was slightly higher for the private sector–78 percent versus 85 percent. The numbers suggest that, despite being a relatively new intervention, the inclusion of zinc for the management of diarrhea is now an integral part of public health services and is also widely available from private-sector providers. Despite the almost universal availability, the low utilization of the same by mothers could be a reflection of the lack of knowledge, and its conversion to behavior change, in the caregivers.34

0%

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Pemulihan

Early stimulation,SDITK

Class for mothers ofchildren under five

Nutrition statussurveillance

Child Nutrition Services

Figure 2.11 Spectrum of Child Health Services Available at Puskesmas and Private GP Clinics


34 IDHS 2012 showed that while the knowledge of use of ORS was 94 percent, only 39 percent actually used it.

21

Within the spectrum of childhood diseases, service availability for management of childhood malaria appeared to be a cause of concern. Less than two-thirds (63 percent) of puskesmas and one-third (28 percent) of private-sector facilities, offered management of malaria in children. Within the public sector, there was a wide interdistrict variation in availability of malaria treatment–districts like Tegal provided this service in none of the puskesmas while, in stark contrast, districts like Banjar Baru, Tomohon and Yalimo were providing treatment in all of their puskesmas. This regional difference can probably be attributed to the variable endemicity of the disease.

Child nutrition-related services were almost universally available in the puskesmas. These included counseling on breastfeeding and complementary feeding (MP-ASI)35 (99 percent), weighing the child (99 percent) or providing supplementary food (Pemberian Makanan Tambahan or PMT) for children aged 6-59 months (98 percent). In stark contrast, only one-third (35 percent) of the private-sector facilities offered nutrition services for children under five years of age; among those that did, nonequipment or product-dependent services such as counseling on breastfeeding and complementary feeding were offered by almost all.

According to QSDS 2016, Vitamin A supplementation was provided primarily at puskesmas. Almost all (99 percent) puskesmas offer Vitamin A supplementation services, however, even in the 35 percent of private-sector facilities where nutrition services were available, only 25 percent of them (or 9 percent of total private-sector facilities) provided Vitamin A supplementation. According to the IDHS 2012 data, 61 percent of the children aged 6-59 months had received Vitamin A supplements in the six months preceding the survey.

The QSDS 2016 showed that 15 percent of puskesmas had no nutritionist. Most of the nutritionists that were there had a health-related qualification, such as nursing, midwifery, or public health. Most (83 percent) of the available nutritionists were regular government staff (civil servants), while the remainder were honorary and contractual workers. Similar information is not available for the private sector as the availability of a nutritionist is not mandated for private clinics and was not, therefore, part of the data collection tool for them.

In addition to preventive and curative care, QSDS also enquired about promotive health care activities for growth and development of children, such as the early childhood stimulation (Stimulasi, Deteksi dan Intervensi Dini Tumbuh Kembang or SDITK). The QSDS 2016 showed that SDITK were available in almost all (99 percent) the puskesmas but only one-half (49 percent) of the private-sector facilities providing any child-care services. About three-quarters of the puskesmas also hold “Kelas ibu balita”,36 which are facilitated group discussions for mothers of children under five years of age. In these sessions, mothers share their experiences and opinions related to child care, health-service utilization, child nutrition, early childhood stimulation and overall growth and development of the child. These classes are facilitated by the village Kader or the midwife. Concomitant data is not available for the private clinics as no such classes are mandated for the private sector.

35 MP-ASI: Makanan Pendamping- Air Susu Ibu (Complementary feeding – breastfeeding).36 Kelas ibu balita (bawah lima tahun): (Class for mothers of children below five years of age).

22


MALARIA Indonesia is characterized by complex malaria epidemiology with more than 21 confirmed mosquito vectors of malaria and five Plasmodia species commonly infecting humans (WHO 2013). Malaria transmission in Indonesia is unsurprisingly highly variable as well, including across and within districts. Consequently, the National Malaria Program needs to be designed to address these complexities. Over the decade to 2016, the MoH has made a concerted effort to collect district-wide malaria data for the entire country. Table 2.3 summarizes these data for three broad regions of the country: (i) Java and Bali; (ii) Sumatra, Kalimantan and Sulawesi; and (iii) Eastern Indonesia, including East Nusa Tenggara, Maluku, and Tanah Papua. These regions roughly correspond to areas of the country in the WHO-defined stages of malaria elimination, pre-elimination, and control.

Communicable Diseases

Five of Indonesia’s 34 provinces–Papua, West Papua, East Nusa Tenggara, Maluku and North Maluku–have only 8 percent of the country’s population but 70 percent of its malaria cases. Most of the districts with sustained high transmission of malaria are located in this part of the country. Much of the region also happens to fall in the Australasian biogeographic zone which has more anthropophilic malaria vectors than elsewhere in Indonesia. Together with higher relative poverty, this leads to the high levels of malaria transmission.

Table 2.3 Distribution of Annual Parasite Index (API) (by Provinces and Districts) (2016)

API Java-BaliSumatra, Kalimantan, Sulawesi, West Nusa

Tenggara

East Nusa Tenggara,

Maluku, Papua

Number of Provinces/

Districts

Number of Population

Provinces

Eliminated 2 0 0 2 14,477,697 <1 5 22 0 27 232,241,411 1<5 0 0 3 3 8,104,974 >=5 0 0 2 2 4,100,806

Total 7 22 5 34 258,924,888

Districts

Eliminated 113 134 0 247 178,715,165 <1 15 138 13 166 63,653,328 1<5 0 26 34 60 11,681,806 >=5 0 3 38 41 4,874,589

Total 128 301 85 514 258,924,888

Source: Findings shared from the WHO-led Joint Malaria Program Review report, November 2016.

23

In the private sector, availability of malaria-related services was marginally higher in those facilities that were part of the BPJS network (31 percent) compared to those that were not (26 percent), however, significant interdistrict variation in service availability was noted (Figure 2.12). Of the 22 districts that were included in the national sample for QSDS 2016, 14 districts had some malaria-related services available in all the puskesmas of their district. Another five districts had these services in 63 percent to 92 percent of their puskesmas, however, there were three districts where less than one-half of the puskesmas were providing these services–that is, Pasuruan (50 percent), Cilegon (13 percent) and Tangerang (0 percent), all of which are nonendemic for malaria. It was interesting to note that, while none of the puskesmas in Tangerang stated having services for diagnosis or treatment of malaria, 35 percent of the same facilities reported availability of malaria treatment for children under five years of age. Overall, availability of malaria services for adults and for children under the age of five years at the puskesmas was 88 percent and 63 percent, respectively.

Puskesmas and private-sector facilities used different methods to diagnose malaria. While the puskesmas used both clinical symptoms (78 percent) and the results of laboratory tests like microscopic examination of peripheral smear of blood (73 percent) and rapid diagnostic tests or RDT (54 percent) for diagnosis, the private sector relied almost exclusively on clinical symptoms (94 percent) to diagnose malaria. There was low availability of preventive management of malaria in both puskesmas and private clinics–fewer than one-half (46 percent) of the puskesmas and only one-fifth (20 percent) of the private facilities. The availability of preventive malaria treatment was higher in in rural puskesmas (51 percent) compared to those in urban areas (38 percent).

100%

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Kab. SimeulueKab. Aceh Jaya

Kota LhokseumaweKab. Tapanuli Selatan

Kab. Pesisir SelatanKota Padang

Kab. Indragiri HilirKota Sungai Penuh

Kab. CilacapKab. Semarang

Kota TegalKota Pasuruan

Kota TangerangKota Cilegon

Kota MataramKota Bima

Kab. BanjarKota BanjarmasinKota Banjar Baru

Kota TomohonKab. Merauke

Kab. YalimoAll Puskesmas

Malaria services for children under fiveMalaria Service General

Figure 2.12 Availability of Malaria Services for the General Population (Adults and Children Under Five Years of Age) in Puskesmas Across the Sampled Districts


24


TUBERCULOSIS (TB) Indonesia has the second highest national TB burden in the world. In 2015, WHO estimated an incidence rate of 39537 per 100,000 population which translates to about 1,020,000 TB cases annually, including new and relapse cases (WHO 2017). TB incidence and prevalence are, however, estimated to be falling at a rate of 1 percent and 2 percent per year respectively (Figure 2.13).

Almost all the puskesmas offered TB-related services (Figure 2.14)–the two puskesmas that did not offer these services cited lack of trained staff as the reason. The services included diagnosis of the disease (89 percent) (passive case detection using microscopy, diagnostic kits like Mantoux test and physical examination of the patient presenting with suspicious symptoms), prescribing antitubercular drugs (99 percent), and providing supervised administration of the medicines to patients (96 percent) (Directly Observed Treatment Short-course or DOTS). The puskesmas also offered active follow-up of the patients, including home visits, especially for defaulters (97 percent). While there was no urban-rural difference in the provision of treatment, including DOTS, urban puskesmas were more likely to offer diagnostic services compared to rural ones (94 percent versus 85 percent).

In addition to patients who present to the facility with symptoms, the program also calls for “active case detection”, which is a key strategy to meet the case detection rate goals (70 percent of estimated new smear-positive cases) set by WHO. Active case detection for TB was primarily carried out by the puskesmas (86 percent) and by very few private-sector clinics (21 percent). The puskesmas facilities that conducted active case detection relied on the services of the TB kaders as well as other health facilities and even NGOs for this purpose.

Figure 2.13 Trend of TB Incidence in Indonesia

Source: WHO-led Joint External Monitoring Mission’s Indonesia TB Program report, January 2017.

37 A 95 percent confidence interval (CI) is 255-564 per 100,000 population (or 658,000-1,450,000 TB cases annually).

1990 1995 2000 2005 2010

0

400

200

Incidence, all forms

600

Notified, all forms

Incidence, HIV+

Rate per100,000/year

25

Availability and quality of care for TB management in the private-sector clinics was a cause for concern. Only one-half (49 percent) of the private-sector GPs provided TB-related services (Figure 2.14). Even among those that did, the modality for diagnosis was questionable, as less than one-third (27 percent) of the facilities used examination and tests to finalize the diagnosis–90 percent of the private clinics based their diagnosis on clinical symptoms, and only two-thirds used sputum microscopy. This was in stark contrast to the puskesmas where more than 90 percent of the facilities used microscopy to diagnose TB. The puskesmas that did not offer sputum microscopy cited patient-related issues (like refusal for diagnosis), whereas the private sector cited the absence of laboratory facilities as the primary reason for not offering diagnostic tests for TB.

While almost 85 percent of the private-sector facilities give prescriptions for TB patients, fewer than one-half of them (43 percent) offered DOTS (Figure 2.14). In addition, only one-quarter (26 percent) offered follow-up services, presumably because of a lack of outreach staff cadres. In the absence of DOTS and patient follow-up, compliance with treatment can become one of the big challenges to complete successful treatment. Many of the private-sector clinics did not follow the recommended fixed-dose combination (FDC) for TB. Almost all puskesmas provided FDCs for TB treatment, compared to about one-third (38 percent) of the private-sector facilities that provide TB management. Combined with the low rates of DOTS, this can have adverse effects on treatment efficacy rates for patients receiving care from the private clinics.

0% 20% 40% 60% 80% 100%

86%

97%

96%

99%

89%

21%

26%

43%

85%

27%

Active TB case detection

Treatment follow-up (home visit,monitoring) for TB patients

DOTS for TB patients on treatment

Prescription of TB treatment

TB examination and TB diagnostic test

Spectrum of TB Related Services

Private Puskesmas

0%

20%

40%

60%

80%

100%

TB services

Facility Offer TB Services

Puskesmas Private

Figure 2.14 TB Diagnosis, Management and Referral Services Available in Puskesmas and Private Clinics


26


0%20%40%60%80%

100%

Counseling to all pregnantwomen on reproductive health,

STI, and HIV

HIV counseling and testingservices to pregnant women

Provide ARV as treatment forHIV positive pregnant women

Provide ARV prophylaxis forneonates of HIV positive

pregnant women

Nutritional counseling for HIVpositive pregnant women and

their infants

Family planning counseling toHIV positive pregnant women

Spectrum of PMTCT Related Services

Puskesmas Private

54%

19%

0%

20%

40%

60%

80%

100%

Preventing mother-to-child transmission(PMTCT)

Facility Offer PMTCT Services

Puskesmas Private

Figure 2.15 Spectrum of PMTCT Services Available at Puskesmas and Private GP Clinics


HIV PREVENTION OF MOTHER-TO-CHILD TRANSMISSION (PMTCT)PMTCT-related services for HIV were available in only about one-half (54 percent) of the puskesmas and one-fifth (19 percent) of the private-sector facilities (Figure 2.15). Provision of PMTCT services usually requires additional equipment (for laboratory testing) and medicines (antiretroviral therapy/ART), and those that did not offer these services cited various supply-side deficiencies such as the lack of necessary infrastructure, equipment or trained staff for this lack of service provision.

In addition to supply-side issues, quite a few facilities quoted a lack of demand for this service (“never had a patient ask for these services” was stated as a reason by 20 percent of the puskesmas and 27 percent of the private clinics not providing PMTCT services). Such responses are an indirect reflection of the quality of care being provided in this arena as the national guidelines mandate screening of all pregnant women for HIV, and provision of ART should she be positive, be conducted in all high-risk areas. Providing these tests only when the woman asks for it is not part of the recommended clinical protocol. The fact that only 16 percent of the puskesmas and 24 percent of the private-sector facilities refer all pregnant women to other facilities for HIV counseling and testing (HCT), while most of the others refer only select cases also gives credence to this apparent nonadherence to clinical protocols.

The availability of ART at the primary-care facilities for HIV-positive pregnant women and/or their newborns was dismally low. The proportion of facilities offering various services included under the PMTCT umbrella was variable (Figure 2.15). While counseling for HIV testing was available in almost all the puskesmas that offer PMTCT services, the actual testing for HIV was available in only 70 percent of these puskesmas. ART for both the pregnant women who test positive and their neonates was available in only 18 percent of the puskesmas and in almost none (1 percent) of the private sector clinics offering PMTCT. In fact, the private sector fared much worse than the puskesmas on all the parameters of PMTCT care.

HIV CAREAvailability of HIV-related services was a cause of concern, especially in the private sector. Only about two-thirds of the puskesmas and one-quarter of private-sector clinics offer HIV diagnosis, care and treatment-related services for the general (nonpregnant) population (Figure 2.16). HIV care and support services and special services directed towards target groups–such as a needle exchange program and methadone maintenance therapy for injecting drug users–were provided by even fewer puskesmas. The situation in the private sector was even worse, and the services meant for special target groups were conspicuous by their absence in the private sector.

27

0%10%20%30%40%50%60%70%80%90%

HIV Counseling adntesting services (HCT)

Care Support andTreatment (CST)

PMTCT

Diagnose andtreatment for STI

Needle SyringeProgram (NSP)

MethadoneMaintenance

Therapy (MMT)

Spectrum of HIV Related Services

Puskesmas Private0%

10%

20%

30%

40%

50%

60%

70%

Puskesmas Private

Facility Offer HIV/AIDS Services

Figure 2.16 Spectrum of HIV-related Services Available at Puskesmas and Private GP Clinics


Within the spectrum of HIV care, “general” services like counseling and testing and PMTCT were available in a large proportion of facilities offering HIV care (Figure 2.16). HCT services were available in almost three-quarters (73 percent) of the puskesmas that offered any HIV services. Most of these facilities (86-87 percent) provided both voluntary counseling and testing (VCT) as well as provider-initiated testing and

counseling (PITC). The availability was higher in the urban puskesmas (82 percent) compared to the rural ones (62 percent). In contrast, HCT services were available in very few private-sector facilities (21 percent) and most of these were located in urban areas. Data specific to DKI Jakarta shows that only 4 percent of the private-sector facilities in that area offer any ART services–compared to 26 percent of the puskesmas.

28


The facilities–both puskesmas and private clinics–which did not offer these services referred cases most commonly to the public hospitals that provided HIV services, and sometimes to other puskesmas. In fact, about two-thirds of the puskesmas that offered counseling and testing services had received referrals from other facilities. The fact that: (i) very few (less than 30 percent) of the private-sector clinics that offered HCT services received referrals from other facilities; and (ii) private clinics also referred cases to public hospitals, add to the evidence indicating the relative lack of counseling and testing services in the private sector–probably including private hospitals (Figure 2.17).

As mentioned above, very few facilities offered HIV care and support services, and within these limited numbers too, none of the facilities offered the complete range of services (Figure 2.17). One of the most concerning issues was the relative lack of facilities providing ART–only 10 percent of the puskesmas–and none of the private clinics provided ART. The others referred patients to either public or–at times–private-sector hospitals to receive treatment. This would impact access in terms of both distance and time taken to reach the facility.

0%

20%

40%

60%

80%

100%

Treatment ofopportunistic infections

Provide or prescribetreatment for TB

Prescription ofmicronutrient

supplementation forpeople living

with HIV

Family planningcounseling forpeople living

with HIV

Prescription of ARVfor people living

with HIV

Screening or testingfor TB among people

living with HIV

Provision of malecondoms to prevent

further transmissionof HIV

Nutritionservices

Spectrum HIV-Care Support & Treatment Related Services

Puskesmas Private

0%

20%

40%

60%

80%

100%

HIV/AIDS Care, Support and Treatment services

Facility Offer HIV-Care Support & Treatment Services

Puskesmas Private

Figure 2.17 Availability of HIV Care, Support and Treatment (CST) Services in Puskesmas and Private38 Sector


38 The apparent high proportion of availability of certain HIV CST services in the private clinics is because of the very few private clinics offering any CST services.

29

Figure 2.18 Availability of STI Diagnosis and Management Services in Puskesmas and Private Facilities


52%

67%

38%

43%

19%

51%

93%

92%

93%

94%

100%

93%

All

Urban

Rural

All

Urban

Rural

Pu

skes

mas

Pri

vat

e

Provide or prescribe treatment for STIs available

Diagnosis of STIs that is confirmed by laboratory test available

73%

82%

67% 66%70%

64%

All Urban Rural All Urban Rural

Puskesmas Private

Facility offer sexually transmitted infections (STI) service

SEXUALLY TRANSMITTED INFECTIONS (STIS)According to QSDS 2016, about 73 percent of the puskesmas and 66 percent of the sampled private-sector facilities offered some STI-related services (Figure 2.18). While over 90 percent of these facilities offered treatment services, only about one-half had laboratory-based diagnostic services available. The availability of these laboratory services for STIs was significantly lower in the rural facilities compared to the urban ones, for the puskesmas (38 percent vs. 67 percent) but was the reverse for the private sector (19 percent vs. 51 percent). The availability of treatment in the

absence of a confirmed laboratory-based “diagnosis” indirectly indicates that these health facilities may be following the syndromic management approach for treatment of STIs. These interpretations cannot be generalized across the country, however, because there was a wide interdistrict variation in the availability of these laboratory tests–from the lowest to the highest possible, that is in 0 percent of the sampled facilities in districts like Pesisir Selatan district in West Sumatra to 100 percent of the sampled facilities in districts like Yalimo district in Papua and Banjar Baru in South Kalimantan.

30


Non Communicable Diseases (NCDs)

0%

20%

40%

60%

80%

100%

Diagnosis of type 2 diabetesmelli tus

Diagnosis of cardiovasculardiseases

Diagnosis of chronicrespiratory diseases

Diagnosis of primaryhypertension

Diagnosis of dyslipidemiawithout complication

Prescription of type 2diabetes mellitus treat ment

Prescription ofcardiovascular diseases

treatment

Prescription of chronicrespiratory diseases

treatment

Prescription of primaryhypertension treatment

Prescription of dyslipidemiawithout complication

treatment

Puskesmas Private

Figure 2.19 Availability of Diagnostic and Treatment Services for NCDs in Public and Private-sector Health Facilities


This survey studied the availability of services for the five most common NCDs and conditions. These include three diseases: Type 2 diabetes mellitus (DM), cardiovascular diseases (CVDs), and chronic respiratory diseases (CRDs) as well as two risk factors–hypertension and dyslipidemia–the presence of which predisposes the patient to other NCDs, most notably CVDs. National health programs, including standards and protocols, are available for the management of NCDs.

Diagnostic service availability for DM and hypertension was almost universal (96-99 percent of the facilities) with negligible difference between the availability rates in the puskesmas and the private sector (Figure 2.19). There was no significant difference between the private rural and urban facilities, however there was a relative lack of services (67-81 percent

of the facilities) for the diagnosis of the other three conditions that were enquired about. There are two plausible explanations for this. As the rates of DM and hypertension are relatively higher compared to other NCDs, there is a greater focus and monitoring of the health system for provision of these services. Additionally, the diagnosis of DM and hypertension does not need the availability of a skilled doctor and can be provided by a laboratory technician and/or nursing staff in a health facility. In contrast, conditions like CVD and CRDs need examination by a qualified doctor, while that for dyslipidemia needs advanced laboratory equipment.

The proportion of facilities providing treatment and/or prescribing medicines for the management of the five NCDs was variable. The management of DM was available in over 90 percent of the facilities in both the public and private sector, while treatment for CVDs was available in only 73 percent of the puskesmas and 80 percent of the private clinics. This is probably a reflection of the high priority accorded to addressing DM and hypertension in MoH’s strategic plan.

31

Service Readiness

Health service readiness is the measure of the ability of a facility to provide general and specific health services (WHO 2013).

32


General service readiness refers to the capability of the health facility to provide any health services and is measured in terms of availability of basic amenities, basic equipment, standard precautions for infection prevention, diagnostic capacity and essential medicines.

General Services

COMMUNICATIONSThe puskesmas were found to be lacking in availability of the means of communication–such as telephones and radios. A health facility needs communication systems to interact with patients and other beneficiaries, other health facilities as well as the health administration system (such as the district health office – DHO) to be able to function optimally. While communication services are needed for multiple purposes, one key area that it impacts is referral, as prior information to a facility can facilitate better preparedness to receive and treat emergency cases without delay. The sampled facilities were asked about the availability of various communication means such as a telephone (landline and/or cellular) and/or a radio39 for this purpose. The most common means of communication available for puskesmas was the landline phone, but even this

was available in less than one-half (46 percent) of the facilities, followed by the cell phone (29 percent) and the radio (12 percent) (Figure 3.1). In comparison, the availability of cellular mobile phones was far higher in private-sector clinics (69 percent), while landline phone availability was similar to that of the puskesmas (43 percent).

There was a wide interdistrict variation in the availability of communication in puskesmas. In six of the 22 sampled cities and districts, only one-third or fewer puskesmas had any means of communication40, with none of the sampled puskesmas in Simeulue district having a telephone or a radio within their premises. In contrast, there were six other cities and districts where all the sampled puskesmas had at least some means of communication.

46%

23%

79%

43%

25%

47%

29% 28% 29%

69%

79%

67%

12% 15%7%

2%6%

1%

All Rural Urban All Rural Urban

Puskesmas Private GP/Clinic

Type of Facility

Land lineCellular phoneShort-wave radio

Figure 3.1 Availability of Communication Services at Puskesmas and Private-sector Facilities


39 The “radio” refers to a short-wave radio to make radio calls.40 Refers to a telephone or a radio that belonged to the puskesmas and was not the private property of any staff member.

33

Puskesmas in urban areas were almost twice as likely to have communications systems compared to those in rural areas. For example, while 88 percent of the urban puskesmas had some means of communication, less than one-half (49 percent) of the rural ones did (Appendix 5A). The primary difference was in the availability of a landline telephone, wherein only 23 percent of the rural puskesmas had a landline phone compared to 79 percent of the urban facilities. The cell phone penetration was almost similar (28 percent and 29 percent respectively) (Figure 3.1). The rural facilities, in contrast, depended more than the urban ones on radios to communicate. A similar trend was seen with the private-sector facilities too.

Unlike the private sector, computer availability was almost universal in the puskesmas. Computers allow for communication through emails, maintain the facility-related records in a soft format, and use different applications and information systems to transmit information. Almost all the puskesmas (98 percent) had a computer at the facility, however, significantly fewer (68 percent) private-sector clinics have this facility. There was no major difference between urban and rural areas for both puskesmas and private sector. There was, however, a difference between a private-sector facility that is part of the BPJS network (97 percent) compared to those not in the BPJS network (46 percent).

Of those having a computer, only 82 percent of the puskesmas and 86 percent of the private-sector facilities had access to emails or Internet. While almost all (99 percent) urban puskesmas had access to the Internet, only about two-thirds (68 percent) of the rural puskesmas did. While there was no significant urban-rural difference in Internet availability for the private-sector facilities, almost all facilities (97 percent) that were part of the BPJS network had Internet access compared to only about half (46 percent) of those facilities that were not part of the BPJS network (Appendix 5, Part A). The difference in computer and Internet availability between the public and the private sector as well as the BPJS-empaneled private and the nonBPJS-empaneled private facilities can be explained by the different incentives and requirements for data recording and sharing by these facility types.

REFERRAL TRANSPORTPHC facilities often offer not just routine health care, but also basic management of emergencies. For definitive management of emergencies and other complications, patients need to be referred to secondary- or tertiary-care facilities. Time to care is of essence here, and delay in reaching the appropriate facility is one of the biggest causes of mortality. Every primary care facility, therefore, needs functional referral services, including the availability of a vehicle for this purpose.

Most of the puskesmas (as many as 93 percent) had access to their own emergency transport (referral) vehicle. Of these, the majority (98 percent) were four-wheeled vehicles, which is the ideal form of emergency transportation, although a few also had motorbikes (18 percent), and motor boats (1 percent). Almost all (98 percent) of the puskesmas also had fuel for their transport vehicles/s. There was no significant difference between rural puskesmas (90 percent) and urban puskesmas (98 percent) in vehicle access. Besides their own vehicles, 42 percent of the puskesmas also had access to emergency transportation vehicles stationed at nearby facilities.

In contrast, only one-third (31 percent) of the private sector facilities had their own functional emergency transportation. About one-half (48 percent) of the private-sector facilities shared access to vehicles owned by nearby health facilities. Among those facilities that had their own vehicle, the most common vehicle available was a four-wheeled vehicle (27 percent), followed by motorbikes (14 percent). Almost all (96 percent) private-sector facilities had fuel to run the same. Within the private sector, single doctor run clinics were far less likely to own an emergency transport vehicle (14 percent) compared to those with multiple practitioners (46 percent). Rural private facilities were more likely to have an ambulance than an urban one (43 percent versus 30 percent); there was almost no difference between those in the BPJS network (33 percent) versus those who were not (30 percent).

34


ELECTRICITY SUPPLYAll the facilities, both puskesmas and private, had an electricity supply (except one puskesmas in district Tapanuli Selatan, North Sumatra). Almost all (97 percent) of the puskesmas used the electricity supply to fulfil all the electrical needs of the facility, be it for general lighting, to power medical devices or to maintain the cold chain. This proportion is less for the private sector, where only 86 percent of the facilities used the power supply to provide for all electricity needs of the facility.

Almost all the private-sector facilities (99 percent) and the majority (95 percent) of the puskesmas received their supply from the central source (government supply) (Figure 3.2). Among the very few that relied on alternate sources such as generators or solar panels for their primary source of electricity, it was largely the puskesmas in the rural areas. Nearly three-quarters (72 percent) of the puskesmas and about one-half (53 percent) of the private-sector clinics also had a secondary source of electricity as back-up. The most common back-up source was a battery or fuel-run generator. Almost 96 percent of these generators were found to be functional, and most had ready fuel or a functional battery to run them.

In a large proportion (about four-fifths) of both puskesmas and private clinics, the electricity supply was without any interruption. Less than 10 percent of facilities, puskesmas or private, had frequent prolonged interruptions (more than two hours a day) to the electricity supply. A slightly greater proportion of rural facilities, both for the puskesmas and private facilities, cited prolonged interruptions than their urban counterparts (11 percent versus 6 percent for puskesmas, respectively).

WATER, SANITATION AND HYGIENEMore than 90 percent of the facilities, puskesmas and private, had a water supply from an “improved water source”. Water supply is essential at any medical facility–not only for drinking but also for sanitation and cleaning purposes. There were only three of the total 557 sampled facilities that did not have any water supply in the facility, one puskesmas and two private-sector clinics.

Primary Secondary Primary Secondary

Puskesmas Private clinic/doctor

No Secondary

25%47%

Others

1%

Solar system

2%

1%

1%

Generator

2%

71%

1%

52%Central supply of electricity (e.g. PLN)

95%

4%

99%

1%

Figure 3.2 Source of Primary and Secondary Electricity Supply in the Sampled Facilities

Source: Indonesia QSDS 2016.Note: Due to rounding errors, the breakdown may not total to 100%.

35

While a piped water supply into the facility was the commonest source of water (42 percent and 47 percent of the puskesmas and private facilities respectively), a significant proportion also relied on tube-wells, bore-wells or covered dug-wells for their water (Figure 3.3). Of the various water sources, 63 percent of the puskesmas had this source within the facility itself, while in another 28 percent puskesmas, the water source was within the facility premises. The water source was outside the facility premises for 9 percent of puskesmas and 7 percent of the private-sector facilities. The reasons cited by these facilities was that the available quality of water was bad or that there was an insufficient supply. Such facilities then used water from sources found in the neighborhood.

Almost all sampled facilities, puskesmas and private, also had a functioning toilet for the patients attending the OPD. The proportion was slightly less in the private sector compared to the puskesmas (92 percent vs. 97 percent), and within the private sector, it was the single GP run clinics that were the least likely to have toilets (only 84 percent). Most of the private-sector facilities that did not have their own toilets had their patients/clients use the services in nearby facilities or houses.

Puskesmas

Not improved Piped into facilityPiped onto facility grounds Public tap/standpipeTubewell/borehole Protected dug well

Protected spring

Private Clinic/Doctor

Not improvedPiped into facility

Piped onto facility groundsPublic tap/standpipe

2%

1%

7% 93%

42%

25%

19%

4%

2%

47%

4%

1%30%

13%

4%98%

Figure 3.3 Source of Water Supply for the Sampled Puskesmas and Private-sector Facilities


36


PRIVACYIt is a cause of concern that almost half (48 percent) of the puskesmas did not have any room that offered any privacy for the health provider-client interactions. Visual and auditory privacy in a health facility is essential to not only allow the patient the comfort of discussing his/her problems with the health provider, and be examined in complete privacy, but also to ensure that confidentiality is maintained. Rural puskesmas were twice (60 percent) as likely to have no privacy compared to urban ones (31 percent). Comparatively, only one-fifth (19 percent) of private facilities did not have any privacy, although urban private clinics were again twice as likely to not have privacy compared to rural clinics (29 percent versus 16 percent). Only one-quarter (25 percent) of the

puskesmas, but more than one-half (54 percent) of the private-sector clinics had rooms or consulting chambers that permitted both auditory and visual privacy (Figure 3.4).

INFECTION PREVENTION AND WASTE DISPOSALOnly about one-quarter of the facilities (26 percent of private clinics and 29 percent of puskesmas) met all the criteria regarding infection prevention and waste disposal. Infection prevention is key to patient and health worker safety as it helps prevent nosocomial (health facility acquired) infections. Figure 3.5 shows the gaps in both puskesmas and private facilities in terms of infection prevention and waste management equipment, systems and supplies.

87%

78%

86%

89%

44%

85%

95%

90%

95%

64%

87%

88%

62%

49%

77%

86%

89%

86%

Sterillizer

Safe final disposal or sharps

Safe final disposal or infectious wastes

Appropriate storage of sharps waste

Appropriate storage of infection waste

Disinfectant

Single use of standard disposable syringe

Soap and running water or alcohol based…

Latex gloves

Equ

ipm

ent

Supp

lies

Percentage of Facility

Sta

nd

ard

Pre

cau

tion

Com

pon

ent

PrivatePublic

Figure 3.5 Availability of Infection Prevention-related Equipment and Supplies at Sampled Puskesmas and Private-sector Facilities


Auditoryonly (2%)

Visual only (25%)

BothAuditory & Visual

(25%)

Auditoryonly (0%)

Visual only (28%)

BothAuditory & Visual

(54%)

Figure 3.4 Privacy in Consulting Rooms in Sampled Puskesmas and Private-sector Facilities


37

Sharps waste Medical waste Sharps waste Medical waste


1%8% 5%

7%2%

1%

51%

34%

77%

56%

1%1%

2%

1%1%

2%

3%

8%7%

3%

2%

1%2%

1%

1%4%

5%

2%

1%11%

25%

3%

11%4%

17%

2%10%9% 7%

2%1%

Never have

Others

Have the third party

Stored unprotected

Stored in other protected environment

Stored in covered container

Protected ground or pit

Open-pit - no protection

Covered pit or pit latrine

Pit or protected ground

Flat ground - no protection

1-chamber drum/brick

2-chamber industrial (800-1000+° C)3% 1% 1%

Figure 3.6 Waste Disposal Methods Used by Sampled Puskesmas and Private GP Clinics


At least one item of sterilizing equipment was available in 87 percent and 64 percent of the puskesmas and private-sector facilities respectively. The most common equipment in both these places was the electric dry heat sterilizer, while the electric autoclave, that uses both heat and pressure to sterilize equipment, and is considered the best of all sterilization equipment, was hardly seen in the sampled facilities. The various supplies required for direct patient care such as running water and soap (or disinfectant) to clean hands, latex gloves, or disposable syringes were generally available in over 80 percent of the facilities. Even this seemingly minimal gap is a cause of concern, however, as lack of infection control can lead to adverse and even fatal patient outcomes. The puskesmas were slightly better equipped than the private-sector facilities for these supplies.

Inappropriate storage of biomedical waste is a cause of concern. Appropriate storage of infectious waste (in a plastic-lined waste receptacle) was available in less than one-half the sampled facilities whether in the puskesmas or the private sector. The sharps box for storage of sharp waste was available in 89 percent of the puskesmas but in only 62 percent of the private-sector facilities respectively (Figure 3.5).

In contrast to storage of waste, the facilities performed well in terms of final disposal of these wastes (Figure 3.6). More than one-half (51 percent) of the puskesmas and three-quarters (77 percent) of the private-sector clinics used the services of a third-party professional waste management agency for final disposal of the sharps-related waste; the second most common disposal method for puskesmas (11 percent) was burying their used sharps in a pit or covered ground. The use of third-party services for nonsharps medical waste was much less common–with only about one-third (34 percent) of the puskesmas and just over one-half (56 percent) of the private-sector facilities using their services. The facilities that did not use these services appear to dispose their waste on the ground, with about one-fifth (18 percent) of the puskesmas not even covering the ground or pit that contained these medical wastes. More than three-quarters of the puskesmas and about one-half of the private-sector clinics had infection-prevention guidelines available at the facility.

38


95%

85%

93%

87%

86%

97%

59%

67%

56%

81%

79%

94%

Adult scale

Child scale

Infant scale

Thermometer

Stethoscope

Blood pressure apparatus

Light source

PrivatePublic

Figure 3.7 Availability of Basic Medical Equipment in Puskesmas and Private-sector Facilities


EQUIPMENT Basic health equipment like sphygmomanometer (blood pressure apparatus), stethoscope, oxygen cylinder, and intravenous (IV) infusion kits, amongst others, was available in most of the puskesmas (Figure 3.7). The availability of this equipment was slightly less in the private sector. For emergency management-related equipment–like IV kits and oxygen cylinders, the private sector lagged the puskesmas significantly. Compared to the puskesmas, very few (56 percent vs. 93 percent) private-sector facilities had the infant weighing scale available in their premises. X-ray view boxes and ophthalmic equipment like ophthalmoscope or the tonometer were available in very few facilities, whether the puskesmas or the private sector. One possible reason is that these are more frequently used by specialists and their skills may not be available with the generalist health-care providers at the primary-care facilities.

MEDICINES The SARA guidelines list 20 essential medicines, the availability of which is used to assess the readiness of the facilities for provision of general services (Appendix 2). It includes antibiotics, steroids, anti-inflammatory drugs, ORS and zinc for diarrhea management, anti-hypertensives, and drugs for diabetes and for management of asthma. The private clinics were asked about the availability of very few as these clinics are required to keep only emergency or lifesaving drugs, while the others can simply be prescribed by the practitioner and the patient can purchase the same from a pharmacy.

39

Figure 3.8 Availability of Basic Medicines in Puskesmas and Private GP Clinics


86%

97%

97%

33%

42%

43%

34%

79%

94%

70%

85%

82%

88%

67%

67%

13%

23%

44%

Amlodipine tablet

Amoxicillin syrup

Amoxicillin tablet

Ampicillin powder for injection

Aspirin cap/tab

Beta blocker

Ceftriaxone injection

Diazepam injection

Enalapril tablet or alternative ACE…

Magnesium sulphate injection

Metformin tablet

Simvastatin tablet

Zinc sulphate tablets

PrivatePuskesmas

82%

80%

74%

74%

79%

38%

20%

83%

25%

66%

16%

21%

46%

Hemoglobin

Blood Glucose

Malaria diagnostic capacity

Urine dipstick-protein

Urine disptick-glucose

HIV diagnostic capacity(RDT kit)

Syphilis rapid test

Urine test for pregnancy

Private

Public

Figure 3.9 Availability (on-site) of Common Diagnostic Tests in Puskesmas and Private GP Clinics

Source: Indonesia QSDS 2016.Note: Syphilis rapid test, HIV diagnostic capacity and malaria were not asked for in private facilities.

The availability of essential medicines was very variable across drug types (Figure 3.8). While basic antibiotics were readily available, higher-end ones like ceftriaxone were available in less than 40 percent of the puskesmas. Most of the drugs for NCDs were also relatively readily available; their availability matches the availability of diagnostic and treatment services for NCDs (Figure 2.21). As expected, the availability of drugs in the private clinics was far less than in the puskesmas.

DIAGNOSTICS As is the case with medicines, SARA guidelines also list about eight diagnostic tests as part of the assessment for general service readiness (Appendix 2).

Most of the puskesmas offered a wide variety of diagnostic services. Some of the infrequently used tests like rapid diagnostic tests for syphilis or for HIV were, however, less commonly available (Figure 3.9). The figure also shows a significant difference between the puskesmas and the private sector for all the laboratory tests, with the private sector lagging in terms of provision of these services.

40


While 91 percent of the puskesmas had a diagnostic laboratory within their premises, only 39 percent of the private-sector facilities did. Private facilities that are part of the BPJS network were more diagnostic “ready” than those that were not (47 percent versus 33 percent). There is not much difference between rural and urban puskesmas (88 percent vs. 96 percent) or between rural and urban private-sector facilities (38 percent versus 40 percent).

A large proportion of the private-sector clinics did not offer basic laboratory tests (Figure 3.10). Among those that did, many basically acted as sample collection centers, and the laboratory was

located outside the facility (off-site). Most of the tests offered by a greater proportion of private clinics–such as blood glucose using a glucometer or urine tests using dipsticks–are those that do not need a sophisticated laboratory set-up but can easily be done in an outpatient setting. This is linked to the fact that most of the private clinics, unlike the puskesmas, did not have an in-house laboratory. In contrast, a much greater proportion of the puskesmas offered a wider variety of tests and most of the tests were conducted within the facility (on-site). The management of a laboratory requires space, equipment and human resources, many of which may be outside the budgetary and management capacities of private clinics–even more so for the single-provider ones.

Figure 3.10 Diagnostic Tests Conducted (On- or Off-site) at Puskesmas and Private-sector Clinics


93%

83%

79%

50%

86%

90%

47%

48%

47%

96%

16%

16%

17%

15%

2%

2%

1%

1%

1%

1%

2%

2%

1%

0%

1%

1%

1%

1%

5%

16%

20%

49%

14%

9%

51%

50%

52%

4%

83%

83%

82%

84%

Urine rapid tests for pregnancy (PP test)

Urine protein dipstick testing

Urine glucose dipstick testing

Urine ketone dipstick testing

Blood glucose tests using a glucometer

Hemoglobin testing

White blood cell testing

Thrombocyte testing

General microscopy/wet-mounts

Cholesterol test

Liver function SGOT test

Liver function SGPT test

Renal function ureum test

Renal function creatinin test

Puskesmas

On-site Off-site No

60%

21%

21%

15%

78%

31%

13%

14%

8%

73%

12%

12%

12%

12%

3%

8%

8%

9%

3%

7%

8%

8%

6%

4%

8%

8%

9%

8%

38%

71%

71%

77%

20%

62%

79%

78%

86%

23%

80%

80%

80%

80%

Private Clinic/GP

96%

88%

91%

Urban Rural All

Availability of On-site Diagnostic Capacity at Puskesmas

40% 38%

47%

33%

39%

Urban Rural BPJS Non-BPJS All

Availability of On-site Diagnostic Capacity at Private Clinic/GP

41

There are four broad themes against which service readiness was assessed: (i) (trained) staff and guidelines; (ii) equipment; (iii) diagnostics; and (iv) medicines and commodities (Appendix 3).

Specific Services

STAFF TRAINING AND GUIDELINESPuskesmas were significantly more likely to have the technical guidelines available in the facilities compared to the private sector. Technical guidelines are one way of ensuring quality of services as they list standard management protocols based on most recent evidence. For almost all the thematic areas, the puskesmas were more likely than private-sector facilities to have the guidelines available at the facility (Table 3.1). The probable reason is because the government publishes these guidelines and is mandated to share those with the puskesmas.

Between the various special services, the puskesmas were more likely to have reproductive, maternal, neonatal and child health (RMNCH) related guidelines compared to ones for communicable diseases and

NCDs (Table 3.1). It should be noted that for some guidelines, such as TB, the figure is the “average” score reflecting the availability of two or more guidelines. For example, almost one-half of the puskesmas (48 percent) had the TB diagnosis and treatment guidelines available on the day of the survey, but only 17 percent had the national guidelines for HIV and TB coinfection–thus reducing the “average” availability rate for the TB guidelines to just about one-third of the facilities.

Staff at the puskesmas were also more likely than the private-facility staff to be trained in the RMNCH and communicable diseases arena (Table 3.1). The gap between the puskesmas and the private sector reduces, to some extent, for NCDs. The one exception where a greater proportion of the private-sector staff appears to be trained is HIV treatment, however, this is misleading because of inadequate sample size. There were only three private-sector facilities offering these services in this sample, the staff in two of which were trained.

EQUIPMENT FOR SPECIFIC SERVICESEquipment availability for most specific services was close to 90 percent for most thematic areas, in both puskesmas and private

Table 3.1 Specific Services Readiness of Puskesmas and Private Facilities (Availability of Guidelines and Status of Staff Training)

THEMATIC AREAGuidelines Training in Last 2 Years

Puskesmas Private Puskesmas PrivateFamily Planning 61% 82%ANC 97% 88%Basic Obstetric and Newborn Care 61%44 82%45

Immunization 69% 34% 76% 47%

Child Health 75%46 27%49 63%49 17%49

Malaria 42%47 18% 50 55% 48 7%51

Tuberculosis49 48%50 | 44%51 14% 49%64 | 43%65 19%HCT 29% 5% 68% 31%HIV CST 18% 0% 50% 77%HIV/AIDS ART Prescriptions & Client Management 33% n.a 53% n.a.HIV/AIDS PMTCT 45% 19% 56% 29%STIs 29% 20% 35% 12%Diabetes 50% 33% 65% 49%CVDs 50% 32% 64% 47%CRDs 51% 28% 64% 43%

Source: Indonesia QSDS 2016.Note: Blue boxes indicate that data for this indicator did not emerge from QSDS due to sampling or other issues.

42


44 The SARA guidelines refer to two types of guidelines in this indicator–essential childbirth care and essential newborn care. In QSDS, three guidelines were asked for–on essential newborn care, a pocketbook on maternal health care in primary and referral health facilities and any other obstetric and newborn care guidelines. This proportion reflects the number that had any of the three.

45 The SARA guidelines refer to two types of training in this indicator–essential childbirth care and essential newborn care. In QSDS, four trainings were asked for–on assisted vaginal delivery, on BEmONC, on management of newborn asphyxiation, and any other training on obstetric and newborn care.

46 The SARA guidelines refer to two guidelines and training under child health–IMNCI (Integrated Management of Neonatal and Childhood Illness) and growth monitoring. The QSDS had questions related to the IMNCI guideline and training only.

47 The QSDS asked for only one guideline in this domain–guideline for diagnosis and treatment of malaria.48 The public and private sector figures are not strictly comparable under this indicator. The data for the puskesmas represents the

average for two trainings–one on diagnosis and treatment of malaria, and the second one on Intermittent Preventive Treatment (IPT); the private-sector figure captures only the first one.

49 The QSDS asked for three trainings on TB–value average from two trainings which are diagnosis and management of TB, and management and treatment of MDR-TB.

50 Puskesmas with status Referral and Independent Laboratory.51 Puskesmas with status Satellite.52 Average from two guidelines: PMTCT and Infant and Young Child Feeding (IYCF).

86% 86%

74%

87%

79%74%

67%

20%

35%

23%

Childweighing

scale

Heightmeasurement

tape/Microtoise

Lengthmeasurement

board

MUACmeasuring

tape

Growthcharts

PublicPrivate

facilities (Table 3.2). Maintenance of cold-chain immunization services in the private sector was a cause of concern as an ineffective cold chain can lead to rapid degradation of vaccine potency and efficacy. While most (90 percent) of the private facilities offering vaccines in their services had refrigerators, only two-thirds (65 percent) had vaccine carriers with ice packs. The probable reason for this could be relative lack of need for this because of low rates of outreach immunization sessions in these facilities which is where the carrier is required. The real concern, however, was the lack of care in ensuring the temperature of the refrigerators. About one-half (53 percent) of the private facilities had thermometers in their refrigerators, and only 42 percent of the refrigerators in the private clinics had maintained correct temperature for storage of vaccines.

A low proportion of puskesmas (69 percent) and private-sector facilities (56 percent) had auto-disable (AD) syringes. While AD syringes are not essential to ensure infection prevention (and even disposable syringes with disposable needles are good enough), AD syringes help to reduce repeat use which is sometimes seen even with the disposable syringes and needles.

The private sector lacked equipment needed for anthropometric measurements, especially for infants and younger children (Figure 3.11). For example, while three-quarters (74 percent) of private-sector facilities had weighing scales for children, only 61 percent of the clinics had the infant weighing scale. Similarly, while two-thirds (67 percent) had a measuring tape or stadiometer to measure the height (standing up) of the child, only

Figure 3.11 Availability of Anthropometry-related Equipment in Puskesmas and Private GP Clinics Offering Child Health Care Services


43

Table 3.2 Specific Services Readiness of Puskesmas and Private Facilities (Availability of Equipment)

THEMATIC AREAMean Availability For All

Equipment (Domain Score)Proportion of Facilities With

All Equipment Available

Puskesmas Private Puskesmas PrivateFamily Planning 83% 68%ANC 90% 69%Basic Obstetric and Newborn Care 69% 0%Immunization 87%54 67%55 53% 23%

Child Health 77% 55 52%56 17% 3%

Malaria

Tuberculosis HCT 40% 44%HIV CSTHIV/AIDS ART Prescriptions & Client ManagementHIV/AIDS PMTCT 31% 10% 31% 10%STIsDiabetes 93% 56 78% 57 79% 56%CVDs 94% 57 76%58 64% 38%CRDs 51%58 34%59 2% 0%

Source: Indonesia QSDS 2016.Note: Grey boxes indicate that this indicator is absent from the SARA guidelines. Blue boxes indicate that data for this indicator did not emerge from QSDS due to sampling or other issues. Yellow boxes mean that data could not be generated because only one item was measured

53 “Training” here refers to any staff of the facility having received any training on that topic in the two years preceding the survey.54 SARA guidelines mention eight pieces of “equipment” under this indicator. The present data reflects information for only six. The

QSDS did not ask about the availability of immunization cards and immunization tally sheets.55 In calculating this indicator, the weighing scale and the stadiometer (for measuring length/height) have each been included twice–

one for infants and one for older children.56 Includes stethoscope, BP apparatus, adult weighing scale and oxygen. 57 Includes stethoscope, BP apparatus and oxygen.58 Includes peak flow meters and spacers for inhalers.

one-fifth (20 percent) had the equipment to measure the length (lying down) of infants and younger children. One probable reason for this could be that maternity clinics, which are the key centers dealing with newborn and infant care, were not included in the QSDS national sample. In contrast, over three-fourths of the puskesmas had the infant weighing scale and equipment to measure length of infants (95 percent and 74 percent) respectively. Other anthropometry and growth monitoring related equipment like MUAC tapes and growth charts were available in about one-third or less (35 percent and 23 percent) of the private-sector clinics offering child health services, respectively. Even within the private sector, fewer single-provider clinics had the necessary equipment compared to multiple-provider ones.

The lack of auditory and visual privacy for clients seeking HCT services is another cause for concern, in both the puskesmas (available in only 40 percent of facilities) and the private sector (available in only 44 percent of facilities). A lack of privacy has an adverse impact on the quality of counseling services.

While the availability of equipment for diagnosis and management of some NCDs, like diabetes and CVDs, is sufficient, especially in the public sector, there is a shortage of needed equipment for CRDs. Peak flow meters, which are required to diagnose disorders like asthma, were available in only 13 percent and 3 percent of the public and private-sector facilities that were offering NCD coverage respectively. The availability of spacers for inhalers was slightly better–in 33 percent and 23 percent of the puskesmas and private clinics respectively.

44


DIAGNOSTICSThe readiness of the facilities in terms of availability of diagnostics is a weak link. The availability of diagnostic tests does not exceed 90 percent in any thematic area (Table 3.3). In those areas where a battery of diagnostics is required to fulfil the readiness index, such as for STIs, the average rates are much lower.

The private sector fared significantly worse than the public sector in availability of diagnostics (Table 3.3); and within the private sector those managed by single providers were even less diagnostic “ready”. The probable reason for this gap is the measurement standard used by the survey, wherein availability of diagnostics is required within the facility. As mentioned earlier, while 91 percent of the puskesmas have onsite laboratories, only 39 percent of the private clinics do. The situation is worse for single-provider run private

clinics compared to those managed by multiple providers. For example, hemoglobin estimation for children was found in 44 percent of the multiple-provider private clinics that offer child-health services, compared to only 14 percent of the single-provider clinics. The one area where the proportions suggest a better performance by the private sector is for HIV care and support. The high proportions are misleading, however, as the number of private facilities offering CST services is very low.

The low rate of diagnostics for diabetes care in the private sector is mainly due to the lack of availability of dipsticks for protein and ketone testing of urine. The private sector significantly lagged the puskesmas for these two tests (15 percent and 10 percent respectively for the private sector compared to 77 percent and 45 percent for puskesmas).

Table 3.3 Specific Services Readiness of Puskesmas and Private Facilities (Availability of Diagnostics)

THEMATIC AREAMean Availability For All

Diagnostics (Domain Score)Proportion of Facilities With

All Diagnostics Available

Puskesmas Private Puskesmas PrivateFamily PlanningANC 78% 67%Basic Obstetric and Newborn CareImmunization

Child Health 70% 14%59 37% 1%

Malaria 71% 15% 41% 3%Tuberculosis

Puskesmas: Referral and Independent Laboratory 80% 28%Puskesmas: Satellite60 70% 31%61 45% 13%

HCT 89% 9%HIV CST 79% 77%HIV/AIDS ART Prescriptions & Client ManagementHIV/AIDS PMTCT 67% 2%STIs 33% 3% 24% 2%Diabetes 67% 31% 37% 6%CVDsCRDs

Source: Indonesia QSDS 2016.Note: Grey boxes indicate that this indicator is absent from the SARA guidelines. Blue boxes indicate that data for this indicator did not emerge from QSDS due to sampling or other issues. Yellow boxes mean that data could not be generated because only one item was measured

59 Compared to the data for the public sector, this reflects availability of only one diagnostic test–hemoglobin estimation. The public-sector data, on the other hand, also includes two other tests–testing stools for parasites and malaria diagnosis.

60 These facilities offer diagnosis by clinical symptoms, Mantoux test, and provision of drugs to TB patients. 61 Private facilities have been compared to satellite puskesmas as they typically do not have inhouse laboratory facilities, like satellite

puskesmas.

45

Stock-out of RDT kits for various diseases (malaria, syphilis and HIV) was common in both puskesmas and private-sector facilities (Figure 3.12). It should be noted, however, that the number of private-sector facilities offering these tests–especially for syphilis and malaria–were very few (one and six, respectively) and comparisons with the puskesmas should, therefore, be done cautiously.

Stock-outs at the puskesmas generally tended to be for longer durations (>14 days). One of the reasons that the puskesmas gave for this was the inability of the warehouse (national, provincial or district level) to send the needed stocks on time. In some cases, the puskesmas also stated that they received a higher than expected case load of patients leading to stock-out of the test kits.

In contrast, stock-outs at the private clinics were usually for less than a week; and the reason given was that the facility forgot to order the same on a timely manner. These differences suggest that, while the public sector does have a system in place for indent of diagnostics, it is not an efficient one, and suffers from delays. On the other hand, the private sector, while not dependent on external-to-the-facility factors and

institutions, does not have a logistics management information system (LMIS) in place to regularly assess the availability of diagnostics and order replacement stock in a timely manner. By and large, stock availability of diagnostics appears to be better in rural facilities than the urban ones.

MEDICINES AND SUPPLIES MANAGEMENT AND STOCK-OUTSAn LMIS was used by the puskesmas to order resupplies of medicines and commodities. QSDS data shows that in almost two-thirds of the puskesmas, the responsibility for ordering the medicine stocks lay with the pharmacist or his/her assistant. The facilities were using a mix of the push and pull systems for restocking of supplies; the system probably varies with the category of the drug being ordered or the program the drug falls under. Most (85 percent) of the puskesmas reported using some formula to assess the need for medicines and commodities at their facility.

The products were usually sourced from the district-level warehouses; in more than one-third of puskesmas the facility went to the warehouse to collect the medicines, while in about another one-third the responsibility of

Figure 3.12 Stock-out of RDT Kits (for Malaria, Syphilis and HIV) at Puskesmas and Private-sector Facilities

Source: Indonesia QSDS 2016.Note: Only a few private facilities were sampled: malaria diagnostics (six facilities); syphilis diagnostics (one facility); and HIV diagnostics (one facility).

13%16%

3%

51%

0%

51%

11%7%

13%

0% 0% 0%

42%

36%

47%

100%

0%

100%

All Rural Urban All Rural Urban

Puskesmas Private

Stock out for Malaria RDT Kits

Stock out for Syphilis RDT Kits

Stock out for HIV RDT Kits

46


transporting the supplies to the puskesmas lay with the warehouse. The system was such that about 68 percent of puskesmas received their supplies within two weeks of ordering them and another 20 percent within one month. Almost 90 percent of the puskesmas, therefore, received their supplies within one month of placing the order. While three-fifths (59 percent) of the puskesmas placed their orders every month, two-fifths (39

percent) placed them every two or three months. This variation in frequency probably reflects the variation in buffer stock levels maintained by the facilities (which also varied from one to three months) and the time taken to receive the supplies.

The efficacy of the LMIS is questionable given the frequent stock-outs. Given the frequency of ordering, the system for maintenance of buffer stock

Table 3.4 Specific Services Readiness of Puskesmas and Private Facilities (Availability of Medicines and Commodities)

THEMATIC AREA

Mean Availability of All Essential Medicines / Commodities (Domain

Score)

Proportion of Facilities With All Medicines

/ Commodities Available

Proportion of Facilities With Stock-outs in Last 3 Months

Puskesmas Private Puskesmas Private Puskesmas PrivateFamily Planning 79%62 12% 13%ANC 89%63 81% 15%Basic Obstetric and Newborn Care 76% 0% 34%Immunization 84%64 44%65 75% 23% 18% 10%

Child Health 92%65 47%66 66% 9%

Malaria 53%66 28%67 15% 0% 17% 4%Tuberculosis 43% 7%67 10%68

Puskesmas: Referral & Independent Laboratory

95%7% 10%

Puskesmas: Satellite 88%HCT 44% 15% 10%HIV CST 86% 59% 44% 0%HIV/AIDS ART Prescriptions & Client Management

31% 0% 9%

HIV/AIDS PMTCT 4% 0%STIs 54% 33% 5% 0%Diabetes 72%68 53%69 19% 11%CVDs 74% 57% 19% 22%

28% 8%CRDs 78%69 49%70 38% 16%

Source: Indonesia QSDS 2016.Note: Grey boxes indicate that this indicator is absent from the SARA guidelines. Blue boxes indicate that data for this indicator did not emerge from QSDS due to sampling or other issues. Yellow boxes mean that data could not be generated because only one item was measured.

62 The SARA guidelines include four contraceptives in this indicator: (i) combined oral contraceptive pills; (ii) progestin-only pills; (iii) injectables; and (iv) condoms. As the QSDS questionnaire did not enquire about the availability of progestin-only pills, this number reflects the average availability of only the other three contraceptives.

63 The SARA guidelines include five products in this indicator: (i) iron tablets; (ii) folic acid tablets; (iii) tetanus toxoid vaccine; (iv) drugs for IPT; and (v) Long-lasting Insecticidal Nets (LLINs), with the latter two being for endemic areas. In the QSDS, IFA tablets were asked for as a single commodity (as that is how it is available in the country). IPT drugs and LLINs were not asked for as part of routine ANC as the whole country is not endemic for malaria.

64 Includes vaccines with eight antigens as specified in the national immunization schedule–BCG, OPV, DPT + HiB+ Hep B (pentavalent) and measles.

65 The SARA guidelines include six drugs under child health. The QSDS has measured all except mebedazole/albendazole for deworming. This score is, therefore for only five drugs.

66 Does not include availability of drugs for IPT.67 Refers to stock-out of any TB-related drug in the QSDS.68 Includes average availability of Metformin, Glibenclamide and Glucose injectable solution.69 Includes average availability of oral and injectable steroids, epinephrine and drug for acute asthmatic attack.

47

Table 3.5 Overall Readiness of Puskesmas and Private-sector Facilities to Provide Specific Services

THEMATIC AREAService Index

(Mean Proportion of Facilities)Proportion of Facilities

With All Indicators

Puskesmas Private Puskesmas PrivateFamily Planning 79% 27%ANC 88% 36%Basic Obstetric and Newborn Care 72% 0%Immunization 84% 55% 28% 3%

Child Health 80% 40%59 13% 4%

Malaria 56% 19% 1% 0%Tuberculosis 1%

Puskesmas: Referral and Independent Laboratory 70% 3%Puskesmas: Satellite 58% 25% 6% 13%

HCT 54% 21% 6% 9%HIV CST 74% 57% 16% 77%HIV/AIDS ART Prescriptions & Client Management 33% 0%HIV/AIDS PMTCT 46% 12% 0% 0%STIs 45% 24% 1% 0%Diabetes 74% 49% 3% 1%CVDs 78% 59% 5% 3%CRDs 62% 40% 1% 0%

Source: Indonesia QSDS 2016.Note: Grey boxes indicate that this indicator is absent from the SARA guidelines. Blue boxes indicate that data for this indicator did not emerge from QSDS due to sampling or other issues.

and quick time frames for supply, it is surprising that 70 percent of the puskesmas reported stock-outs of at least one (or more) product one month prior to the survey. The stock-out rates for individual drugs and commodities were generally low–from 2 to 8 percent but at the collective level (that is availability of all the listed drugs and commodities) the stock-out rate was very high.

The duration of stock-outs was very variable–from less than two weeks to more than two months. As with the diagnostics, the common reason reported for these stock-outs was the inability of the warehouse to provide the supply. Districts procure most of their own drugs using an e-catalogue, except for specific programs such as ART for HIV management. This points out to an issue of supply-chain management (SCM) between the districts and the suppliers under the e-catalogue system. Another relatively common reason mentioned was an increased patient load; this reflects the need to develop a scientific system to calculate demand and an adequate buffer stock to cover any increase in the number of patients that may occur.

The facilities used different mechanisms to deal with stock-outs depending on the product that was out of stock and whether it was a puskesmas or a private clinic. In case of stock-outs, one of the commonest actions taken by the puskesmas was to give the patient a substitute of the item or drug that was not available. The private sector, on the other hand, said that they purchased new items. In many other cases, however, both the puskesmas and the private clinics asked the patient/ user to purchase the drug from an off-site pharmacy.

Unlike the case with other drugs, in the case of stock-out for HIV ART, the facilities referred the patient to another facility with ART or reordered the drugs from the DHO. The reason for this is obvious– ART is not available in the open market and cannot be purchased from a pharmacy like other drugs. Similarly, when puskesmas faced shortages of antitubercular drugs, they tended to borrow from other facilities or reordered supplies from the DHO. In this case, the private-sector facilities also reordered from the DHO and fewer facilities asked patients to purchase the drugs from a pharmacy.

48


Overall, the puskesmas seemed better prepared to provide the specific services than the private-sector facilities (Table 3.5). They not only had higher average (mean) availability scores but were also more likely to have all the needed components measured under readiness, especially in the RMNCH arena.

The puskesmas were most ready to provide the RMNCH services compared to other thematic areas. The average scores for most of the RMNCH services were around 75 percent or more compared to around 50 percent or lower for the communicable diseases.

The low levels of readiness for provision of HIV-related services is cause for concern. Not only were the overall mean scores for HIV service readiness low, reflecting a smaller proportion of facilities that are ready to provide these services, but the readiness for ART was even lower. While the private sector is involved in counseling and testing services for HIV, HIV care and management seem to be the exclusive domain of the public sector; only three private-sector clinics stated that they provide these services, and even here, none of them was ready in terms of supplies and other logistics.

This section compares similar indicators measured under Rifaskes in 2011 to the QSDS 2016. Only some results are comparable because of different methodologies–while Rifaskes 2011 was a census of all public-sector health facilities, QSDS 2016 is a sample-based survey. Rifaskes also covered public-sector hospitals; while QSDS covered the private clinics, which were not included in the Rifaskes survey. This section, therefore, only compares the puskesmas, which is the only common facility type between these two surveys. There were also other methodological differences in data collection and analysis, such as the data fields captured and the various elements that contributed towards calculating an index.

The tables below compare “like with like”–that is, the indices have been recalculated to include only those elements that were captured in both the surveys. The readiness index figures in Table 3.6 and Table 3.7 should not be compared with similar indices on service readiness shared previously. The variation is because of a relatively reduced number of elements captured in the comparison tables below. The various elements that have been used to constitute the index have been specified in Table 3.7. Further details on the availability of each element that has constituted the readiness indices are included at Appendix 6.

Understanding Temporal Trends: Comparison of QSDS 2016 with Rifaskes 2011

Table 3.6 General Service Readiness (Comparison Between Rifaskes 2011 and QSDS 2016)

Survey Instrument

Basic Amenities (Mean %)

Basic Equipment

(Mean %)

Standard Precaution

(Mean %)

Basic Diagnostic

(Mean %)

Essential Medicine (Mean %)

Readiness Index

(Mean %)

Readiness Index – All

met (%)Rifaskes 2011 (Puskesmas

N= 8,981)74% 84% 71% 61% 70% 71% 0%

QSDS 2016 (Puskesmas

N=268)83% 86% 83% 66% 71% 78% 0%

Note: Yellow: QSDS levels within 2 percentage points (+/-) of Rifaskes; Light Green: An improvement of 2-10 percent-age points seen in QSDS; and Dark Green: An improvement of more than 10 percentage points seen in QSDS. This table compares “like with like”–that is, the indexes have been recalculated to include only those elements that were captured in both the surveys.

49

Table 3.7 Spesific Service Readiness (Comparison Between Rifaskes 2011 and QSDS 2016)Thematic

AreaSurvey Type /

Elements CapturedGuidelines and

Trainings70 Equipment71 Diagnostics72 Medicines and Commodities72

Family Planning

Rifaskes 2011 60% 96% 78%

QSDS 2016 71% 97% 87%Elements captured Guidelines Training BP apparatus Combined pill

Injectable contraceptive

ANC

Rifaskes 2011 53%72 98% 64% 96%QSDS 2016 93% 93%73 78% 89%Elements captured Guidelines Training73 Weighing scale

StethoscopeBP apparatus

Hb estimationUrine dipstick for protein

IFATetanus toxoid injection

Obstetric Care

Rifaskes 2011 61% 65% 40%QSDS 2016 72% 70% 77%Elements captured Guidelines Training Emergency transportation

Examination lightDelivery packDoppler ultrasoundManual vacuum aspiratorNeonatal bag and maskDisposable latex glovesSterilizerMucus extractorBP apparatus

ErgometrineOxytocinMagsulfDiazepamInjectable antibioticsIV fluidAntibiotic eye ointment

Immunization

Rifaskes 2011 58% 89% 95%QSDS 2016 73% 88% 84%Elements captured Guidelines Training Cold box

RefrigeratorTemperature monitoring device in refrigeratorSharps containerAD syringe

Measles vaccinePentavalent vaccineOPVBCG vaccine

Child Health

Rifaskes 2011 58% 68% 41% 79%QSDS 2016 69% 87% 70% 92%Elements captured Guidelines (IMCI)74

Training (IMCI)Infant weighing scaleTape (for height) or microtoiseGrowth chartStethoscopeThermometer

Hb estimationStool for parasiteMalaria tests

ORSTab amoxicillinSyp co-trimoxazoleSyp paracetamol Tab ZincCap Vitamin A

Malaria

Rifaskes 2011 59% 54% 67%QSDS 2016 49% 63% 69%Elements captured Guidelines Training RDT for malaria Antimalarial (first line)

Paracetamol

TB

Rifaskes 2011 75% 73% 48%QSDS 2016 49% 95%75 95%Elements captured Guidelines Training Sputum microscopy Antitubercular Treatment - ATT

(first line)

Diabetes

Rifaskes 2011 - 76 84% 51% 79%QSDS 2016 93% 79%77 23%78 Elements captured BP apparatus

Adult weighing scaleTape (for height) / microtoise

Blood glucoseUrine dipstick for protein

Injectable glucose solution

CVDs

Rifaskes 2011 -76 94% 84%QSDS 2016 94% 98%79

Elements captured StethoscopeBP apparatusAdult weighing scaleOxygen

ACE inhibitor

CRDs

Rifaskes 2011 -76 90% 84%QSDS 2016 91% 82%Elements captured Stethoscope

OxygenAntiasthmaticOral corticosteroid

Note: Red: A deterioration of more than 5 percentage points seen in QSDS 2016; Pink: A deterioration of 2-5 percent-age points seen in QSDS 2016; Yellow: QSDS levels within 2 percentage points (+/-) of Rifaskes 2011; Light Green: An improvement of 2-10 percentage points seen in QSDS; Dark Green: An improvement of more than 10 percentage points seen in QSDS; Blue: Data not available; and Grey: Indicator not part of SARA. This table compares “like with like”–that is, the indexes have been recalculated to include only those elements that were captured in both the surveys.

50


Overall, QSDS 2016 found an increase in general service readiness at the puskesmas when compared to the Rifaskes 2011 data (Table 3.6). While the average (mean) of some components of general services readiness such as the availability of basic amenities and adherence to standard precautions show a major positive shift of about nine percentage points or more, there was not much change in the availability of medicines and needed equipment in the facility. In both the surveys, lack of availability of all basic diagnostics was a cause of concern. The average (mean) availability of individual components, however, varied much more (Appendix 5). None of the facilities met all the indicators for general service readiness in both the surveys.

70 The figures mentioned below are an average (mean) of the two components, that is, availability of guidelines and the proportion of facilities where staff have been trained in the thematic area.

71 The figures mentioned below are an average (mean) of the various components under the head. The number of components (whether equipment, diagnostics or medicines) varies with each thematic area.

72 The Rifaskes 2011 data does not cover the training component; this is the figure for availability of guidelines only.73 Although an additional piece of equipment (Doppler ultrasound) was covered in QSDS 2016, it is not included here to allow for

comparability with Rifaskes 2011 which did not ask for this equipment.74 IMCI: Integrated Management of Childhood Illness.75 While QSDS 2016 covered multiple elements under diagnostics for TB, only sputum microscopy is covered here to allow for

comparison with Rifaskes 2011 as the latter covered only this element. 76 This indicator was not covered under Rifaskes 2011; hence comparison with QSDS 2016 is also not shown.77 Although an additional diagnostic (urine test for ketones) was covered in QSDS 2016, it is not included here to allow for comparability

with Rifaskes 2011, which did not ask for this diagnostic.78 This compares availability of only one commodity (glucose injectable solution) as that was the only commodity covered under

Risfaskes 2011. QSDS 2016 also included other drugs such as metformin and glibenclamide. On inclusion of the latter two, the average availability of medicines for diabetes was 67 percent under QSDS 2016.

79 While QSDS covered multiple drugs for management of CVDs, only “ACE inhibitors” are covered here to allow for comparison with Rifaskes as the latter covered only this medicine.

Within each of these broad domains of general service readiness, there were multiple elements that were asked for and the difference with Rifaskes was variable. As an example, (Figure 3.13) shows in detail the various subelements captured under “basic equipment” and “standard precautions”. There was significant improvement in the availability of some (such as child and infant weighing scales in the basic equipment); while issues such as safe disposal of infectious waste continued to be an area of concern even in the QSDS survey.

In terms for readiness for provision of specific services, the QSDS 2016, by and large, showed an improvement over the Rifaskes 2011 results (Table 3.7). The areas where the puskesmas were

QSDS-2016 Rifaskes-2011

Basic Equipments

0%

20%

40%

60%

80%

100%Adult scale

Childscale

Infantscale

ThermometerStethoscope

Blood pressureapparatus

Lightsource

0%

20%

40%

60%

80%

100%Sterillizer

Safe finaldisposal for sharps

Safe final disposalfor infectious wastes

Appropriate storageof sharps waste

Appropriate storage of infection wasteDisinfectant

Single use ofstandard disposable

syringe

Soap andrunning water

or alcohol…

Latexgloves

Standard Precaution

Figure 3.13 General Service Readiness: Basic Equipment and Standard Precautions Subdomains (Comparison Between Rifaskes 2011 and QSDS 2016)

51

performing well under the Rifaskes 2011, continued to do so even under the QSDS 2016, such as the availability of equipment for family planning or immunization services.

Obstetric care was one thematic area, where the overall indexes showed significant improvement. Averages hide variations, however, and, even with this well-performing specific service domain, there were elements–such as the availability of a manual vacuum aspirator for provision of comprehensive abortion care, including the management of incomplete abortions in the first trimester; or the availability of delivery packs/kits–that had dropped below Rifaskes 2011 levels (Figure 3.14).

Moreover, there were other complete indexes, where services have worsened since Rifaskes 2011 (Table 3.7). The most important amongst these were availability of commodities for ANC (IFA tablets and injectable tetanus toxoid) and vaccines for childhood immunization; there was a significant reduction in the availability of all the basic vaccines when compared to the previous survey (Figure 3.15). Similarly, availability of guidelines for important programs like TB and malaria have also shown reductions.

The large reduction seen in commodities for diabetes management is probably more of a measurement issue. As Rifaskes 2011 asked for the availability of only injectable glucose solution, this was the only item that lent itself for comparison under this head. So, while QSDS 2016 showed a much greater availability of other diabetes related drugs such as Metformin (89 percent) and Glibenclamide (88 percent), these have not been reflected in the comparison above; while the reduction in the availability of injectable glucose solution is resulting in the dip seen on the comparison chart.

0%10%20%30%40%50%60%70%80%90%

100%Guideline book

Training

Emergenc transportation

Examination ligth

Delivery pack

Dopplerultrasound

Manual vacuumextractor

Neonatal bagand mask

Disposable latex gloves

SterilizerSuction apparatus (mucus extractor)

Blood pressure apparatus

Ergometrine (Inejectable)

Oxytocin (injectable)

Magnesium sulphateInjectables

Diazepam (Inejectable)

Injectables antibiotics

Intravenous solution(normal) saline

Antibiotics Eye ointment


0%

20%

40%

60%

80%

100%

Guidelines

Staff Trainned

Cold box

Refrigerator

Sharps container

Auto-disable syringesTermperatur monitoring

MeaslesVaccine

DPT-Hib+HepBVaccine

Oral PolioVaccine

BCGVaccine


Figure 3.14 Specific Service Readiness: Obstetric Care Subdomain (Comparison Between Rifaskes 2011 and QSDS 2016)

Figure 3.15 Specific Service Readiness: Childhood Immunization Subdomain (Comparison Between Rifaskes 2011 and QSDS 2016)

52


53

Human Resourcesfor Health

54


Availability of skilled human resources is key to efficient functioning of health services. According to the norms set by the MoH,80 the required staff at the puskesmas vary with the location of the puskesmas as well as the availability of beds within the facility (Table 4.1). In general, the puskesmas with inpatient services are required to have a greater number of staff compared to the ones offering only OPD-based care. Similarly, there is some discretion provided to puskesmas in the rural and remote areas for the availability of support staff.

Staff Availability

Table 4.1 Minimum Staffing Norms at Puskesmas

No HEALTH WORKER

Urban Puskesmas

Rural Puskesmas

Puskesmas in Remote and Very

Remote Areas

Without Beds

With Beds

Without Beds

With Beds

Without Beds

With Beds

1 Physician or Primary Health Care Physician 1 2 1 2 1 2

2 Dentist 1 1 1 1 1 1

3 Nurse 5 8 5 8 5 8

4 Midwife 4 7 4 7 4 7

5 Public Health 81 1 1 1 1 1 1

6 Sanitarian81 1 1 1 1 1 1

7 Laboratory Technician 1 1 1 1 1 1

8 Nutritionist 1 2 1 2 1 2

9 Pharmacist 1 2 1 1 1 1

10 Administration 3 3 2 2 2 2

11 Pekarya*81 2 2 1 1 1 1

Total 21 30 19 27 19 27

Source: Minister of Health Regulation No. 75/2014.Notes: (i) *Pekarya is a high-school graduate who is recruited to assist any other puskesmas staff. (ii) Does not include staff based in puskesmas pembantu/subhealth center or village midwives who report to the puskesmas. (iii) The level of education of type 3-10 varies: academy level (three-year education) or bachelor (four-year education).

80 Minister of Health Regulation No. 75/2014. 81 This cadre was not inquired about in the QSDS 2016 tool.

55

Table 4.2 Human Resource Availability in Puskesmas Compared to Minimum Staffing Norms

HEALTH WORKER82

Urban Rural

Norm83Staff Positions Filled

Norm83Staff Positions Filled

Mean Median Mean Median

General Practitioner 1.42 2.3 2 1.65 1.6 1

OBGYN Specialist n.a. 0 0 n.a. 0 0

Other Specialist n.a. 0 0 n.a. 0 0

Nurse 6.27 9.7 8 6.95 9.2 9

Midwife 5.27 7.4 6 5.95 6.8 5

Dentist/Dental Specialist 1.00 1.1 1 1.00 0.6 1

Dental Nurse n.a. 1.5 1 n.a. 0.9 1

Medical Lab Analyst 1.00 1.1 1 1.00 0.8 1

Medical Lab Assistant n.a. 0.2 0 n.a. 0.1 0

Nutritionist 1.42 1.1 1 1.65 0.8 1

Pharmacist 1.42 0.4 0 1.00 0.3 0

Pharmacist Assistant n.a. 1.1 1 n.a. 0.5 0

Administrative Staff 3.00 6.4 6 2.00 4.1 4

Medical Record Staff n.a. 0.5 0 n.a. 0.4 0

Medical Record Assistant n.a. 0.1 0 n.a. 0 0

Source: QSDS 2016.Note: (i) The boxes colored pink show an average staff strength that is below the MoH norm. (ii) The boxes colored green show an average staff strength that meets or exceeds the MoH norm

82 Although they are listed in the norms for the puskesmas, three cadres–public health, sanitarian and perkaya–were not captured in the QSDS 2016.

83 This is a weighted calculation, based on the proportion of facilities with and without beds included in the sample. Using this method, the staffing requirement of the urban facilities appears to be less than that for the rural facilities because in the QSDS 2016 sample, a smaller proportion of urban puskesmas provided inpatient care (with beds) compared to the rural puskesmas.

When compared with the norms, the puskesmas were found to be short on nonmedical staff. On average, the puskesmas had adequate numbers of general physicians, nursing and midwifery personnel (Table 4.2), however, these averages hide variations. For example, the number of doctors available at a puskesmas ranged from zero to as many as ten; the range for the availability of nurses and midwives was even higher–zero to 50, and zero to 61 respectively–reflecting that despite having a higher than required average HRH, there were puskesmas with insufficient staffing numbers. Paramedical staff such as the nutritionists and pharmacist were available in fewer numbers than needed. While there was a variation in the numbers for these cadres too, it was not as steep as for the other staff.

The gap between staff requirement according to norms and the actual staff on-board is greater in the rural puskesmas compared to the urban puskesmas. Even medical staff like the general physician and the dentist were fewer in number than mandated in terms of average availability in the rural areas, while they were in sufficient numbers in the urban ones. For some cadres like the pharmacists and the nutritionist, where there were gaps in both the urban and rural puskesmas, the difference was wider in the rural puskesmas.

56


Compared to the puskesmas, the private clinics had fewer nursing, paramedical and support staff. The average number of physicians per private clinic in the overall sample was slightly higher than the availability at the puskesmas (Table 4.3). There is, however, a striking lack of nursing and midwifery staff at the private clinics, when compared to the puskesmas. Compared to an average of over nine nurses in a puskesmas, a private clinic had less than two. While one puskesmas had as many as 50 nurses on-board, the maximum any private clinic had was 11 nurses.

Some of these differences are probably a reflection of the spectrum of services as well as the patient load catered to by the puskesmas and private facilities. For example, in the present private-sector sample, maternity centers were not included, and that could explain the relative lack of midwives. Similarly, private-sector clinics in the sample were also less likely to offer inpatient care,

thus reducing the need for nursing staff. Laboratory analysts or technicians were also not available at these private facilities, which correlates with a lower availability of on-site laboratory services in the private-sector facilities compared to puskesmas.

The overall pattern of availability of staff in the private clinics reflects a relatively heavy reliance on doctors. This is probably the case in most single-GP run clinics, where the burden of all medical tasks, including those that can be delegated to nursing staff and paramedical workers, as well as the administrative and management load of the clinic are handled by the doctor himself/herself. This situation is probably due to the financial and logistical challenges of maintaining a larger staff strength in the private sector. In a few facilities, especially in the private sector, other specialists were also employed. The availability of specialists was seen more in the multiple-GP run clinics compared to single GP ones.

Table 4.3 Human Resources Mean Availability in Puskesmas and Private-sector Facilities

HEALTH WORKERUrban Rural All

PuskesmasPrivate Clinics



General Practitioner 2.3 2.2 1.6 1.3 1.9 2

OBGYN Specialist 0 0.1 0 0 0 0.1

Other Specialist 0 0.1 0 0 0 0.1

Nurse 9.7 1.4 9.2 1.7 9.4 1.5

Midwife 7.4 0.9 6.8 0.6 7 0.8

Dentist/Dental Specialist 1.1 0.5 0.6 0 0.8 0.4

Dental Nurse 1.5 0.1 0.9 0 1.1 0.1

Medical Lab Analyst 1.1 0.2 0.8 0.1 0.9 0.2

Medical Lab Assistant 0.2 0 0.1 0.1 0.2 0

Nutritionist 1.1 0 0.8 0.1 0.9 0.1

Pharmacist 0.4 0.3 0.3 0.2 0.3 0.3

Pharmacist Assistant 1.1 0.5 0.5 0.2 0.8 0.4

Administrative Staff 6.4 1.5 4.1 1.3 5.1 1.5

Medical Record Staff 0.5 0.1 0.4 0 0.5 0.1

Medical Record Assistant 0.1 0 0 0 0.1 0

Source: QSDS 2016.

84 Causes of legitimate absenteeism included authorized leave, off shift hours, on administrative duty, on outreach activities (which was the most common reason for being absent), and others.

57

Table 4.5 “Legitimate Absenteeism” and “Absenteeism Without Cause” in Puskesmas

HEALTH WORKER

Rural Puskesmas Urban Puskesmas

Number of Staff

Staff not present on survey day

Legitimately absent

Absent without

cause

Number of Staff

Staff not present on survey day

Legitimately absent

Absent without

causeGeneral Practitioner 194 35% 35% 0% 440 24% 24% 0%ObGyn Specialist 0 n.a. n.a. n.a. 1 0% 0% 0%Other Specialist 0 n.a. n.a. n.a. 4 75% 75% 0%Nurse 1,103 34% 33% 1% 1,692 26% 26% 0%Midwife 774 38% 37% 1% 1,310 25% 25% 0%Village Midwife 1,233 95% 95% 0% 687 87% 87% 0%Total 3,304 59% 58% 1% 4,134 41% 41% 0%

Source: QSDS 2016.

Table 4.4 Absenteeism Rate Among Puskesmas Staff on the Day of the Survey

HEALTH WORKER

Urban RuralStaff

Position Filled

(Mean)

Staff Attendance

on Survey Day (Mean)

Absenteeism rate (%)

Staff Position

Filled (Mean)

Staff Attendance

on Survey Day (Mean)

Absenteeism Rate (%)85

General Practitioner 2.3 1.7 26% 1.6 1.1 31%OBGYN Specialist 0 0 n.a. 0 0 n.a.Other Specialist 0 0 n.a. 0 0 n.a.Nurse 9.7 7.1 27% 9.2 6.1 34%Midwife 7.4 5.6 24% 6.8 4.2 38%Dentist/Dental Specialist 1.1 1 9% 0.6 0.4 33%Dental Nurse 1.5 1.3 13% 0.9 0.6 33%Medical Lab Analyst 1.1 1 9% 0.8 0.6 25%Medical Lab Assistant 0.2 0.2 0% 0.1 0.1 0%Nutritionist 1.1 1 9% 0.8 0.5 38%Pharmacist 0.4 0.4 0% 0.3 0.2 33%Pharmacist Assistant 1.1 1 9% 0.5 0.4 20%Administrative Staff 6.4 5.8 9% 4.1 3.5 15%Medical Record Staff 0.5 0.4 20% 0.4 0.3 25%Medical Record Assistant 0.1 0.1 0% 0 0 n.a.Others 0.2 0.2 0% 0.2 0.1 50%

Source: QSDS 2016.

85 Absenteeism rate = {(Staff in position – Staff present on day of survey)/Staff in position}*100

Absenteeism amongst puskesmas staff does not seem to be an issue in either the urban or the rural puskesmas, across all cadres of staff. Some 26 percent and 31 percent of the doctors on the sampled puskesmas’ payrolls in the urban and rural areas, respectively, were not available at the facility on the day of the survey (Table 4.4).

These numbers were slightly higher for nurses and midwives (in urban puskesmas). On deeper analysis of the responses to differentiate between those who were “legitimately”84 not present at the clinic and those who were “absent” without cause, at the time of the survey there was almost no unauthorized absenteeism amongst staff (Table 4.5).

58


The availability of doctors and “other health worker cadres” (non-physician, non-nursing cadres) in the puskesmas is positively correlated (statistically significant at p<0.05) with the number of outpatient visits at the puskesmas (Figure 4.1). As this is a cross-sectional survey, it cannot be said whether increased availability of doctors is the cause or the effect of increased outpatient visits at the facilities. Given that such a correlation is also visible for “other health worker cadres” (nonphysician, nonnursing), it may be presumed that rising numbers of outpatient visits pushes the facility to increase its staff strength to manage the increased workload. No statistically significant correlation was found between the availability of nurses and midwives and outpatient visits. Similarly, no statistically significant correlation was found between availability of doctors and specialists and inpatient visits at the puskesmas.

1

0

2

3

Number of OtherHealth Care Worker

Ou

tpat

ien

t vis

it p

er p

erso

n/y

ear

0 5 10 15

1

0

2

3

Number ofNurse/Midwife

Ou

tpat

ien

t vis

it p

er p

erso

n/y

ear

0 20 40 60 80 100

1

0

2

3

Number of GP/Dentist/Specialist

Ou

tpat

ien

t vis

it p

er p

erso

n/y

ear

0 5 10 15

r=0.0917 (p>0.05)

r=0.1683 (p<0.05)

r=0.414 (p<0.05)

Figure 4.1 Correlation Between Availability of Human Resource Cadres and OPD Attendance at Puskesmas

Source: QSDS 2016.

59

Puskesmas are mandated to conduct mini-workshops in their premises for their staff. The topics are related to overall management of the puskesmas and are meant for all staff. On average, the puskesmas had conducted over 12 workshops (rural - 12.4; urban - 12.8) in the 12 months preceding the QSDS survey.

Staff Training The most common topics on which mini-workshops were conducted were related to program management, including planning for the subsequent month’s activities and assessing coverage of the program activities (Figure 4.2). Both of these workshop topics were mentioned by over 99 percent of the puskesmas and were the most spontaneous of all responses. There was no specific urban-rural trend seen in the conduct of these workshops–whether a workshop was more common in the urban or the rural area varied from topic to topic.

Figure 4.2 Mini-workshop Topics Held in Puskesmas in the 12 months Preceding the Survey

Source: QSDS 2016.

14%

81%

5%1%

Pharmacy

36%

58%

6%0%

Staffing

28%

70%

2%0%

Data

84%

15%

1%0%

Program,Coverage,

Output

64%

35%

1%0%

Plan ofAction

32%

63%

6%0%

Financing

26%

71%

4%0%

MinimumService

Standard

24%

75%

1%0%

Local AreaMonitoring

26%

16%

58%

0%

Other

Spontaneous

Prompted

No

Dknow

60


In addition to the mini-workshops, puskesmas staff are also mandated to receive training on various themes. From the preventive and promotive health care basket, the most common theme on which puskesmas staff had received training was “Counseling on Clean Behavior” (Perilaku Hidup Bersih Sehat – PHBS), which was received by at least one staff member from three-quarters (76 percent) of the puskesmas in the year preceding the survey (Figure 4.3). Training on

community empowerment was conducted at only 55 percent of the puskesmas. Of the seven predefined training topics, only about one-third (31 percent) of the puskesmas had one or more persons from their staff who had attended all of them. The reasons cited for staff members not attending these training sessions included not being selected as participants or, in some cases, the training not being conducted in their district.

Figure 4.3 Training Related to Health Promotion and Preventive Programs Received by Puskesmas Staff in the 12 Months Preceding QSDS

Source: QSDS 2016.

Table 4.6 Reasons Given by Puskesmas Staff for Not Receiving Training on Specific Health Services Themes86

Thematic AreaNot

Selected as Participant

No Such Training in This District/

City

Never Heard of Such

Training

Training Not Available in the Last Two Years

Family Planning 59% 20% 8% 17%ANC 51% 25% 13% 19%Basic Obstetric and newborn Care 48% 29% 10% 18%Immunization 36% 33% 12% 17%Child health 53% 18% 12% 22%Child Nutrition 62% 22% 6% 15%Malaria 51% 23% 4% 16%Tuberculosis 67% 21% 4% 11%HCT 41% 29% 7% 14%HIV CST (including ART) 56% 19% 15% 20%HIV/AIDS PMTCT 58% 11% 13% 10%STIs 57% 20% 12% 13%Diabetes 52% 30% 9% 9%

Source: QSDS 2016.

86 Denominator for calculating the proportions is those facilities who mentioned not having received any training listed under that specific health theme.

76%

Counselingon CleanBehavior

(PHBS)

58%

Developmentof health postdevelopment

and/or villageallert

Any othertraining on

healthpromotion

44%

PKPR(Program

KesehatanPeduli Remaja)

/ HealthPrograms forAdolescence

73%

Garbage orwastewatertreatment

59%

Food/beverage

sanitation

67%

Drinking/clean water

63%

Communityempowerment

andmobilization

55%

61

Table 4.7 Reasons Given by Private Clinic Staff for Not Receiving Training on Specific Health Services Themes86

Thematic AreaNot

Selected as Participant

No Such Training in This

District/City

Never Heard of Such

Training

Training Not Available in the Last Two Years

Family PlanningANCBasic Obstetric and Newborn CareImmunization 0% 29% 17% 8%Child Health 0% 38% 27% 8%Child Nutrition 0% 37% 20% 6%Malaria 2% 35% 31% 8%Tuberculosis 0% 36% 29% 5%HCT 0% 13% 36% 3%HIV CST (including ART) 0% 0% 0% 0%HIV/AIDS PMTCT 0% 36% 19% 3%STIs 0% 42% 30% 5%Diabetes 0% 41% 26% 9%

Source: QSDS 2016.Note: (i) The boxes colored blue show that the service was not measured at private facility

The most common reason mentioned by puskesmas staff for not receiving training on specific health themes was that none of their staff members was selected as a participant (Table 4.6). This was similar to the reasons given for not receiving training on preventive and promotive care. Many puskesmas shared that they were not aware of some of the training, even on RMNCH-related topics, which is surprising given that this training has been going on for many years.

All these responses indicate the need to strengthen the training system such that all puskesmas are given a chance for their staff to be trained on various issues. Training needs to be held close to the facility to avoid travel and other logistical issues that may hinder participation in the training. Training closer to the facility will also reduce the time that the staff is absent from facility, thus reducing the disruptive impact staff training sometimes has on staff attendance at the facility. The local government that is responsible for conducting training needs to streamline the system.

In contrast, the main reason given in the private sector for not receiving training on specific health themes was because they were unaware of the same (Table 4.7). From a practical viewpoint, it is difficult for private practitioners, especially those managing their OPDs in single-provider settings, to excuse themselves from their work for the training duration, as that would mean shutting down the services completely for that time, which may not be feasible.

In the absence of formal training on specific health themes, the health facilities, both puskesmas and private clinics, resorted to convening discussion forums within the facility to share information related to the various specific services, or relied on the staff themselves to upgrade their own knowledge and skills (Table 4.8 and Table 4.9). The latter was used even more for the comparatively newer technical services like HIV and AIDS care or management of NCDs. Such a relatively heavy reliance on the staff to be responsible for upgrading their own skills reflects a lack of updated knowledge and/or training and mentoring capacities within the facilities. It is probable that because of the newness of these topics, there were fewer staff who knew enough to be able to guide and mentor other staff or even convene discussion forums on these issues.

62


Table 4.9 Action Taken by Private Clinics to Make Up for Lack of Training on Specific Services

Thematic Area Provide book or module to read

Convene coordination meeting or discussion session/forum to share information

Arrange internal training systems where the senior staff train junior staff (on-the-job training)

Support staff to attend seminar, workshop, or other capacity-building activities

Motivate staff to improve knowledge/skills independently

Family PlanningANCBasic Obstetric and Newborn CareImmunization 4% 26% 5% 35% 30%Child Health 21% 20% 3% 44% 36%Child Nutrition 28% 23% 3% 37% 39%Malaria 18% 12% 2% 44% 44%Tuberculosis 20% 16% 2% 36% 42%HCT 10% 24% 0% 48% 33%HIV CST (including ART) 50% 0% 0% 0% 50%HIV/AIDS PMTCT 15% 21% 4% 47% 20%STIs 24% 16% 4% 41% 38%Diabetes 25% 17% 2% 47% 40%

Source: QSDS 2016.Note: (i) The boxes colored blue show that the service was not measured at private facility.

Table 4.8 Action Taken by Puskesmas to Make Up for Lack of Training on Specific Services

Thematic Area Provide book or module to read

Convene coordination meeting or discussion session/forum to share information

Arrange internal training systems where the senior staff train junior staff (on-the-job training)

Support staff to attend seminar, workshop, or other capacity-building activities

Motivate staff to improve knowledge/skills independently

Family Planning 18% 41% 10% 20% 26%ANC 20% 43% 11% 20% 30%Basic Obstetric and Newborn Care

25% 37% 14% 25% 32%

Immunization 22% 45% 10% 20% 32%Child Health 20% 29% 12% 15% 45%Child Nutrition 32% 35% 8% 24% 36%Malaria 22% 32% 6% 13% 42%Tuberculosis 20% 44% 9% 18% 37%HCT 11% 41% 17% 24% 23%HIV CST (including ART) 18% 25% 11% 13% 45%HIV/AIDS PMTCT 23% 31% 12% 11% 41%STIs 24% 27% 9% 17% 44%Diabetes 24% 30% 6% 23% 37%

Source: QSDS 2016.

63

Financing ofPuskesmas

64


Health financing in Indonesia is marked by low public health expenditures (PHE), high out-of-pocket (OOP) expenditures and a complex and fragmented intergovernmental fiscal transfer system (World Bank 2016). PHE at 1.5 percent of GDP (IDR 118 trillion or US$9.1 billion) is amongst the lowest in the world and forms only 41 percent of total health expenditures (THE). THE constituted 3.6 percent of GDP or US$126 per capita in 2014. Government revenue as a share of GDP is also low at 17 percent and PHE is only 5.3 percent of national government expenditure. OOP is very high at 46 percent of THE and is 1.2 percent of GDP.

Both supply-side financing of public-sector provision and demand-side financing through the JKN exists. On the supply-side financing, several intergovernmental fiscal transfer mechanisms (from the Ministry of Finance (MoF) to local governments (LGs)87 exist. The main ones are general allocation funds (Dana Alokasi Umum, DAU), revenue sharing (Dana Bagi Hasil, DBH), and special allocation funds (DAK). About 75 percent of DAU is allocated to spending on personnel, limiting districts’ flexibility on their annual budgets. Indonesia’s health sector has low dependency on external financing except for some health programs.88

DAK is the largest conditional transfer and an important lever for the national government to influence subnational service-delivery outcomes (World Bank 2016). There are two forms of DAK: DAK Fisik is focused mainly on infrastructure, equipment and medicines; and DAK Non-Fisik finances some operational expenditures (largely for outreach and accreditation). DAK Fisik increased more than four-fold between 2014 and 2018, to IDR 17.45 trillion (US$1.29 billion).89 It forms

Health Financing Landscape

close to 9.4 percent of the district health budget, and is an important source of capital spending (Figure 5.1). There are four types of health DAK Non-Fisik: health operational assistance (Bantuan Operasional Kesehatan – BOK) (for preventive and promotive services); childbirth services guarantee (Jampersal); puskesmas accreditation; and hospital accreditation (DAK akreditasi).90 In 2018, the total DAK Non-Fisik allocation is IDR 8.55 trillion. Neither DAK Fisik nor DAK Non-Fisik have been strongly linked to results. Both are allocated based on formulas that ascertain need, with DAK Fisik also based on proposals from provinces and districts. More importantly, DAK forms a pivotal source of resources for the health sector in underdeveloped districts, such as those in Eastern Indonesia.

87 Local governments (LGs) refer to provincial and district governments.88 HIV, TB, malaria and immunization program budgets are significantly donor financed and sustainability is a key issue as Indonesia

transitions out of donor financing.89 This does not include the DAK Fisik for family planning, which is managed by BKKBN. There is also a clear shift in favor of primary

health care. The DAK Fisik allocation to primary health care increased 300 percent between 2015 and 2016, and the allocation to pharmaceuticals has increased by more than 350 percent.

90 Not including DAK Non-Fisik for family planning managed by BKKBN.

Figure 5.1 Sources of District Revenue for Health (as % of Total Revenue) (2013–15)

Source: Indonesia QSDS 2016.Note: Data is based on a nationality representative sample of 22 districts

2014

9%

9%

10%

28%

24%

10%

10%

2015

12%

5%4%

42%

18%

9%

9%

2013

8%

20%

12%

19%

17%

1%

23%

Social security fund

Province

Other interfiscal transfers

Dekon-TP

DAK

BPJS

User fees

Other PAD

65

The JKN (BPJS), with expenditures at about IDR 53 trillion84 (approximately US$4.1 billion) or 42 percent of the district health budget in 2015 (Figure 5.1), is an underused financial lever to improve health outcomes and supply-side readiness. Key challenges include clarifying institutional roles, covering the informal nonpoor, a nonexplicit benefits package, and weak strategic purchasing of services. The JKN is also poorly integrated with supply-side financing to improve public-sector supply-side readiness and is also being underused to harness private-sector provision. JKN needs to ensure the poorest 40 percent of the population are targeted better, and that contribution collection among nonpoor informal workers increases.91 JKN implementation is done through BPJS Health, which is not well integrated with other health authorities across all levels. About 65 percent of the expenditure claims in 2014 have been hospital-based and another 20 percent were used for noncapitated fee-for-service payments to facilities. Claims for NCDs dominate, with CVDs, kidney failures and stroke being among the top five diseases accounting for most of JKN expenditures. Even though JKN capitation forms a large source of revenue for puskesmas, its use for supply-side readiness continues to be problematic due to a lack of clarity on capitation spending at the puskesmas level.

JKN Program

Strategic purchasing92 under JKN will provide an opportunity for increased efficiency and accountability in service delivery. Primary care is currently paid through capitation and hospitals are reimbursed based on diagnosis-related groups known as INA-CBGs (Indonesia Case-based Group). In 2016, the GoI implemented Kapitasi Berbasis Komitmen (KBK)–a capitation payment to primary-health facilities that is linked to agreed performance indicators.93 In its first year of implementation, up to 25 percent of the capitation payment could be deducted if targets or criteria were not met–offering puskesmas’ a significant financial incentive. Since then, the payment deduction has been scaled back–ranging from 2.5 percent to 10 percent. The choice of indicators is also reflective of the current needs of BPJS Health, which is more focused on cost containment and general oversight rather than health system performance overall. The scheme presents an opportunity to develop an additional set of indicators that would meet both BPJS and MoH performance-monitoring objectives.

In line with the goals of the JKN program, all puskesmas surveyed under the national sample in QSDS 2016 were empaneled with BPJS Health. The average number of members covered by puskesmas was 11,729 with a range from 1,929 to 43,250. The average number of members covered by a rural puskesmas was 8,698 (ranging from 1,929 to 35,618) while that for the urban puskesmas was 15,710 (ranging from 2,596 to 43,250).

91 Very few nonpoor informal workers have enrolled to date, and those that have been are adversely selected (that is, there are currently more unwell people enrolled into the program as the healthy do not want to pay premiums; such a situation is not good for risk pooling of the population).

92 Which services to be included and how best to buy the right quantity and quality of services. This will typically involve some form of contracting between purchasers of health care (for example, BPJS Health) and providers (for example, public and empaneled private facilities) to clarify each party’s obligations.

93 There are currently only three ‘performance-based’ indicators: contact rate (150 contacts per 1,000 people per month); referral rate for services that could have been treated at puskesmas based on agreed set of services; and rate of visit of chronic disease patients.

66


In contrast, only 43 percent of private-sector facilities were empaneled by BPJS, with a big difference between urban (47 percent) and rural (30 percent) facilities. One-third (35 percent) of private-sector facilities were “not interested” in being empaneled, with urban private-sector facilities being twice more than twice as likely to cite this reason than rural ones (40 percent vs. 19 percent) (Figure 5.2). This disinterest is probably linked to the capitation amount, which about 11 percent of providers stated was lower than their expectation. The second most common reason for non-

empanelment was inability of the facility to fulfil the BPJS requirements (22 percent), with more rural private-sector facilities (28 percent) being unprepared than urban private-sector facilities (20 percent).

The average number of members covered by a private clinic was 4,150–with a wide range from 142 to 25,000. The average number of members covered by a rural private GP was 1,240 with a range from 200 to 4,750 and the average number of members covered by an urban private GP was 4,400 with a range from 142 to 25,000.

92 Which services to be included and how best to buy the right quantity and quality of services. This will typically involve some form of contracting between purchasers of health care (for example, BPJS Health) and providers (for example, public and empaneled private facilities) to clarify each party’s obligations.

93 There are currently only three ‘performance-based’ indicators: contact rate (150 contacts per 1,000 people per month); referral rate for services that could have been treated at puskesmas based on agreed set of services; and rate of visit of chronic disease patients.

Figure 5.2 Reasons for Nonempanelment of Private Clinics with BPJS


3

3

22

8

35

8

6

4

11

3

3

20

8

40

9

6

2

8

4

4

28

9

19

5

4

9

18

Rural Urban AllOther

Does not know JKNpartnership mechanism

Has not proposed yet becauseof unfulfilled requirement

Has proposed, but didn’tpass credentialing...

Not interested

Drastic increase in workload becauseof high patient volume

There is limited partnership quotafor health facility empanelled with BPJS

Non-capitation claim is too small

The capitation amount is too small

Percentage

Table 5.1 Reasons for Puskesmas Not Getting Maximum Capitation of IDR 6,000

REASONS FOR NOT GETTING MAXIMUM PREMIUM ALL URBAN RURALNumber and type of provider below BPJS requirement 43.2% 28.7% 47.9%Infrastructure below BPJS requirement 13.7% 2.9% 17.2%Services offered below BPJS requirement 29.9% 27.4% 30.8%Others 31.4% 47.3% 26.3%


67

The capitation received per member per month at the puskesmas ranged from IDR 3,000 to IDR 6,000, and 43 percent of puskesmas received less than the maximum capitation of IDR 6,000 per member per month. The main reasons for not getting maximum capitation payments were lack of adequate HRH (in terms of numbers and/or cadres) as mandated by BPJS (cited by 43 percent of the facilities), followed by deficiency in services in comparison to the BPJS requirement (cited by 30 percent of the facilities) (Table 5.1). The reasons varied between the urban and rural facilities; for example, availability of providers was a reason for lower capitation in 48 percent of the rural puskesmas compared to only 29 percent of the urban ones.

There was no significant difference observed between puskesmas that received maximum capitation versus those that did not in terms of supply-side readiness for child health, diabetes or CVDs (Table 5.2). While the mean service index for some selected components of specific services was lower for the facilities that had not received the complete/maximum allowable capitation fee, the difference was not statistically significant. This indirectly indicates that availability of funds may not be a critical barrier for improving service readiness of facilities (puskesmas).

In 2015, over 85 percent of the puskesmas were unable to utilize all revenue from the capitation funds. There was not much difference between urban and rural puskesmas. The main reason given for same was the absence of local government regulation on the use of these funds. About 97 percent of the puskesmas used the capitation funds for operational costs, with no significant difference between urban and rural puskesmas.

Table 5.2 Correlation Between Receipt of JKN Capitation Fees and Service Readiness (for Selected Specific Services) of Puskesmas

Supply-side Readiness Score for Child Health

N Mean SE Sd95% CI

Diff t-test p-valLower Upper

Puskesmas Received Maximum Capitation

No 88 16.51 0.29 2.70 15.94 17.08 -0.63 -1.70 0.09Yes 180 17.14 0.22 2.91 16.71 17.57All 268 16.93 0.17 2.85 16.59 17.28

Supply-side Readiness Score for Diabetes

N Mean SE Sd95% CI


Puskesmas Received Maximum CapitationNo 80 8.80 0.19 1.70 8.42 9.18 -0.26 -1.13 0.26Yes 179 9.06 0.13 1.68 8.81 9.30All 259 8.98 0.10 1.69 8.77 9.18

Supply-side Readiness Score for CVDs

N Mean SE Sd95% CI


Puskesmas received maximum capitationNo 65 8.35 0.19 1.55 7.97 8.74 -0.23 -0.99 0.33Yes 156 8.58 0.13 1.59 8.33 8.83All 221 8.52 0.11 1.58 8.31 8.72


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There was a negative correlation observed (at p=0.05) between puskesmas utilization of JKN funds and supply-side readiness for child health, however, no such linkages were seen for diabetes and CVDs. Contrary to expectations, puskesmas that are unable to expend all the funds received from BPJS have marginally better service-readiness scores than those that are able to manage 100 percent expenditure (Table 5.3). These differences need to be interpreted with caution, however, as not only is the difference not statistically significant (other than for child health), the number of puskesmas in one comparative arm is very small. As most of the capitation is used to fund operational costs (paragraph 160), its ability to impact service readiness at the facility is also relatively limited.

The average capitation received per member per month at the private-sector facilities was IDR 8,000 (with a range from IDR 4,000 to IDR 10,000), while 46 percent of the private-sector facilities received less than the maximum capitation of IDR 10,000 per member per month. The maximum capitation amount for private-sector facilities (IDR 10,000 per member per month) is more than the maximum capitation amount received by the puskesmas (IDR 6,000 per member per month) because the latter also receives other government budgetary sources of revenue. Rural private-sector facilities were twice as likely to receive less than the maximum capitation of IDR 10,000 than urban private-sector facilities (82 percent vs. 42 percent).

Table 5.3 Correlation Between Utilization of JKN Capitation Fees and Service Readiness (for Selected Specific Services) of Puskesmas


N Mean SE Sd95% CI


Able to use all fund received from CapitationNo 252 17.02 0.18 2.85 16.67 17.37 1.46 1.99 0.05Yes 16 15.56 0.65 2.61 14.17 16.95All 268 16.93 0.17 2.85 16.59 17.28


N Mean SE Sd95% CI




N Mean SE Sd95% CI




Table 5.4 Reasons for Private-sector Facilities Not Getting Maximum Capitation of IDR 10,000

REASONS FOR NOT GETTING MAXIMUM PREMIUM ALL URBAN RURALNumber and type of provider below BPJS requirement 22% 26% 0%Infrastructure below BPJS requirement 10% 12% 0%Services offered below BPJS requirement 21% 16% 49%Others 49% 48% 52%


69

A large proportion (49 percent) of the providers who did not get the full capitation fee cited reasons others than the ones prelisted in the data collection tool (Table 5.4). The other reasons were similar to the ones cited by the puskesmas such as shortage of human resources, and inability to provide the services as required under BPJS. As is the case with puskesmas, lack of infrastructure was the lowest ranked reason for receiving lower amounts of capitation, indicating once again that shortage of human resources is a bigger bottleneck than infrastructure–even for the private sector. The difference in services not meeting BPJS requirements between rural and urban private-sector facilities was three-fold (49 percent vs. 16 percent).

Overall, the private clinics empaneled under BPJS were more service ready than the nonempaneled ones (Figure 5.3). The average score for general service readiness increased from an availability of less than 19 items in non-empaneled private clinics to about 22 items (out of a total possible score of 34) in BPJS-empaneled private clinics. BPJS empanelment resulted in the average readiness scores for child health shifting from about 8 to 10. Further details on this for various subdomains of general service readiness and for other themes under specific services can be found in Appendix 5 and 6 respectively. The only two areas, where BPJS-empaneled private clinics appear to perform slightly better than non-empaneled private clinics are readiness for immunization and cardiovascular services, however, even here, the difference is not significant.

Figure 5.3 Comparison of Average Service Readiness Scores for General Services’ Provision and for Child Health Services Between BPJS-empaneled and Nonempaneled Private Clinics


General Service Readiness

05

1015

0 2 6 10 14 18 22 26 30 34Number of Component (34)

EmpaneledNot empaneled

Percentage

Note : vertical solid line=mean; vertical dash line=median

Child Health Service Readiness

05

1015

0 2 4 6 8 10 12 14 16

Empaneled

Not empaneled

Percentage

Number of Component (21)18 20

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Table 5.5 Correlation Between Receipt of JKN Capitation Fees and Service Readiness (for Selected Specific Services) of the BPJS-empaneled Private Clinics


N Mean SE Sd95% CI


Private facility received maximum capitationNo 77 8.87 0.41 3.59 8.05 9.69 -3.16 -4.18 0.0001Yes 39 12.03 0.69 4.29 10.63 13.42All 116 9.93 0.38 4.11 9.18 10.69


N Mean SE Sd95% CI




N Mean SE Sd95% CI




Unlike the case with puskesmas, service readiness of the private-sector clinics empaneled with BPJS for select specific services appeared to be positively correlated with the amount of capitation fee received (Table 5.5). The clinics that did not receive the maximum allowable capitation fee had higher average service readiness scores for selected specific services. This is an indirect indication that some of the capitation fee may be used by the private clinics for upgrading of needed infrastructure and purchasing equipment and supplies. This also indicates that JKN capitation is a key instrument that can be used to influence supply-side readiness for the private sector.

71

The puskesmas revenue patterns from 2013-15 indicate an approximate four-fold increase from an average (mean) revenue of IDR 293 million in 2013 to IDR 1.056 billion in 2015 (Table 5.6). The increases have primarily been due to increasing capitation payments from BPJS, which provided close to two-thirds of the revenue of the puskesmas in 2015. Non-capitation claims, at 3 percent, form only a small portion of the revenue. Jamkesda now contributes a far reduced proportion of total revenues (2 percent) and Jampersal, Jamkesmas and Askes contributed no revenue to puskesmas in 2015, in line with the objective of JKN replacing these schemes.

Puskesmas Revenue

As a proportion, revenue from OOP has also shown a decrease–from 2 percent in 2013 to only about 1 percent in 2015. This appears to be encouraging, however, in absolute monetary terms, OOP has varied from about IDR 6 million per puskesmas in 2013, to IDR 13 million in 2014, to just over IDR 10 million in 2015. The contribution from the budget of regional governments94 to puskesmas revenue has reduced from 20 percent in 2013 to 14 percent in 2015. BOK’s contribution95 to puskesmas revenue has reduced by one-half, from 35 percent in 2013 to 16 percent in 2015. This indicates the importance of JKN in puskesmas revenue, which is, therefore, a very important lever to drive performance of puskesmas.

Table 5.6 Source of Revenue for Puskesmas

94 The DAK is reflected in the district health budget (Anggaran Pendapatan dan Belanja Daerah – APBD) and is not reflected separately as part of the puskesmas revenue.

95 The BOK is now channeled through DAK Non-Fisik and not Tugas Pembantuan (TP).


1%

0%

3%

1%

0%

0%

14%

62%

0%

0%

16%

0%

65%

0%

2%

0%

0%

2%

2%

0%

0%

18%

52%

0%

0%

19%

1%

55%

0%

5%

0%

0%

0%

2%

16%

0%

20%

0%

0%

20%

35%

0%

0%

1%

6%

Unclassified

Donor

BPJS-Non Capitation

OOP

Jamkesmas

Other

APBD

BPJS-Capitation

Jamsostek

Jampersal

TP-BOK

BPJS-Others

BPJS (Total)

Askes

Jamkesda

Total (Million IDR) 293 659 1,056

2013 2014 2015Year

72


Monetary incentives to puskesmas staff accounted for more than two-thirds (66 percent) of puskesmas expenditures in 2015 (Table 5.7). It is important that this is studied further to see that these increased incentives are resulting in productivity increases and quality improvements. The next largest share is for monitoring and supervision activities, which form close to one-fifth (18 percent) of expenditures. Expenditures on equipment, consumables, and medicines form a small part of operational expenses. Unless these are being made available from other sources such as the APBD, it is a matter of concern as expenditures on medicines is also a large driver of OOP expenses. In cases of stock-outs of drugs, consumables and

Puskesmas Expenditure

diagnostics, when supply from the warehouse is delayed, puskesmas are entitled to make local purchases from their own funds. The relatively low level of spending on these items could, however, be one of the contributory reasons for frequent stock-outs of the same. A detailed study of this head may also provide interesting insights into the spending pattern of puskesmas.

No clear link between increased operational expenditures with supply-side readiness was observed. There was no significant difference observed between puskesmas that retained all revenue versus those that did not and supply-side readiness for general services.

Table 5.7 Puskesmas Heads of Expenditure as a Proportion of Total Expenditure

Percentage allocation and expenditure 2013 2014 2015

Actual Actual Actual

A. Medicines 0% 1% 2%

B. Consumables 1% 2% 2%

C. Equipment 0% 3% 5%

D. Bonus or other financial incentives 58% 65% 66%

E1. Monitoring and Supervision: Transportation 33% 22% 18%

E2. Monitoring and Supervision: Food and beverage 8% 7% 6%

I. Total 100% 100% 100%

J. Budget Carried Forward From Previous Year 0% 0% 2%


73

Management ofHealth Facilities

74


Decentralization has been accompanied by increased complexity of fiscal transfers, diffuse governance and accountability and strained subnational capacity to improve health service delivery. In 2001, responsibility for the delivery of most health services was shifted to the district level, with fund transfers being made directly to the district level, bypassing the provincial level. In principle, decentralized health sector decision making, coupled with large fiscal transfers from the center to subnational levels, was intended to empower LGs to efficiently and effectively design and implement health programs, especially by adapting to local contexts (Rokx et al. 2009). In practice, however, health financing flows are much more complex and difficult to manage, marked by seven vertical intergovernmental financing channels, each with different rules and procedures. The introduction of demand-side financing through the JKN in 2015 has further fragmented the fund flows. This splintered model strains LGs capacity to plan, manage, and allocate funds efficiently in order to maximize results, and hinders governance and accountability systems (World Bank 2008).

Central government has underutilized levers to direct service-delivery improvement at the local level. The majority of intergovernmental transfers are unconditional, and those transfers that are conditional have weak performance orientation. There are multifaceted and competing mixtures of central and subnational regulations governing authority over key decisions which complicates health service delivery, and is one reason behind the disparity of HRH distribution in the country (Rokx et al. 2010). Finally, another challenge of decentralization in the health sector has been the disruption to, and varying quality of, monitoring, reporting, and data systems (Rokx et al. 2009).

Health information management in Indonesia is characterized by high fragmentation, poor compliance, little data verification and

Governance for the Health Sector

underutilization of data.96 MoH’s Center of Data and Information (Pusdatin) has developed a standard application for puskesmas (SIKDA-Generic) that incorporates or can link to other applications. This is, however, currently (in 2017) used in only about 10 percent of facilities; 20-30 percent of puskesmas use other electronic systems, with the remainder using paper-based systems.97 BPJS collects data through two systems that are distinct from MoH (p-Care and e-Klaim), which are much widely used (more than 90 percent coverage, by both public and private providers and facilities) but only for JKN patients.

Between the various systems, there is a lack of consistency in data fields, such as facility and patient identifiers and treatment, which does not allow the various systems to communicate with each other and share data. The fragmentation of systems is driven by low levels of coordination among different MoH Directorates-General, between MoH and BPJS, and between line ministries and MoF, along with competing demands from development partners. The fragmentation is also driven by innovation from LGs seeking to fill gaps left by the central level and meet local needs. Fragmentation increases the reporting burden on facilities (reducing time for service delivery), reduces compliance, heightens the chances of error and confusion (that is, the same information shows up differently in different systems) and reduces the availability of comparable data for policy making and programming.

Very little is done to verify the quality (including completeness) of data, which will become even more problematic as performance elements are introduced into financing, and thus incentives for gaming the system increase. Despite the many online, offline and paper-based information systems used by MoH, local governments and BPJS Health, there is no system for comprehensively benchmarking performance of districts and facilities. The lack of complete, timely and credible data makes it difficult to properly assess the performance of facilities and LGs, or truly understand the kinds of capacity, resourcing and incentives needed to improve service delivery and health outcomes.

96 Technical assessment: Proposed World Bank-supported Program – Strengthening Primary Health Care Reform (I-SPHERE).97 Discussions with MoH in 2017.

75

Table 6.1 Availability of Operational Guidelines at Puskesmas (%)

Name of GuidelineProportion of Puskesmas Where

Guidelines Were Available

All Urban Rural

Health Minister’s Decree No. 75/2014 90.4 97.9 84.9

Guidelines on Puskesmas Level Planning 84.5 90.7 80.0

Guidelines on Puskesmas Mini-Workshop 90.3 97.9 84.7

Guidelines on Assessment of Puskesmas’ Performance 86.1 94.0 80.3

Guidelines on Quality Assurance for Basic Health Services Model for Puskesmas

72.4 81.3 65.9

Minimum Service Standards (MSS) 90.3 98.3 84.5

JKN/BPJS Guidelines 94.6 94.9 94.3


The majority of puskesmas had the operational guidelines available within their facilities (Table 6.1). These guidelines are important to understand and follow the management and quality assurance systems set up by GoI.

Availability of Operational Guidelines

76


Figure 6.1 Monitoring Visits From the DHO to the Puskesmas in the 12 Months Preceding QSDS

53%

92%

65%

69%

90%

94%

93%

94%

52%

93%

52%

82%

90%

98%

96%

96%

54%

91%

74%

60%

89%

92%

91%

92%

Others

Nutrition

Malaria

HIV/AIDS

Tuberculosis

Immunization

Child health

Maternal Health

Rural Urban All


Monitoring of health facilities is important to ensure quality of services. These visits by the “authorities” also serve as mentoring opportunities to improve areas of work that were found lacking. As the puskesmas are primary health care facilities, they are monitored by the DHO members.

Monitoring visits to the puskesmas from the DHO were more common for RMNCH-related issues compared to those for infectious diseases (Figure 6.1). More than 90 percent of the puskesmas had received such visits for maternal health, child health, immunization and nutrition. The proportion of facilities that received monitoring visits for HIV and AIDS and malaria dropped down to as low as 65 to 70 percent. While there was not much urban-rural difference seen in the RMNCH-related visits, the difference in the visits for HIV and AIDS was stark, with 82 percent of the urban puskesmas having received such visits compared to only 60 percent of the rural ones.

Monitoring and Evaluation

Posyandu visits by the puskesmas staff were conducted regularly. Puskesmas supervise the village-level centers like posyandu and are required to pay monitoring visits to each posyandu under them once a month. Only about 9 percent of the sampled puskesmas did not monitor all the active posyandu in their area on a monthly basis. This was slightly more common for the rural puskesmas (12 percent) than the urban ones (6 percent). Among those who could not monitor each posyandu every month, the commonest reason given was the distance of the posyandu from the puskesmas, which resulted in increased travel time. Others stated shortage of resources, both in terms of human resources and funds to carry out this activity.

77


33 13 54Do Nothing

74 23 3Provide Clinical Treatment

15 82 3Conduct Household Visits with Kader Posyandu

16 79 5Review Work Plans and Results

10 85 6Plan Follow Up Actions on The Identified Problem

13 83 3Discuss Problems Identified by Puskesmas Staffs

26 70 5Provide Updates on Administrative or Technical Issues

20 78 2Provide Encouragement

4 68 28Provide Written Feedback

17 76 7Observe Cader Posyandu Interaction with Mothers

26 72 2Check Record Keeping and Reporting

18 63 19Check Supplies

Spontaneous Prompted No/Dknow

Percentage

While visiting the posyandu is an important first step for monitoring, the visit is meaningful only if the staff reviews the activities, discusses problems, and offers solutions and technical updates to the posyandu staff (kader). Reviewing records and reporting formats was the most common activity carried out by the puskesmas staff during posyandu monitoring visits, and was mentioned spontaneously by 26 percent of the puskesmas staff and another 72 percent when prompted (Figure 6.2). The staff also said that they shared regular technical updates with the kader during their visits. One area that requires improvement was the provision of written feedback to the posyandu staff which was offered spontaneously by only 4 percent of respondents. Written feedback maintains a documentary trail that is important not just as a certification of the visit, but also helps record the feedback in a form that can be referred to during future visits.

Collection and analysis of data from the posyandu was a regular activity done by the puskesmas; however, provision of feedback on the data collected has scope for improvement. Another means of monitoring the puskesmas activities is the collection and assessment of the coverage (of outreach services) data from the kaders. All but three of the sampled puskesmas had a dedicated staff member who was responsible for collecting coverage data from the posyandu. Over 95 percent also had a staff member to analyze this data. They lagged in terms of providing feedback to the posyandu with respect to this coverage data, however, with only 88 percent of the puskesmas doing it. Even among those that provided the feedback, only 70 percent provided it on a monthly or more frequent basis.

Figure 6.2 Activities Carried Out by Puskesmas Staff During Posyandu Monitoring Visit

78


In many countries, including through pilot projects in Indonesia, the problem of not providing regular feedback has been addressed using mHealth technology. This involves digitizing the family-level data onto a platform that can be accessed and updated using mobile phones and/or computers. This enables health workers to access real-time information of clients and patients, get worksheets related to services that need to be provided (for example, names of children that need to be immunized), and update records in real time. This enables better supervision of staff, including providing feedback as well as substantially reducing time taken by staff on administrative tasks.

There is no correlation between receipt of monitoring visits from the DHO to the puskesmas and the service readiness index of the latter (Table 6.2). These findings need to be interpreted with caution, however, because most of the facilities had received at least one visit from the authorities on a particular theme in the 12 months preceding the survey; thus, the sample size for the ones which did not receive these visits is small. That could also be the reason why, contrary to expectations, the average service-readiness scores for TB is higher, for the facilities that did not receive the monitoring visits, although the difference is not statistically significant.

Table 6.2 Correlation Between Monitoring by the DHO (in the 12 months Preceding the Survey) and Service Readiness (for Selected Specific Services) of the Puskesmas.

Supply-side Readiness Score for Obstetric Care

N Mean SE Sd95% CI


Received Monitoring for Maternal HealthNo 12 25.25 1.40 4.86 22.16 28.34 -0.77 -0.55 0.58Yes 169 26.02 0.36 4.62 25.32 26.72All 181 25.97 0.34 4.63 25.29 26.65

Supply-side Readiness for Child Health

N Mean SE Sd95% CI


Received Monitoring for Child Health ProgramNo 16 16.31 0.73 2.94 14.75 17.88 -0.66 -0.90 0.37Yes 252 16.97 0.18 2.85 16.62 17.33All 268 16.93 0.17 2.85 16.59 17.28

Supply-side Readiness for Immunization

N Mean SE Sd95% CI


Received Monitoring for Childhood Immunization ProgramNo 13 9.85 0.44 1.57 8.90 10.80 -0.43 -0.72 0.47Yes 252 10.27 0.13 2.10 10.01 10.53All 265 10.25 0.13 2.07 10.00 10.50

Supply-side Readiness for TB

N Mean SE Sd95% CI


Received Monitoring for TB ProgramNo 19 6.84 0.19 0.83 6.44 7.24 0.46 1.38 0.17Yes 193 6.38 0.10 1.42 6.18 6.59All 212 6.42 0.10 1.39 6.24 6.61

Source: Indonesia QSDS 2016.Note: Only for Independent & Referral Puskesmas

79

Most of the sampled health facilities, both in the public and the private sector, reported using SP2TP98 which has been designed by the GoI for recording and reporting data on health services (Table 6.3). The puskesmas were significantly more likely to be using computers for data entry (both with and without a corresponding paper record) compared to the private clinics. The puskesmas staff were also more likely than the private-sector staff to have received training in the use of computers for SP2TP.

Health Information System

98 SP2TP: Sistem Pencatatan Pelaporan Terpadu Puskesmas (Puskesmas Integrated Reporting and Recording System).

Table 6.3 Use of Health Information System (SP2TP) With Public and Private-sector Health Facilities

FUNCTION Puskesmas Private Clinics

Use of SP2TP 94.1% 91.1%

Mode of Data Entry:

Computerized 12.1% 5.7%

Paper-based 12.6% 39.6%

Both computerized and paper-based 75.3% 54.7%

Staff Training:

On computer use for SP2TP 55.8% 21.0%

On data recording in SP2TP 62.8% 22.0%

Use of ICD10 to encode diseases 79.3% 56.7%

Reporting coverage of MSS indicators to DHO 96.2% n.a.


80


81

Summary ofFindings and Key Issues

to be Addressed

82


The key findings are summarized in Table 7.1 which also compares differences in key service-readiness indicators for puskesmas based on national estimates from Rifaskes 2011 and QSDS 2016. It must be reiterated here that the Rifaskes was a facility census of public-sector health facilities–unlike the QSDS. In addition, Rifaskes did not include private-sector facilities in its sample, hence there are no comparisons available for the same. Overall, both service availability and service readiness for general and specific services

have improved (green color) during the period, some indicators (such as the availability of electricity supply) have shown no change (yellow color), simply because they were already at high levels and there was no room for change. Despite improvement over Rifaskes levels, many other indicators–such as the management of infectious waste– leave room for considerable improvement even now. Although very few indicators have shown a dip compared to Rifaskes (red color), these are still a cause of concern.

Findings

Table 7.1 Key Findings From QSDS 2016 and Comparison With Rifaskes 2011

THEME AND SUBTHEME

(if any)

PUSKESMAS(Public Sector)

GENERAL PRACTITIONERS(Private Sector)

SERVICE AVAILABILITY

Access to Facilities

• On average, each puskesmas served about 29,000 to 30,000 people.

• The relatively stable average catchment area over the years shows that the increase in the number of puskesmas has kept pace with the increasing population on average.

• There was a wide variation in the catchment area (almost a 50-fold difference between the puskesmas with the highest and lowest numbers of population served).

• The average time to reach a puskesmas was 15 minutes. There was, however, a five-fold difference in the maximum and minimum average time to reach the facility. Average time taken to reach a rural puskesmas was double that taken to reach an urban one.

Data not captured in QSDS.

• Both public and private facilities were functioning all seven days of the week, with the private sector operating for a greater number of hours per day.

General Health Services

• All the sampled puskesmas offered outpatient care.

• About one-half of the puskesmas offered inpatient care.

• All the sampled private GPs offered outpatient care.

• Only 13 percent of the sampled clinics provided inpatient services.

Specific Health Services – Family Planning

• There was an almost universal availability of family planning services in the puskesmas. This is a significant increase over the Rifaskes data where only 74 percent of the facilities were providing family planning services.

• The availability of various methods matches the contraceptive use method mix ascertained by other surveys; hormonal methods like OCPs, injectables and implants are widely available, whereas there was a dearth of facilities offering male sterilization services.


83

THEME AND SUBTHEME

(if any)



Specific Health Services – ANC

• There was universal availability of ANC. As with family planning services, this also indicates an increase over Rifaskes when only 83 percent of puskesmas were providing ANC.

• Within ANC services, basic laboratory investigations like hemoglobin estimation and blood grouping were not available in in about 10-15 percent of puskesmas. The wide interdistrict variations revealed even further reduced availability in a few districts.

• The lack of availability of laboratory tests to detect concomitant diseases like HIV (51 percent) and syphilis (40 percent) was a cause for concern.


Specific Health Services – Obstetric Care

• Availability of obstetric care has also shown an increase from only 62 percent of the facilities providing delivery services in 2011 (Rifaskes) to three-quarters of the puskesmas sampled under QSDS.

• Routine interventions required for normal delivery, such as administration of oxytocin for prevention of PPH or maintenance of partographs, were being performed by almost all (97-99 percent) puskesmas.

• Very few puskesmas, even among those that stated that they provide BEmONC services, provided all the BEmONC signal functions. For example, less than one-half provided services for removal of retained products of conception and only 17 percent provided corticosteroids in cases on preterm labor.


Specific Health Services – Childhood Immunization

• While 86 percent of the public-sector facilities provided immunization services in 2011 according to the Rifaskes data, almost all (98 percent) of the puskesmas provided immunization services according to QSDS.

• Almost all the puskesmas that provided immunization also provided the same through outreach sessions.

• Newer vaccines like IPV, pneumococcal vaccines and those against rotavirus and Japanese Encephalitis were conspicuous by their absence from the list of vaccines provided by puskesmas.

• Only 15 percent of private GP clinics provided immunization services.

• Only 15 percent of the private clinics that provided immunization also did so through outreach sessions.

• Almost all the private clinics that offered immunization services also offered the newer vaccines like the ones against pneumococcus, rotavirus and Japanese Encephalitis.

• All the facilities in the public and private sector that provided immunization services covered the six basic antigens included in the original list of WHO’s EPI.

Specific Health Services – Childhood Health

• All the puskesmas and 90 percent of the private clinics provided child health services. This indicates a significant jump in the availability of services in the public sector from only 66 percent in 2011 as reported under Rifaskes.

• Services for management of childhood diarrhea (with ORS and zinc) and childhood ARI (with co-trimoxozole) were widely available in around 90 percent of the puskesmas and 75 percent of the private facilities.

• Availability of services to diagnose and manage malaria in children is a cause of concern, as it was available in only 63 percent of the puskesmas and 28 percent of the private clinics.

• Nutrition services for children were almost universally available in the puskesmas.

• Nutrition services for children were available in only one-third (35 percent) of the private clinics.

• Among those that did, the facilities focused primarily on counseling for breastfeeding and complementary feeding.

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THEME AND SUBTHEME

(if any)



Specific Health Services – Malaria

• Some 88 percent of the puskesmas offered services for malaria.

• Only 28 percent of the private facilities offered any malaria services.

• Health staff at the puskesmas relied on both clinical symptoms and laboratory tests to diagnose malaria.

• The private clinics depended almost exclusively on clinical symptoms to diagnose malaria.

• There was low availability of preventive treatment for malaria in both puskesmas (46 percent) and private-sector facilities (20 percent).

Specific Health Services – Tuberculosis

• Almost all the puskesmas offer TB services.• Active case detection for TB is almost

exclusively carried out by the public-sector facilities, using the services of the TB kaders for this purpose.

• Puskesmas rely primarily on sputum microscopy for diagnosis of TB.

• Almost all puskesmas use FDCs for treatment of TB.

• Only one-half of the private-sector clinics offer any services for TB.

• Only 21 percent of the facilities that offer any TB services also offer active case detection.

• Most of the private clinics rely on clinical symptoms to diagnose TB, with only two-thirds opting for sputum microscopy; only 38 percent offer FDCs for treatment and less than one-half of the clinics offer DOTS for TB. The quality of care for TB offered in the private sector is, therefore, questionable.

Specific Health Services – PMTCT

• There was a lack of PMTCT services in the health system, which was even starker in the private sector (19 percent) than in the puskesmas (54 percent).

• Within the PMTCT bandwidth of services, availability of ART for the HIV-positive pregnant women was abysmally low, with only 18 percent of the puskesmas and almost none (1 percent) of the private clinics that offer PMTCT services providing ART.

Specific Health Services – HIV Services

• There is limited availability of HIV services–in only two-thirds of the puskesmas and one-quarter of the private clinics.

• While counseling services are available in a larger proportion of the above facilities, especially in the puskesmas, care and support services and services meant for special target groups are available in very few facilities.

• The puskesmas and private clinics that did not offer counseling and testing services referred cases to the public hospitals where these services were available.

• As with PMTCT, there were very few facilities that offered ART.

Specific Health Services – STIs

• A total of 73 percent of puskesmas and 66 percent of the private clinics offer STI services.• Services were more readily available in urban compared to rural areas.• Only about one-half of the puskesmas and a smaller proportion of the private clinics had

diagnostic services for STIs, indicating that treatment for STIs was probably based on the syndromic management approach.

Specific Health Services – NCDs

• Diagnostic services for hypertension and diabetes were almost universally available in puskesmas and private clinics.

• There was a lot of variation in the availability of treatment of the five NCDs and conditions that were explored. There was no significant difference between the private rural and urban facilities.

SERVICE READINESS

General Services – Communication

• There was a lack of communication means at the puskesmas.

• There was a wide interdistrict as well as urban-rural variation in the availability of communication means.

• Almost all the puskesmas had a computer available at the facility.

• Urban puskesmas were more likely to have Internet access.

• Private clinics were more likely to have at least some means of communication.

• The availability of cell phones was higher in the private clinics compared to puskesmas.

• Only two-thirds of private clinics had computers; those that are part of the BPJS network were more likely to have one.

General Services – Referral Transport

• Some 96 percent of the puskesmas had their own means for referral transportation and it was functional on the day of the survey. This was an increase from 82 percent of the facilities under Rifaskes.

• Only 33 percent of the private clinics had their own functional referral transportation.

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THEME AND SUBTHEME

(if any)



General Services – Electricity

• As with Rifaskes, the QSDS too found that almost all the facilities had electricity supply.• The primary source of power for most facilities was the central grid supply.• Puskesmas were more likely to have a secondary/back-up source of power.• Generators were the most common source of back-up power supply.

General Services – Water, Hygiene and Sanitation

• The proportion of facilities that received water supply from an “improved water source” increased from 72 percent in 2011 to over 90 percent in 2016.

• Piped water into the facility was the commonest source of water supply.

• Almost all the facilities had functioning toilets for patients’ use.

General Services – Privacy

• Only one-quarter of the puskesmas had at least one room that allowed both auditory and visual privacy.

• One-half (48 percent) of the puskesmas did not offer any privacy.

• Rural puskesmas were more likely to offer no privacy compared to urban ones.

• More than one-half of the private clinics had chambers that offered both auditory and visual privacy.

General Services – Infection Prevention and Waste disposal

• Only one-quarter of all facilities met all the infection prevention and waste disposal standards. Although still low, this is an increase from just 13 percent of the facilities as reported under Rifaskes.

• More than one-half of facilities in both the public and private sector did not store infectious waste appropriately.

• Most facilities used the services of a professional agency for medical waste for final disposal of the medical waste generated at the facility.

• Some 87 percent of the puskesmas had at least one piece of medical sterilizing equipment.

• Only 64 percent of private clinics had a medical equipment sterilizer.

General Services – Equipment

• While only 28 percent of the facilities had all the basic equipment available in 2011, it increased marginally to 39 percent in 2016–still leaving considerable scope for improvement.

• Equipment was less available in the private clinics.

• Facilities were more likely to have generic equipment like BP apparatus and stethoscope compared to equipment usually used by specialists only (such as an ophthalmoscope and tonometer).

General Services – Medicines

• The availability of the drugs at the puskesmas was variable depending on the type of drug. For example, basic oral antibiotics were readily available, whereas injectable and high-end antibiotics were less likely to be found in stock.

QSDS tool inquired about the availability of only a limited number of drugs in the private clinics.• Lifesaving medicines were available in a

smaller proportion of the private clinics compared to the puskesmas.

General Services – Diagnostics

• More than 90 percent of the puskesmas had a laboratory within their premises.

• Less than 40 percent of the private clinics had laboratory facilities; the availability of all diagnostic tests was, therefore, significantly lower in the private clinics.

Specific Services – Staff Training and Guidelines

• Puskesmas were more likely than private facilities to have the various technical guidelines available in their facilities.

• The availability of RMNCH-related guidelines was higher compared to those for communicable diseases and NCDs.

• Puskesmas staff were more likely to be trained in provision of RMNCH and communicable diseases compared to NCD services.

• The availability of guidelines is very similar to what was found in Rifaskes for most of the thematic domains, the key exceptions being communicable diseases like TB and malaria, where a major dip was observed in the availability of technical guidelines.

The QSDS tool did not inquire about the availability of maternal health and family planning-related guidelines in the private clinics.• The availability of guidelines and staff

trained for NCDs almost matched that in the puskesmas.

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THEME AND SUBTHEME

(if any)



Specific Services – Equipment

• Most of the equipment for specific services was readily available in the public and private-sector facilities.

• AD syringes were available in a limited number of facilities.• There was a lack of auditory and visual privacy that is needed for HIV counseling.• Among all the NCDs, the availability of equipment for CRDs needs attention.

• Maintenance of cold chain for vaccines, especially ensuring appropriate temperature in the refrigerator, was a cause for concern.

• The private clinics lacked equipment for anthropometric measurement of children.

Specific Services – Diagnostics

• The availability of diagnostics was low, especially in single-provider managed clinics.

• Stock-outs of RDTs for various diseases was common.

Logistics Management of Drugs and Consumables

• Stock-outs of drugs and diagnostics was common in both the public and private sector.

• The puskesmas had a functioning LMIS.• The quality of the LMIS was questionable given

the frequent stock-outs.• In most cases, the facility stated that the

inability of the warehouse to supply the needed drug/diagnostic was the reason for the stock-out.

• Private clinics did not appear to have a formal system for logistics management.

• The common reason for a stock-out was the failure of the clinic to place an order for the product on time.

• In case of stock-outs, patients were often asked to purchase the product from the open market/pharmacy.

HUMAN RESOURCES FOR HEALTH

Staff Availability

• When compared to the norms set by GoI, puskesmas were found to be short on the availability of nonmedical staff such as the nutritionist and pharmacists.

• The availability of staff was poorer in the rural facilities compared to the urban ones.

• The nonlegitimate absenteeism rate among the puskesmas staff was almost nonexistent.

• While there are no norms for staff availability in the private clinics, the availability of paramedical and nursing staff in these clinics was far less than that of the puskesmas.

• The overall staffing pattern in the clinics reflects a reliance on doctors to provide patient care as well as to manage the facility.

Staff Training

• The puskesmas regularly conduct mini-workshops in their premises, most commonly on topics related to program management.

• Reasons for missing out on other training organized by GoI or the local governments was the nonselection of a staff member for the training or the distance of the training venue from the puskesmas.

• The private-sector staff were less likely to be trained on various themes compared to the puskesmas.

• Most of the clinics stated lack of awareness and information about the existence of such training as the reason for not attending the same.

• To make up for lack of formal training, both the puskesmas and private clinics organized discussion forums within their premises or asked the staff themselves to be responsible for updating their own knowledge base.

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THEME AND SUBTHEME

(if any)



FINANCING OF PUSKESMAS

JKN Empanelment

• All puskesmas were empaneled with BPJS. • Only 43 percent of private clinics were empaneled under BPJS.

• There was a disinterest in JKN from those who were not empaneled.

• Urban clinics were more likely to be empaneled.

Capitation Fee

• Some 43 percent of the puskesmas and 46 percent of the private clinics received less than the maximum allowed capitation fee of IDR 6,000 and IDR 10,000 per member respectively.

• The lack of an adequate number and type of staff as mandated by BPJS was the key reason for receipt of less capitation fees.

Utilization of Funds• Over 85 percent of the puskesmas were unable

to utilize all the funds received through the payment of capitation fees.

Data not available.

Revenue

• Between 2013 and 2015, puskesmas have seen a four-fold increase in revenue–from IDR 293 million to IDR 1,056 million.

• The primary reason for this increase is the increase in capitation fees from BPJS.

• Revenues from OOP have reduced as a proportion although there is no reduction in terms of absolute amounts.


Expenditure

• Monetary incentives and bonuses to staff account for more than one-half of puskesmas’ expenses.

• Spending on equipment and consumables is a very small part of puskesmas’ expenses.


MANAGEMENT OF HEALTH FACILITIES

Monitoring and Evaluation

• The DHO was more likely to visit the puskesmas to monitor for RMNCH-related services compared to communicable disease and NCD programs.

• Puskesmas staff visit the posyandu regularly.• During these visits to the posyandu, the staff

reviewed the records and reports regularly, however, they generally failed to provide written feedback to the posyandu.

• The puskesmas also collected data from the posyandu on a regular basis, however, they failed to give any feedback to the latter on the data submitted.


Health Information system

• Both the puskesmas and the private clinics were using the HMIS designed by GoI, that is, the SP2TP.

• Some 87 percent of the puskesmas were using computers for data entry into SP2TP, both with and without a back-up paper trail.

• Only 60 percent of the private clinics were using computers for data entry.

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QSDS 2016 shows an overall improvement in service availability and readiness at puskesmas. This survey has also yielded important information related to the service availability, readiness and functioning of the private-sector primary-care clinics, which was not available through any of the previous studies.

Despite the overall progress, there are many areas of concern which will need focus and corrective action, including:

a. The service availability and readiness of the private-sector clinics lagged that of the puskesmas. The mean readiness index for general services for the private clinics was 61 percent compared to 78 percent for the puskesmas (Appendix 5). Similar differences in readiness index were visible across the specific-services spectrum (Appendix 6).

b. Within the private sector, the clinics that were not empaneled with BPJS fared worse than the empaneled ones. As this is a cross-sectional survey, it cannot be said whether empanelment with BPJS is the cause or the effect of improved readiness. On one hand, there were many facilities that did not get empaneled as they did not meet the human resource and service-delivery criteria set by the agency. On the other hand, the receipt of maximum capitation fees from BPJS did have a positive correlation with improved service readiness in the BPJS-empaneled private clinics. At a minimum BPJS, therefore, appears to be a platform that can be used to improve service readiness of private facilities, whether it is through setting stringent standards for empanelment and/or by encouraging facilities to improve their position further through appropriate use of capitation fees.

c. Besides being less “ready” than the public sector to provide services, the quality of services provided by the private clinics was also questionable in many cases:• Some 90 percent of the private clinics that

offered TB services based their diagnosis on clinical symptoms and only two-thirds used

Issues of Concern

the gold standard, that is, sputum microscopy, to confirm their diagnosis. These facilities cited the absence of a laboratory in the facility as the reason for not offering these diagnostic services. In addition, less than one-half of the private clinics that prescribed ATT (43 percent) offered FDCs and/or DOTS. Owing to the long duration of the antitubercular drugs’ course, nonDOTS treatment is known to increase treatment default. Additionally, only one-quarter (26 percent) offered follow-up services of patients, which means that cases of default are neither captured not brought back into the system for treatment continuation. Both these can lead to a rise in MDR-TB rates.

• In contrast to the puskesmas that used both clinical presentation and laboratory tests like microscopic examination of peripheral smear and RDTs to diagnose malaria, practitioners in private clinics relied almost exclusively on clinical symptoms.

d. While the average population served by a puskesmas has remained constant over the years (at around 30,000), ensuring equitable distribution of the puskesmas deserves greater attention. While this confirms that the increase in the number of these primary-care facilities has kept pace with the rising population in Indonesia, QSDS 2016 has revealed a wide variation in access to the puskesmas in terms of both distance and time to reach care, indicating that factors beyond the population size served need to be borne in mind when improving access to primary health care services.

e. The restricted availability of the following specific services deserves attention:• While 75 percent of the puskesmas provided

delivery services, only one-half had BEmONC services. Even in these limited facilities, however, key signal functions of BEmONC (such as manual removal of placenta) was provided by very few facilities. This lack of services to manage obstetric complications could be a direct cause of the slow progress in MMR reduction in the country.

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• Availability of malaria-related services–especially for childhood malaria–were limited. Less than two-thirds (63 percent) of puskesmas and less than one-third (28 percent) of private-sector facilities offered these services for children. While a higher proportion of puskesmas (88 percent) stated that they provide these services for the general population, the proportion remained similarly low (28 percent) for the private sector. Within the spectrum of malaria services, preventive treatment for malaria was available in only 46 percent of the puskesmas and 20 percent of the private facilities. While it is recognized that malaria services are linked to endemicity of the disease, no province or district can be presumed to be completely free of the disease and, therefore, not having any facility in that area provide services requires attention.

• Very few facilities, especially in the private sector, offer HIV-related services. Even among those that do, the focus is on HIV-related counseling, whereas testing facilities and the provision of ART (both for the people living with HIV and AIDS and under the PMTCT program) is provided by very few. For example, while only about one-half of the puskesmas provide PMTCT services, the availability of ART for HIV-positive women and/or the newborns was restricted to only 18 percent of these facilities, which translates to less than 10 percent of the sampled puskesmas. The figure is similar for provision of ART for the “general” (nonpregnant) population. Such a low availability at primary-care facilities drastically reduces access to these services and increases the risk of treatment noncompliance, which, in the case of HIV and AIDS, also results in an increased risk of transmission. Other than provision of ART, other HIV-related services directed towards special target groups, such as methadone maintenance therapy and a needle syringe program, are offered by very few puskesmas and none of the private clinics.

• While the health sector appears to be geared up to handle some NCDs, like diabetes and CVDs, there appears to be a lack of focus on CRDs. Compared to other NCDs like diabetes, not only do fewer facilities offer services for this component, but are less ready in terms of availability of trained staff and equipment (for example, peak flow meters were available in only 13 percent and 43 percent of the public and private-sector facilities that were offering NCD coverage respectively).

f. QSDS has revealed frequent stock-outs of diagnostics, medicines and other commodities in both the puskesmas and private-sector clinics. • The biggest reason for the stock-outs cited by

the puskesmas was the inability of the local/regional warehouse to provide supplies in a timely manner, which points towards an issue of SCM between the districts and the suppliers under the e-catalogue system. In some other cases, the flaw lay with the estimation made by the facility of its requirements. While the puskesmas can, and should, expend part of their facility budget on local purchase of items in case of impending stock-outs, the very low level of expenditure under this head indicates that this is not being done by the puskesmas. Most of the puskesmas did, in fact, have a functioning LMIS, which included a system and designated personnel to calculate requirements, ordering for commodities and its supply to the facility.

• Unlike the puskesmas, the private clinics are not mandated to keep stocks of many of the items that the QSDS enquired about. The QSDS revealed that these clinics do not have a system to ensure adequate stocks of even the essential commodities such as emergency drugs.

Solutions specific to the type of facility would need to be explored to ensure regular and constant availability of essential drugs, diagnostics and other commodities. For example, public-private partnerships could be used to expand diagnostic availability to both puskesmas and BPJS-empaneled private-sector clinics. Similarly, an improved LMIS that enables both puskesmas and BPJS-empaneled private-sector clinics to do better demand forecasting for medicines and supplies, along with provision of quality generic medications could be rolled out–with these supplies being reimbursed under the JKN.

a. Staff of both the puskesmas and the private clinic were found to be missing out on the training being offered by MoH and employing alternate means for professional development of staff.• The reasons cited by the public-sector facilities

(such as staff not being selected for the same, or the training not being available in their district) point towards certain flaws in the selection system and planning of this training. In comparison, the private clinics were not

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aware of much of the training, indicating the need for MoH to improve communication with the private sector and regularly inform them about the training on offer. There is, therefore, a need to strengthen the training system such that all puskesmas are given a chance to get their staff trained on various issues. Training needw to be held close to the facility to avoid travel and other logistical issues that may hinder participation in the training. Providing training sessions closer to the facility will also reduce the time that the staff are absent from facility, thus reducing the disruptive impact staff training sometimes has on staff attendance at the facility.

• In the absence of government-led training, the facilities rely on alternate means such as holding internal discussions and/or relying on the staff to take the initiative to update themselves depending on the technical topic concerned. The latter is not a reliable way to ensure technical updates and wherever government training is not available, the facility management needs to take charge to update its staff on evidence-based technical standards.

b. While QSDS 2016 found an overall increase in service readiness at the puskesmas when compared to Rifaskes 2011, the following areas of concern were noted:• There was not much change in the availability

of general medicines and basic equipment required for general service readiness in the facility.

• Availability of medicines and commodities for a number of specific services such as ANC, immunization and diabetes management showed a decline compared to Rifaskes.

• In both the surveys, lack of availability of basic diagnostics was a cause of concern.

• The availability of guidelines for various specific services generally improved. The exceptions were guidelines for TB and malaria, which showed a steep decline of over 10 percentage points (from 75 percent to 49 percent for TB and from 59 percent to 49 percent for malaria) compared to Rifaskes.

• None of the facilities met all the indicators for general service readiness in both the surveys.

c. Other issues related to service readiness include:• In contrast to the puskesmas all of which had

at least one functioning emergency transport

vehicle, only one-third (33 percent) of the private clinics had such facilities–with single-provider run clinics being far less likely to have such a referral transport system ready. As these are primary-care facilities that are more likely to refer complicated cases than manage them at the facility, there is a need for a more systematic ambulance system to be introduced for timely referrals, especially by the private sector.

• About one-half of the sampled facilities in both the public and private sector were found to be not adhering to waste segregation guidelines for infectious medical waste. Storage of sharp waste material was also an issue with the private sector.

• Lack of privacy in the clinics for provider-patient interaction, was a cause for concern, especially in the puskesmas. This was of greater concern in the facilities offering HCT services, where less than one-half of these facilities had these amenities.

d. Lack of availability of skilled human resources was concerning. When compared to the norms set by GoI, there was an overall lack of nonmedical staff such as the pharmacist and nutritionist at the puskesmas. In contrast, the private-sector clinics, especially the single-provider ones, were overly dependent on the doctors and had significantly fewer nursing, administrative and other support staff. Lack of staff was also the main reason for the facilities receiving less than the mandated maximum capitation fee per member as their staff strength did not meet the norms set by BPJS.

e. The maximum capitation fee per registered member provided to a puskesmas was IDR 6,000, whereas it was IDR 10,000 for the private facilities as puskesmas also receive other government budgetary financing. Some 43 percent of the puskesmas and 46 percent of the private clinics received less than the maximum capitation fee–the primary reason for being lack of staff as mandated by BPJS. There was no significant difference observed between puskesmas that received maximum capitation versus those that did not in terms of supply-side readiness. In contrast, the difference in service readiness between empaneled private-sector facilities that received the maximum capitation fee versus those that received less than the full fee was statistically significant. This indicates that JKN is a key instrument that can be used to influence supply-side readiness for the private sector.

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f. About one-half of puskesmas revenue was spent on providing monetary incentives to their staff, with relatively little being spent on drugs and consumables. Further analysis reveals that the facilities that utilize the funds completely are, contrary to expectations, less service ready than those that do not expend the complete allocated amount. These differences were not, however, found to be statistically significant except for child-health preparedness. It points to the need to direct and monitor spending of BPJS funds by the puskesmas and ensure that JKN serves as a driver to improve supply-side readiness.

g. The public sector had a functional monitoring system with a few lacunae: • While regular monitoring visits from the DHO

to the puskesmas and by the puskesmas staff to the posyandu were being performed, the system of providing written feedback needs improvement.

• The fact that there was no significant difference in terms of supply-side readiness between puskesmas that received regular monitoring and supervision versus those that did not reflects the need to improve the system so that it has the desired effect of improving supply-side readiness and quality of services being provided by the facility.

h. Both the public and private-sector facilities were using the SP2TP (health management information system) for recording and reporting health information. While the public-sector facilities were using computers to maintain these records, the private sector was more dependent on a paper-based system.

This report brings out the key findings in primary health care supply-side readiness across public and private facilities, rural and urban facilities, private facilities empaneled by BPJS Health versus those who have not, amongst others. The primary aim of the report is to present findings from the survey that can inform policy choices. It is important that these findings are addressed through key policy and implementation actions related to health financing, service delivery and governance. While this report itself does not cover these recommendations, many of these have been covered by other publications and will also be covered in other forthcoming work.

As mentioned earlier, supply-side readiness improvement is necessary, but not sufficient, to improve service-delivery access and outcomes. There needs to be a package of policy interventions to improve performance and quality of primary health care quality, including strengthening performance monitoring and accountability, ensuring supply-side readiness verification and improving managerial capacity as well as strengthening adherence to clinical processes through accreditation, incentivizing local governments and providers to achieve results by linking supply-side (DAK) and demand-side (JKN) financial transfers to performance, strengthening human resource skills and competencies, enabling better distribution of human resources as well as introducing innovations for better service delivery by frontline providers.

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Appendixes

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Introduced in 2015, the GoI’s fl agship health program is the Healthy Indonesia Program (HIP). The program aims to improve the health and nutritional status of the community through health and community empowerment efforts, backed by financial protection and the equitable distribution of health services. HIP is an umbrella program that encompasses the entire public health expenditure, through central and local governments, and was IDR 178 trillion (US$13.2 billion) in 2016.

HIP is organized around three pillars: Promoting a Healthy Paradigm (Pillar 1); Strengthening Health Care Services (Pillar 2); and The National Health Insurance Scheme (JKN) (Pillar 3). HIP has 12 subprograms, the first three are related to priority outcomes, the remaining nine subprograms are designed to achieve these

Appendix 1A Brief Description of GoI’s Health Program

three priority outcomes. Promoting a Healthy Paradigm, is implemented through strengthening of preventive and promotive efforts such as the Healthy Indonesia through the Family Approach Program or Program Indonesia Sehat Melalui Pendekatan Keluarga (PIS-PK) and a community campaign for healthy living (Gerakan Masyarakat Hidup Sehat or GERMAS). The aim of Strengthening Health Care Services is to improve access to quality primary health care and hospital services, and to strengthen the referral system, including through accreditation and human resources. The third pillar, which is the National Health Insurance Scheme (JKN) is focused on beneficiary enrolment and expansion of benefits, as well as a focus on achieving quality and cost control. The cross-cutting strategies support all three pillars.

Priority outcomes:• Family health – including maternal and child health;• Nutrition; and• Disease control and environmental health: including both communicable diseases (HIV and AIDS, TB and

malaria), and NCDs (Diabetes Mellitus, Hypertension, cervical and breast cancer, obesity and mental health)

PILLAR 1:Promoting a Healthy Paradigm

PILLAR 2:Strengthening Health Care Services

PILLAR 3:The National Health Insurance

Scheme

OBJECTIVE

Strengthening preventive and promotive efforts “Healthy Indonesia” through the Family Approach Program (PIS-PK) and Community Campaign for Healthy Living (GERMAS).

Improve access to quality primary care, hospital care and referral through accreditation and HRH.

Improve beneficiary enrolment and expansion of benefits at the same time as achieving better quality and controlling costs.

SUBPROGRAMS

Health prevention, promotion and community empowerment

• Quality primary care• Quality referral care• Pharmaceutical & Equipment• Food and Drug Regulation• HRH

National Health Insurance (JKN)

CROSS-CUTTING PROGRAMS

-Management, research and development, health information systems; and-Health financing

GoI Healthy Indonesia Flagship Program: Twelve Subprograms Under Three Pillars and Cross-cutting Areas

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DOMAIN PERCENTAGE OF FACILITIES WITH

Basic Amenities • Power (a grid or functional generator with fuel)• Improved water source within 500 meters of facility• Room with auditory and visual privacy for patient consultations• Access to adequate sanitation facilities for clients• Communication equipment (telephone or short-wave radio)• Facility has access to computer with email/Internet access• Emergency transportation

Basic Equipment • Adult scale• Child scale• Infant scale• Thermometer• Stethoscope• Blood pressure apparatus• Examination light (flash light)

Standard Precautions for Infection Prevention

• Electric dry heat sterilizer, electric boiler or steamer (no pressure), nonelectric pot with cover for boiling/steam, heat source for nonelectric equipment

• Safe final disposal of sharps includes incineration, open burning in protected area, dump without burning in protected area, or remove offsite with protected storage. If method is incineration, incinerator functioning and fuel available.to manage (hospital or private service)

• Safe final disposal of infectious wastes includes incineration, open burning in protected area, dump without burning in protected area, or remove offsite with protected storage. If method is incineration, incinerator functioning and fuel available

• Sharps container (“safety box”) • Waste receptacle (pedal bin) complete with lid and plastic bin liner • Environmental disinfectant (for example, chlorine, alcohol) • Disposable syringes with disposable needles, AD syringe • Clean running water (piped, bucket with tap, or pour pitcher), handwashing soap/liquid

soap • Disposable latex gloves

Diagnostic Capacity • Hemoglobin testing• Blood glucose tests using a glucometer • Rapid malaria testing, malaria smear test • Urine protein dipstick testing • Urine glucose dipstick testing • Rapid test HIV • Syphilis Rapid Test • Urine rapid tests for pregnancy (PP test)

Appendix 2Indicators for Measuring General Service Readiness of Health Facilities

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DOMAIN PERCENTAGE OF FACILITIES WITH

Essential Medicines • Oral calcium channel blocker antihypertensive (for example, Amlodipine capsule/tablet [Actapin, Amcor, Amdixal, Cardivask, Divask, Exforge, Lovask, Normoten, Norvask, Sandovask, Tensivask], Nifedipine capsule/tablet [Adalat, Adalat OROS, Farmalat, Cordalat], Diltiazem capsule/tablet [Cordila, Dilmen, Farmabes], Nicardipin capsule/tablet [Blistra, Perdipin])

• Oral antibiotic drugs: Amoxycillin dispersible tablet or syrup/suspension [Amoxilin, Amoxsan, Kalmoxillin, Novax, Opimox, Solpenox, Moxigra, Topcillin, Yusimox]

• Oral antibiotic drugs: Amoxycillin dispersible tablet or syrup/suspension [Amoxilin, Amoxsan, Kalmoxillin, Novax, Opimox, Solpenox, Moxigra, Topcillin, Yusimox]

• Injectables beta-lactam antibiotic (for example, Ampicillin injection, Procaine benzylpenicillin injection) [Ampi, Viccilin, Binotal, Kalpicilin; Procaine Penicillin]

• Oral antiplatelet drug: Acetylsalicylic acid (Aspirin) capsule/tablet [Aptor, Ascardia, Aspilet, Cardio Aspirin, Farmasal, Frosit, Glocar, Thromboaspilet]

Essential medicines • Oral beta-blocker antihypertensive (for example, Bisoprolol capsule/tablet [Lodoz, Concor] Metoprolol capsule/tablet, Carvedilol capsule/tablet, Atenolol capsule/tablet)

• Oral anthelmintic drugs: (for example, Albendazole capsule/tablet,[Helben] Mebendazole capsule/tablet [Gavox, Trivexan] Pyrantel pamoate capsule/tablet, Praziquantel capsule/tablet [Combantrin, Upixon]

• Antiepileptic/anticonfulsion drugs (for example, Diazepam injection, Diazepam per rectal)

• Oral antihypertensive ACE inhibitor drug (for example, Captopril capsule/tablet [Dexacap, Acepress, Farmoten, Otoryl, Vapril], Enalapril capsule/tablet [Meipril, Renacardon, Tenten], Lisinopril capsule/tablet [Noperten, Inhitril, Interpril, Odace, Tensinop, Tensiphar, Zestril], Ramipril capsule/tablet [Candace, Hyperil, Ramixal, Vivace], Perindopril capsule/tablet)

• Injectables anticonvulsant drugs for preeclampsia and eclampsia: Magnesium sulphate injection

• Oral biguanide antidiabetic: Metformin capsule/tablet • Lipid-lowering agent (for example, Simvastatin capsule/tablet [Cholestat, Lipinorm,

Phalol, Rocoz, Simchol, Valemia, Vytorin, Vidastat, Zocor], Atorvastatin capsule/tablet [Actasipid, Atofar, Lipitor, Stator, Caduet, Truvaz], Fenofibrate [capsule/tablet Felosma, Fenolip, fibramed, Hyperchol, Lipanthyl, Profibrat, Trichol, Trolip, Zumafib], Gemfibrozil capsule/tablet [Hypofil, Lapibroz, Lifibron, Lipitrop, Lipres, Lokoles, Lopid, Mersikol, Renabrazin, Zenibroz, Zilop])

• Zinc sulphate dispersible tablet or syrup/suspension [Daryazinc, L-Zinc]

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HEALTH SERVICES GUIDELINES TRAINING EQUIPMENT DIAGNOSTICS MEDICINES AND

COMMODITIES

Basic Obstetric Care

• Pocket book of essential neonatal care (Buku Saku Pelayanan Neonatal Esensial)

• Pocket book of maternal health care in primary and referral health facility

• Any guideline related to obstetric and neonatal care:

• Training on basic emergency obstetric and neonatal lifesaving skills

• Training on management of asphyxia for neonates

• Training on assisted vaginal delivery

• Any training on obstetric and neonatal care, specify:

• Emergency transportation

• Electric autoclave (pressure & wet heat), nonelectric autoclave, electric dry heat sterilizer, Electric boiler or steamer (no pressure), nonelectric pot with cover for boiling/steam, heat source for nonelectric equipment

• Examination light (flashlight)

• Delivery pack• Electric suction

pump (for suction apparatus) and suction catheter

• Suction bulb• Manual vacuum

extractor• Vacuum aspirator or

Dilation & Curettage kit

• Neonatal bag and mask for term babies (for neonatal resuscitation)

• Delivery table• Blank partograph• Disposable latex

gloves• Infant scale• Blood pressure

apparatus• Soap and running

water

• Eye ointment antibiotic• Injectable oxytocin • Injectable beta-

lactam antibiotic: (for example, Ampicillin injection, Benzathine benzylpenicillin injection, Procaine Benzylpenicillin injection)

• Injectable aminoglycoside antibiotic: Gentamycin injection

• Injectable anticonvulsant drugs for preeclampsia and eclampsia: Magnesium sulphate injection

• Skin disinfectant (for example, Povidone Iodine solution)

• Ringer’s lactate IV solution

• Normal saline IV solution (NaCl 0.9%)

• 5% dextrose IV solution• Injectable oxytocic

drugs for prevention and treatment of PPH: Methylergometrine maleate

• Oral oxytocic drugs for prevention and treatment of PPH: Capsule/tablet Methylergometrine maleate

• Antiamoebic and antigiardial drugs: Metronidazole Intravenous Infusion

• Oral macrolide antibiotic: (for example, capsule/tablet Azithromycin, Syrup/suspension Azithromycin)

• Oral beta-lactam antibiotic: capsule/tablet cefixime, Capsule/tablet cefadroxil

• Calcium gluconate injection

• Injectable corticosteroid drugs: (for example, Dexamethasone injection, Hydrocortisone injection)

• Sterile water forinjection• Coagulant modifier drug:

Vitamin K injection (Phytomenadione)

• Injectable antiepileptic-anticonvulsant drugs (for example, Phenobarbital injection, Diazepam injection, Amobarbital injection)

Appendix 3Indicators for Measuring Specific Service Readiness of Health Facilities

97


COMMODITIES

Family Planning Services

Practical guidelines on contraceptive services

• Training on contraceptive technique update

• Training on counseling on family planning using “Alat Bantu Pengambilan Keputusan Ber-KB”

• Blood pressure apparatus (may be digital or manual sphygmomanometer with stethoscope)

• Implant kit• IUD kit

• Contraceptive pills (for example, combined Levonorgestrel and Ethinylestradiol)

• Injectable contraceptive (for example, Medroxyprogesterone acetate)

• Male condoms• IUD• Implant (for example,

Levonorgestrel)

ANC Services • KIA book• National guidelines

on integrated ANC • National guidelines

on PMTCT • Delivery

preparedness and complication readiness program

• Manual and/or training package on pregnant women class (including package and/or facility guidelines and/or pregnant women class operation guidelines)

• Any ANC training• Any guideline

related to ANC• Training on

pregnant women class

• Any intermittent preventive treatment (IPT) of malaria in pregnancy training

• Training on Delivery Planning Program and Complication Prevention

• Training on PMTCT

• Blood pressure apparatus

• Stethoscope• Adult weighing scale• Doppler

• Hemoglobin meter (HemoCue)

• Urine protein dipstick testing

• IFA• Tetanus toxoid vaccine

Routine Child Immunization

• Guideline on Immunization Delivery

• Guideline on Monitoring and Management of Adverse Effects Following Immunization (AEFI)

• Training on microplanning

• Training on immunization service delivery

• Training on injection safety

• Training on vaccine management/handling and cold chain

• Training on data reporting and data monitoring of service delivery

• Training on AEFI

• Vaccine carrier(s)/cold box/thermos

• Refrigerator• Sharps container/

safety box• AD syringes• Temperature

monitoring device in refrigerator

• Adequate refrigerator temperature

• Measles vaccine• DPT-Hib+HepB vaccine• Oral polio vaccine• BCG vaccine

Child Preventive and Curative Care

• Guidelines for IMCI• Guidelines for

growth monitoring

Staff trained in IMCI • Infant weighing scale• Child weighing scale• Height measurement

tape/Microtoise• Length measurement

board• MUAC measuring

tape• Thermometer• Stethoscope pediatric

or any stethoscope• Growth charts • Blood pressure strap

for children • ARI timer/ stopwatch

• Hemoglobin testing

• General microscopy/wetmounts

• Rapid malaria testing/malaria smear test

• ORS• Oral antibiotic drugs:

Amoxycillin dispersible tablet or syrup/suspension

• Oral antibiotic drugs: Co-trimoxazole syrup/suspension

• Oral antipyretic or analgesic: (for example, Paracetamol syrup/suspension

• Retinol capsule (Vitamin A)

• Oral anthelmintic drugs: (for example, Albendazole capsule/tablet, [Helben] Mebendazole capsule/tablet [Gavox, Trivexan] Pyrantel pamoate capsule/tablet, Praziquantel capsule/tablet [Combantrin, Upixon]

• Zinc sulphate dispersible tablet or syrup/suspension

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COMMODITIES

Malaria National Guideline for Malaria Diagnosis and Treatment

• Training on malaria diagnosis and treatment

• Any IPT of malaria in pregnancy training

• Rapid Malaria Testing

• Malaria Smear Test

• Light microscope or Diagnostic Microscopy

• Artemisinin Combination Therapy: Artesunate + Amodiaquine + Primaquine

• Paracetamol 500 mg• LLINS and LLIN vouchers

Tuberculosis • National Guideline for TB Diagnosis and Treatment

• National Guideline for Management of HIV and TB coinfection

• Training on diagnosis and treatment of TB

• Training on management of HIV and TB coinfection

• Training on management and treatment of MDR-TB

• Light microscope• Rapid test HIV • Screening or

testing for TB among People Living with HIV

• Mantoux Test• Provision of drugs

to TB patients• Sputum smear

and microscopy examination

Isoniazid, Pyrazinamide, Rifampicin, and Ethambutol, or combinations to meet first-line TB treatment

HCT National guidelines on HCT, others

Training on HCT (VCT and/or PITC), others

Counseling room has to be comfortable, private, separate from waiting room and blood sampling room, and has separate entry and exit

Rapid test HIV Condoms

HIV – CST • National guidelines for ARV therapy for adults

• National guidelines on HIV treatment for children

• Any guidelines on CST

• Training on HIV CST• Training on HIV

and TB coinfection• Any training on

HIV CST

Screening or testing for TB among People Living with HIV

• Normal saline IV solution, Ringer’s lactate IV solution, 5% dextrose IV solution

• Oral antifungal drugs: (for example, Fluconazole capsule/tablet, Ketoconazole capsule/tablet, Griseofulvin capsule/tablet, Nystatin capsule/tablet)

• Oral sulfa-trimethoprim antibiotic: Co-trimoxazole

• First-line TB treatment medications

HIV – Antiretroviral Prescription and Client Management

National guidelines for ARV therapy for adults

Training on HIV CST • Hemoglobin testing, white blood cell testing, thrombocyte testing

• CD4 count• Specific assay

kit, centrifuge, biochemistry analyzer

• Zidovudine cap/tab (ZDV, AZT)

• Zidovudine syrup/suspension (ZDV, AZT)

• Abacavir cap/tab (ABC)• Lamivudine cap/tab (3TC)• Tenofovir Disoproxil

Fumarate cap/tab(TDF)• Emtricitabine cap/tab

(FTC)• Didanosine cap/tab (DDI)• Zidovudine +

Lamivudine cap/tab(AZT + 3TC)

• Nevirapine cap/tab (NVP)• Nevirapine syrup/

suspension (NVP)• Efavirenz cap/tab (EFV)• Lopinavir + Ritonavir

cap/tab (LPV/r)• Zidovudine +

Lamivudine + Nevirapine cap/tab (AZT + 3TC + NVP)

• Stavudine + Lamivudine + Nevirapine cap/tab (D4T + 3TC + NVP)

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COMMODITIES

HIV - PMTCT • PMTCT guidelines (for example, guidance book, poster on the wall)

• Guidelines on infant and young child feeding practices (IYCF)

Training on counseling on IYCFTraining on PMTCT

Visual and auditory privacy

Rapid test HIV • Oral NNRTI antiretroviral drugs: Nevirapine syrup/suspension (NVP)

• Option A:• AZT, NVP, and 3TC• Option B:• AZT + 3TC + LPV or• AZT + 3TC + ABC or• AZT + 3TC + EFV or• TDF + 3TC (or FTC) + EFV

Diabetes Guidelines for diabetes diagnosis and treatment

Staff trained in diabetes diagnosis and treatment

• Blood pressure apparatus

• Adult scale • Measuring tape

(height board stadiometer)

Blood glucoseUrine dipstick-proteinUrine dipstick-ketones

• Metformin cap/tab• Glibenclamide cap/tab • Glucose injectable

solution• Glipizide

CVDs Guidelines for diagnosis and treatment of chronic cardiovascular conditions

Staff trained in diagnosis and management of chronic cardiovascular conditions

• Stethoscope• Blood pressure

apparatus • Adult scale • Oxygen

• ACE inhibitors (for example, enalapril)

• Beta blockers (for example, atenolol)

• Calcium channel blockers (for example, amlodipine)

• Aspirin cap/taps• Metformin cap/taps• Hydrochlorothiazide

CRDs Guidelines for diagnosis and management of CRD

Staff trained in diagnosis and management of CRD

• Stethoscope• Peak flow meter• Spaces for inhalers• Electrocardiogram• Oxygen

• Antiasthmatic agent for acute attack

• Oral corticosteroid• Injectable corticosteroid• Epinephrine injectable

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Background and Objectives

Indonesia comprises 34 provinces (propinsi) and special administrative areas, such as DKI Jakarta, and 98 urban districts (kota) and 413 rural districts (kabupaten). It consists of a vast archipelago of 250 million people in 18,000 islands ranging from densely populated areas (including one of the largest conurbations in the world–Jabodetabek)99 to remote and isolated islands and jungle communities.

Due to reforms in decentralization, districts have greater autonomy and, therefore, are an important of unit of analysis. Furthermore, within the health sector, a major reform initiative (JKN) was introduced, effective from January 2014. Given this background context, Indonesia QSDS 2016 was envisioned as a primary health care facility and services survey in Indonesia, with a specific ‘disease-focus’ on nutrition, maternal and child health, communicable diseases (particularly, HIV and AIDS, TB, and malaria), and NCDs). Thematically, the survey captured information based on WHO’s SARA conceptual framework, adjusted according to national guidelines, but also included modules on governance, health indicators, health financing (but not costing information), provider ability, and patient satisfaction.

Instruments were developed to survey dinkes, various primary health care facilities (puskesmas, polindes/poskesdes, private MH providers, and private clinics), health workers, and conduct patient exit interviews in DKI Jakarta. As one of the key objectives of this survey is to provide baseline indicators for JKN, facilities established in 2014 or later were excluded from the survey. In addition, a small number of hospitals were also sampled while at the community level the posyandu were also sampled–especially for nutrition-related indicators. For the purposes of this

Appendix 4QSDS Sampling and Analytical Methodology

report, however, only puskesmas and private clinic instruments were used in the analysis.

Where possible, baseline quantitative data–for example on financing and health-related indicators–were collected for the period 2013–15. This time period was selected so that the government could assess changes in the financing of frontline service delivery because of the transition to JKN in 2014 and to serve as a baseline for the implementation of JKN.

As the government indicated its concern for remote and rural areas, for sampling of districts and facilities, methodologies that would oversample large and heavily populated districts or facilities (for example, sampling methodologies that were proportionate to district population) were judged to be less appropriate for the intended objectives of this survey, especially given the large variations in the population and sizes of districts in Indonesia. Sampling was not designed to be regionally representative (for example, regions like Java, NTT, and Sumatra). Resource constraints were a further important consideration and, therefore, an efficient survey methodology was desired.

The primary objectives of, and tradeoffs considered in, the sampling methodology were to provide, especially as a baseline for JKN:

1. National estimates of facility-level indicators for: (i) public primary care (puskesmas); (ii) private primary care; and (iii) posyandu, stratified by urban (kota) and rural (kabupaten) districts;

2. DKI Jakarta estimates of facility-level indicators: (i) public primary care (puskesmas); (ii) private primary care; and (iii) posyandu, not further stratified by urban or rural districts;

96 Jabodetabek: Jakarta, Bogor, Depok, Tangerang, and Bekasi.

101

3. Estimates of facility-level indicators for the 64 high-priority districts: (i) public primary care (puskesmas); (ii) public maternity care (such as polindes, poskesdes, and bidan di desa); (iii) private maternity care (both single and multiprovider facilities); and (iv) posyandu, stratified by kota and kabupaten;

4. Estimates for a sample of matched counterfactual districts to the 64 high-priority maternity districts, for the same facilities as for the priority MH districts, stratified by kota and kabupaten;

5. Estimates for the 75 priority HIV and AIDS and TB districts for: (i) public hospitals; (ii) private hospitals; (iii) puskesmas; and (iv) private primary care;

6. Estimates for a sample of matched counterfactual districts to the 75 priority HIV and AIDS and TB districts for the same facilities as for the 75 priority HIV and AIDS and TB districts;

7. Estimates for the 132 priority malaria districts for: (i) puskesmas; and (ii) private primary, not further stratified by urban or rural districts;

8. For each of the sampled districts, an estimate at the level of that district for facility-level indicators. This was intended to allow comparisons between district-level indicators and district characteristics;

9. Estimates for health care worker (HCW)-level indicators, including provider ability, for health workers at puskesmas, private primary care, public maternity care, and private maternity care; and

10. In DKI Jakarta, where the supply readiness was not anticipated to be a critical constraint, estimates of patient user-level indicators through patient exit surveys.

Field work for this survey was conducted from May 30 to October 31, 2016.

Sampling Methodology Summary

SAMPLING OF DISTRICTSDue to resource constraints and the desire to produce district-level estimates for the sampled districts, there were relatively few districts (Level 1) sampled and a relatively larger number of facilities per district (Level 2) sampled in this two-level clustered random sampling.

To reduce the likelihood of randomly selecting districts that were less typical of sample frame of districts, cube sampling (Grafström 2014) was, therefore, used. This balances the sampled districts with the sample frame of districts, based on observable characteristics: (i) district population in 2013; (ii) GDP per capita; (iii) Human Development Index (HDI); and (iv) district land area. This does not, however, specifically address intraclass correlation issues between the two levels and the variation of facility-level indicators between districts was, therefore, traded off to strengthen estimates within a district.

For each sample frame of districts–that is, DKI Jakarta districts, nonDKI Jakarta national districts, MH priority districts, HIV and AIDS and TB priority districts, and malaria districts–sampling of districts was conducted independently of each other. There was further stratification between urban districts (kota) and rural districts (kabupaten) for nonDKI Jakarta national districts, MH priority districts, and HIV and AIDS and TB priority districts, and counterfactuals for the latter three.

There is, however, overlap in the sampling frame of districts for each of these selected districts, except for DKI Jakarta districts and nonDKI Jakarta districts which were mutually exclusive and commonly exhaustive to represent Indonesia nationally when combined. Due to this overlap in sample frames, there were also overlaps among sampled districts that were sampled out of different but overlapping sample frames. This chance overlap was exploited as similar instruments and facilities were often involved for the different sample frames. All relevant survey instruments and facilities were applied to satisfy the requirements of the different sample frames in an overlap district, although overlaps considerably reduced the resources required for this survey.

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SAMPLING OF COUNTERFACTUAL DISTRICTSFor the populations of two districts–MH priority districts and HIV and AIDS and TB priority districts, and for their urban districts (kota) and rural districts (kabupaten) independently–‘counterfactual’ districts were matched to districts from the overall sample of districts already sampled (for example, DKI Jakarta and nonDKI Jakarta). As these districts had already been sampled, albeit for other purposes, there were fewer additional resources required to include these, apart from ensuring the relevant counterfactual survey instruments and facilities were included.

These counterfactual districts were matched (Hansen and Klopfer 2006) from a counterfactual sample frame comprising districts sampled for other purposes if they were not ‘intervention’ districts–that is, in the case of MH priority counterfactual districts, the counterfactual sample frame excluded all MH priority districts. Matching was based on the same four observable characteristics: (i) district population in 2013; (ii) GDP per capita; (iii) HDI; and (iv) district land area. Health outcomes or health outputs were not considered appropriate parameters for balancing the sample due to endogeneity. The output of the balanced sampling also allows pair-wise matching of an intervention and a counterfactual and this could be exploited for analysis if required.

Table 4A-1: District Sample Frames, Sampled Health Facility Types

District Sample Frame Puskesmas

Private Primary

Care

Public Maternity

Care

Private Maternity

CarePosyandu

Private Hospitals

Public Hospitals

A. DKI Jakarta Yes Yes No No Yes No No

B. National nonDKI Jakarta

Yes Yes No No Yes No No

C. Priority MH and Counterfactual

Yes No Yes Yes Yes No No

D. Priority HIV/AIDS/TB and Counterfactual

Yes Yes No No NoYes, see

noteYes, see

note

E. Priority Malaria Yes Yes No No No No No

Note: Fewer than expected hospitals consented to be part of this survey and therefore: (i) representativeness at the district level for hospitals may be underpowered; and (ii) additional opportunistic samples of hospitals were taken from HIV and AIDS and TB priority districts that were included by chance into the overall sample of districts. District identities for these districts are: 1871, 3171, 3174, 3175, 3204, 3578, and 9171. In these added districts, there was no attempt to sample an adequate number of hospitals to ensure representativeness at the district level.

Table 4A-2: Health Care Worker [HCW] Interviews and Patient Exit [EXIT] Interviews

District Sample FramePuskesmas

Private Primary Care

Public Maternity Care

Private Maternity Care

DKI Jakarta HCW + EXIT HCW + EXIT HCW + EXIT HCW + EXIT

National nonDKI Jakarta HCW HCW HCW HCW

Priority MH and Counterfactual HCW HCW HCW HCW

Priority HIV and AIDS/TB and counterfactual

HCW HCW HCW HCW

Priority Malaria HCW HCW HCW HCW

How many and which HCW type? Two of: doctors, midwives, and/

or nurses

One doctor (generalist or

specialist)

One midwife One midwife

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Matching of counterfactual districts for malaria priority districts was attempted but, due to the systematic differences in the observable characteristics of malaria priority districts, this attempt was discarded.

GENERATING THE HEALTH FACILITY SAMPLING FRAMES AND SAMPLING HEALTH FACILITIESDistrict sample frames, health facility types included, and other instruments used are summarized in Table A4-1 and Table A4-2.

Within each district, health facilities were sampled by simple random sampling, with equal probability of sampling, regardless of catchment population, utilization, or the ‘size’ of the health facility (in terms of staff or financing).

Public Primary and Maternity Care Facilities: The sample frame for puskesmas was obtained from the dinkes. Polindes and poskesdes were treated as essentially the same facility type for the purposes of sampling and analysis. The sample frame for polindes/poskesdes was obtained from sampled puskesmas as these facilities form part of a ‘network’ under the puskesmas.

Generating the sample frame for private facilities (private MH and private primary-care facilities, independently of each other) was challenging, as up-to-date, accurate, and complete information on private facilities was not consistently available at the district level. Although attempts were made to use methods described in an earlier study (Heywood and Harahap 2009), these were insufficient to generate a reliable district-wide sample frame of private facilities.

For this reason, and for field work expediency, the sample frame of private facilities was generated from within the catchment of sampled puskesmas, as puskesmas are responsible for the supervision of private facilities and, therefore, more reliable information on the existence of providers was obtainable at this level. There were, however, inadequate samples, including due to rejection, and private facilities were, therefore, sampled from a nearby unsampled puskesmas catchment area.

SAMPLING OF HCWSDepending on the specific facility, doctors, midwives, or nurses were sampled from among health workers who were present at the time of interview. For private primary care, public maternity care, and private maternity care facilities, simple random sampling with an equal probability of selection from among the desired health worker type present at the facility was used.

For puskesmas, the sampling design intent was to sample two HCWs (doctors, midwives, or nurses), with a slight bias to doctors in the sample. In addition, to allow multilevel analysis, a mechanism was established to ensure the possibility of sampling two doctors, to create a third level, to analyze within and between facility variation in HCW-level indicators. This simple random sampling mechanism, with an equal probability of selection from among the desired health worker type present at the facility.

SAMPLING FOR PATIENT EXIT INTERVIEWSPatient exit interviews were only conducted in the five DKI Jakarta districts (excluding Kepulauan Seribu) and in three facilities types: (i) puskesmas; (ii) private primary care clinic; and (iii) private maternity clinic. Each facility has a specific target number of respondents: for puskesmas four respondents were targeted for interview (two adult general outpatients, one ANC patient, and one [parent of a] child patient). For private primary care clinics, two respondents were targeted (any adult or [parent of a] child patient). For private maternity clinics, two ANC patients were targeted.

There were two types of patient exit interviewees: (i) a ‘linked’ patient seen by a sampled HCW (interviewed with the HCW instrument as part of the overall survey); and (ii) an ‘unlinked’ patient not seen by a sampled HCW. All patient exit interviewees in private general clinic and maternity facility should be linked. In puskesmas, two selected patients would be linked and two would be unlinked. Linked patient interviewees were randomly selected from the list of patients seen by the linked HCW; unlinked patient interviewees were randomly selected from the remaining list of patients not seen by the linked HCW. The interviews were conducted after the clinical encounter, at the patient’s house or in the facility/place preferred by the patient.

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SAMPLE SIZE CALCULATIONS AND ASSUMPTIONSThe target number of facilities to be sampled within a sampled district was based on standard sample size calculations and assumptions used by WHO SARA (2013).

Analytical Methods Summary

SUPPLY-SIDE AND DEMAND-SIDE WEIGHTSAs the survey design is a two-level cluster survey, weights are needed to correct for the differential probability of a district and facility to be included in the sample from the overall sample frame. Depending on the choice of perspective, different weights may be applied. Supply-side weights provide an estimate of facility-level indicators from the perspective of the supply. If Indonesia has, for example, 100 health facilities in total, a supply-side weight would allow the estimate of the mean value for a specific indicator for facilities in Indonesia. Some facilities may, however, be remote and serve a limited population and hardly be utilized and yet would be weighted in the same way as a large and busy facility that serves a much larger population and is heavily utilized.

To construct such weights, the number of facilities in each district forms the basis of this weight. A further option is financing indicators–such as the total income or expenditure of a health facility–that can also be used to weight, depending on the intent of the desired indicator. Alternatively, the perspective of the potential (that is, proxied by the target population in the catchment area) or actual user (that is, proxied by utilization of the relevant health service) may be more important to provide a picture of what would be the mean value for a specific facility-level indicator, as experienced or potentially experienced from the demand side. This would answer the question of what would be the typical expected experience of a health facility by a user of the health facility. For the purposes of this survey, information was collected to allow the use of either weight although, for the purposes of the analysis, supply-side weights were generally used.

SERVICE-READINESS INDICATORSWHO’s SARA framework consists of multiple binary indicators (for example, the availability of specific drugs or equipment). These binary indicators are organized in two-dimensions: (i) the ‘service’ being provided (for example, general or specific service readiness for specific health services); and (ii) domains for staff and guidelines, equipment, diagnostics, and medicines and commodities. These indicators were contextualized with national guidelines as described in Appendix 2. It should be noted that these indicators are generally not comparable to the licensing and BPJS self-assessment list.

To collapse these multiple binary indicators, a simple unweighted mean is used. This methodology, suggested by WHO (2013), is also used in earlier SARA-related reports on Indonesia (World Bank 2014), and more broadly in the published literature for similar surveys such as the Demographic and Health Survey–Service Provision Assessments (Kruk et al. 2016). A mean of 100 percent or 1 would imply that all the binary indicators are met. This simple unweighted mean can apply to a single facility and a simple mean of facility means can be used to compare groups of facilities (for example, private vs public, across time, and across geographical locations). A mean of 100 percent or 1 would imply that all facilities have met all the binary indicators.

HCW ABILITYIn addition to modules that included health worker demographics, workload, compensation, and training, the health worker survey instrument included seven different clinical vignettes. These were: (i) preventive child health (growth monitoring and immunization); (ii) curative child health; (iii) ANC; (iv) obstetrics (PPH); (iv) HIV and AIDS; (v) malaria; (vi) TB; and (vii) an NCD (hypertension). Not all cases were presented to all health workers.

Given the limitation of the survey whereby enumerators were not trained medical practitioners, clinical vignettes were used to assess provider ability. These clinical vignettes present the health worker with a written description of a clinical case, which is read out by the enumerator, and may include data analysis (in

105

the form, for example, of growth charts and blood test results). To standardize the clinical context, the cases included an initial description of the facility and referral context including, where relevant, the expected equipment, medicines, and referral times.

To validate the responses provided by health workers, a panel of Indonesian clinical specialists in the relevant field will be convened and the same case and responses posed to them. Using a modified Delphi technique to gain consensus, appropriate responses expected of a health worker in a local Indonesian setting were elicited and used for the analysis. This report does

not include analysis of the vignettes and will be covered in a forthcoming report on human resources for health.

SAMPLE SIZE & REPRESENTATIVENESS FOR THIS REPORTThis report analyzed data to generate national-level estimates. Hence, sample size calculation was 10 out of 413 districts and 12 out of 98 cities. Table A-4-3 shows the sample sizes for each type of primary health care facility per district.

Table 4A-3 Summary of Selected Facilities (by Type and District) for the National QSDS Estimates

DistrictNumber of Sample

PuskesmasPrivate Primary

Health Carea PosyanduHealth Care

Workerb

Simeulue District 9 5 15 23Aceh Jaya District 9 9 16 27Lhokseumawe City 6 17 15 29Tapanuli Selatan District 14 12 16 40Pesisir Selatan District 15 15 16 126Padang City 17 22 17 109Indragiri Hilir District 20 18 16 121Sungai Penuh City 7 14 14 28Cilacap District 25 22 17 72Semarang District 19 21 17 59Tegal City 8 19 16 35Pasuruan City 8 18 16 34Tangerang City 23 23 17 137Cilegon City 8 18 16 34Mataram City 9 21 16 39Bima City 5 12 15 22Banjar City 18 15 16 51Banjarmasin City 19 21 16 116Banjar Baru City 7 17 15 67Tomohon City 7 12 13 26Merauke District 13 14 16 40Yalimo District 4 2 8 13Total number of sample in 22 District/City

270 347 339 1,248

Notes: a= private primary health care facilities include: private clinics, private general practitioners. b= health care worker includes: doctor, midwife, nurse.

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Appendix 5Factsheets for General Service Readiness

A. BASIC AMENITIES

District/Type of facility

Basic Amenities

Number of facilityPower (%)

Improved water source

(%)

Room auditory privacy only

(%)

sanitation (%)

Communication (%)

Access to computer with internet

access (%)

Emergency transportation

(%)

readiness index (met

all) (%)

PUSKEMAS

Simeulue 100 88 25 100 0 13 100 0 8

Aceh Jaya 100 78 33 100 33 44 100 0 9

Lhokseumawe 100 83 50 100 50 100 100 17 6

Tapanuli Selatan 93 79 50 93 7 57 100 7 14

Pesisir Selatan 100 100 27 80 67 87 100 7 15

Padang 100 100 71 100 88 94 100 53 17

Indragiri Hilir 100 90 60 100 50 90 65 30 20

Sungai Penuh 100 100 33 100 17 83 100 0 6

Cilacap 100 100 73 100 100 100 100 73 26

Semarang 100 84 74 100 100 100 95 58 19

Tegal 100 100 75 100 100 100 100 75 8

Pasuruan 100 100 13 100 100 100 100 13 8

Tangerang 100 100 100 100 100 100 96 96 23

Cilegon 100 88 88 100 100 100 100 88 8

Mataram 100 100 78 100 78 100 100 67 9

Bima 100 80 80 100 20 100 100 20 5

Banjar 100 89 33 94 44 89 94 11 18

Banjarmasin 100 100 58 100 100 95 100 58 19

Banjar Baru 100 100 57 100 57 100 100 29 7

Tomohon 100 57 71 100 43 86 100 29 7

Merauke 100 100 8 100 69 31 100 0 13

Yalimo 100 100 0 100 33 0 33 0 3

Puskesmas-urban 100 95 69 99 88 99 98 56 158

Puskesmas-rural 99 90 40 96 49 66 90 19 110

All Puskesmas 99 92 52 97 65 80 93 34 268

Private

Private-rural 100 93 84 94 91 58 28 15 228

Private-urban 100 95 71 83 83 53 43 23 61

Private-BPJS 100 95 86 99 94 95 33 27 121

Private-non BPJS 100 92 78 86 86 28 30 9 168

All Private 100 93 81 92 89 57 31 17 289

Rifaskes-2011

Puskesmas-urban 97 69 100 71 81 12 81 6 6617

Puskesmas-rural 99 81 100 84 89 27 87 87 2364

All Puskesmas 98 72 100 74 84 16 82 8 8981

107

010

2030

40P

erce

nta

ge

0 1 2 3 4 5 6 7Number of Component



General Service Readiness-Basic Amenitiesby Type of Facility

010

2030

4050

Per

cen

tage


Empaneled Not empaneled


General Service Readiness-Basic Amenitiesat Private GP/Clinic by BPJS Empanelment

020

4060

Per

cen

tage


Urban Rural


General Service Readiness-Basic Amenitiesat Puskesmas by Urban/Rural

010

2030

40P

erce

nta

ge


Urban Rural


General Service Readiness-Basic Amenitiesat Private GP/Clinic by Urban/Rural

108


B. BASIC EQUIPMENT

District/Type of facility

Basic AmenitiesNumber of

facilityAdult Scale (%)

Child scale (%)

Infant scale (%)

Thermometer (%)

Stethoscope (%)

Blood pressure apparatus (%)

Light source (%)

readiness index (met all) (%)

PUSKEMAS

Simeulue 100 50 100 75 75 100 100 25 8

Aceh Jaya 89 78 67 56 44 78 56 11 9

Lhokseumawe 100 83 100 83 100 83 17 0 6

Tapanuli Selatan 93 71 93 71 93 100 43 21 14

Pesisir Selatan 67 67 80 60 80 93 60 27 15

Padang 100 100 94 94 88 94 41 29 17

Indragiri Hilir 100 70 100 90 85 95 65 30 20

Sungai Penuh 100 83 100 67 83 100 67 0 6

Cilacap 96 100 88 88 85 100 85 62 26

Semarang 95 84 100 100 84 100 42 37 19

Tegal 100 88 100 100 100 100 100 88 8

Pasuruan 100 100 100 100 100 100 63 63 8

Tangerang 100 96 96 100 96 100 9 9 23

Cilegon 100 88 75 75 88 75 38 38 8

Mataram 100 89 78 89 67 100 56 33 9

Bima 100 100 100 80 80 80 80 40 5

Banjar 100 100 100 100 100 100 56 56 18

Banjarmasin 100 100 89 89 89 95 53 53 19

Banjar Baru 100 100 100 100 100 100 43 43 7

Tomohon 100 71 100 100 86 100 43 14 7

Merauke 100 92 100 100 100 100 62 62 13

Yalimo 100 100 100 100 100 100 33 33 3

Puskesmas-urban 99 91 96 96 88 98 49 43 158

Puskesmas-rural 93 81 92 81 85 96 67 37 110

All Puskesmas 95 85 93 87 86 97 59 39 268

Private

Private-rural n.a 72 57 84 79 96 n.a 42 228

Private-urban n.a 50 52 69 78 88 n.a 20 61

Private-BPJS n.a 77 77 90 78 92 n.a 56 121

Private-non BPJS n.a 60 39 74 79 95 n.a 24 168

All Private n.a 77 56 81 79 94 n.a 37 289

Rifaskes-2011

Puskesmas-urban 98 37 0 88 99 95 83 29 6617

Puskesmas-rural 98 32 0 88 100 97 90 26 2364

All Puskesmas 98 36 0 88 99 96 85 28 8981

109

020

4060

80P

erce

nta

ge

0 1 2 3 4 5Number of Component


Note : vertical solid line=mean; vertical dash line=medianOnly compared 5 components measured in both facility type

General Service Readiness-Basic Equipmentby Type of Facility

020

4060

Per

cen

tage




General Service Readiness-Basic Equipmentat Private GP/Clinic by BPJS Empanelment

010

2030

40P

erce

nta

ge


Urban Rural


General Service Readiness-Basic Equipmentat Puskesmas by Urban/Rural

010

2030

40P

erce

nta

ge


Urban Rural


General Service Readiness-Basic Equipmentat Private GP/Clinic by Urban/Rural

110


C. ITEMS FOR STANDARD PRECAUTIONS

Distric/type of facility

Standard Precaution

Number of facilitiesSterillizer

(%)

Safe Final disposal for sharps (%)

Safe Final disposal for infectious waste (%)

Appropriate storage of

sharps waste (%)

Appropriate storage of infectious waste (%)

Disenfectant (%)

Single use of standard disposable syringe (%)

Soap and running

water or al-cohol based handrub (%)

Latex gloves

(%)

“Readiness Index

(meet All)” (%)

PUSKEMAS

Simeulue 100 63 63 75 25 88 100 88 100 13 8

Aceh Jaya 78 78 67 89 67 89 89 89 89 22 9

Lhoksumawe 67 100 100 83 67 67 100 83 100 17 6

Tapanuli Selatan 57 64 93 71 21 93 79 86 86 7 14

Pesisir Selatan 67 60 60 80 40 87 87 93 80 13 15

Padang 100 88 82 100 94 100 100 100 100 76 17

Indragiri Hilir 75 45 90 85 30 70 100 80 100 0 20

Sungai Penuh 100 100 100 100 50 100 100 100 100 50 6

Cilacap 96 92 85 88 65 92 96 100 100 54 26

Semarang 95 95 89 95 42 84 95 100 95 42 19

Tegal 100 100 100 100 38 100 88 100 100 38 8

Pasuruan 100 100 100 88 88 88 100 88 88 88 8

Tangerang 96 100 100 100 83 96 96 100 100 74 23

Cilegon 88 100 100 100 75 100 100 88 100 38 8

Mataram 67 100 89 100 67 100 100 100 100 33 9

Bima 100 100 100 100 60 100 100 100 80 60 5

Banjar 100 94 94 100 33 94 100 100 94 28 18

Banjarmasin 100 100 95 100 37 100 100 100 100 32 19

Banjar Baru 100 100 100 100 14 86 100 86 100 14 7

Tomohon 57 100 71 100 29 100 100 86 100 0 7

Merauke 100 62 92 85 23 54 92 46 100 8 13

Yalimo 67 33 100 67 0 33 100 67 67 0 3

Puskesmas-urban 94 94 88 96 56 92 96 95 98 47 158

Puskesmas-rural 82 67 85 83 35 80 94 86 92 15 110

All Puskesmas 87 78 86 89 44 85 95 90 95 29 268

Private: Combined Single & Multiple Provider

Private-Rural 66 87 87 68 53 82 88 92 89 31 228

Private-Urban 58 86 89 44 35 61 79 80 71 10 61

Private-BPJS 77 91 90 76 58 80 87 94 88 37 121

Private-Non BPJS 55 84 86 52 42 75 85 86 84 18 168

All Private 64 87 88 62 49 77 86 89 86 26 289

Rifaskes 2011

Puskesmas-urban 80 30 0 78 38 0 97 29 84 11 6617

Puskesmas-rural 90 45 0 88 55 0 99 26 91 21 2364

All Puskesmas 82 54 0 81 43 0 97 28 86 13 8981

111

010

2030

Per

cen

tage

0 1 2 3 4 5 6 7 8 9Number of Component



General Service Readiness-Standard Precautionby Type of Facility

010

2030

40P

erce

nta

ge




General Service Readiness-Standard Precautionat Private GP/Clinic by BPJS Empanelment

010

2030

4050

Per

cen

tage


Urban Rural


General Service Readiness-Standard Precautionat Puskesmas by Urban/Rural

010

2030

Per

cen

tage


Urban Rural


General Service Readiness-Standard Precautionat Private GP/Clinic by Urban/Rural

112


D. DIAGNOSTIC CAPACITY ITEMS

Distric/type of facility

Diagnostic Capacity

Number of facilitiesHemoglobin

(%)

Blood Glucose

(%)

“Malaria Diagnostic

Capacity” (%)

Urine disptick

capacity (%)

Urine disptick

glucose (%)

“HIV Diagnostic

Capacity (RDT Kit)” (%)

Syphilis Rapid test

(%)

Urine test for pregnancy

(%)

“Readiness Index

(meet All)” (%)

PUSKEMAS

Simeulue 100 75 100 38 63 0 0 75 0 8

Aceh Jaya 100 78 100 100 89 22 11 100 0 9

Lhoksumawe 83 100 83 83 100 67 33 100 17 6

Tapanuli Selatan 14 50 71 71 14 0 29 29 0 14

Pesisir Selatan 80 60 73 73 87 13 0 67 0 15

Padang 88 82 41 88 88 41 24 94 12 17

Indragiri Hilir 75 85 90 65 70 30 30 80 20 20

Sungai Penuh 83 67 100 67 100 0 0 50 0 6

Cilacap 88 73 62 96 81 77 15 92 12 26

Semarang 100 95 53 100 95 32 16 100 11 19

Tegal 100 88 50 100 100 100 75 100 38 8

Pasuruan 75 100 25 75 88 88 88 88 25 8

Tangerang 87 91 0 87 96 52 22 74 0 23

Cilegon 50 50 0 63 88 63 75 50 0 8

Mataram 100 89 100 100 100 44 67 100 44 9

Bima 100 60 100 100 100 20 40 100 0 5

Banjar 100 94 94 72 100 11 6 100 6 18

Banjarmasin 100 95 89 84 95 37 16 100 11 19

Banjar Baru 100 86 100 86 100 100 43 86 29 7

Tomohon 57 86 100 0 43 71 29 57 0 7

Merauke 85 100 100 62 62 77 38 77 31 13

Yalimo 0 33 100 0 67 33 33 67 0 3

Puskesmas-urban 95 89 64 91 91 56 31 90 16 158

Puskesmas-rural 74 74 82 62 69 25 12 77 6 110

All Puskesmas 82 80 74 74 79 38 20 83 10 268

Private: Combined Single & Multiple Provider

Private-Rural 24 67 n.a 15 19 n.a n.a 50 7 228

Private-Urban 28 63 n.a 17 30 n.a n.a 33 7 61

Private-BPJS 32 65 n.a 20 27 n.a n.a 53 8 121

Private-Non BPJS 20 66 n.a 13 16 n.a n.a 41 6 168

All Private 25 66 n.a 16 21 n.a n.a 46 7 289

Rifaskes 2011

Puskesmas-urban 82 51 54 43 43 0 0 43 22 6617

Puskesmas-rural 79 63 53 57 57 0 0 57 30 2364

All Puskesmas 81 54 54 47 47 0 0 47 24 8981

113

010

2030

4050

Per

cen

tage



Note : vertical solid line=mean; vertical dash line=medianComparing 5 components measured in both type of facility

General Service Readiness-Diagnostic Capacityby Type of Facility

010

2030

40P

erce

nta

ge




General Service Readiness-Diagnostic Capacityat Private GP/Clinic by BPJS Empanelment

010

2030

Per

cen

tage

0 1 2 3 4 5 6 7 8Number of Component

Urban Rural


General Service Readiness-Diagnostic Capacityat Puskesmas by Urban/Rural

010

2030

40P

erce

nta

ge


Urban Rural


General Service Readiness-Diagnostic Capacityat Private GP/Clinic by Urban/Rural

114


E. ESSENTIAL MEDICINES

District/type of facility

Essential Medicine

Number of facility

Am

lod

ipin

e ta

ble

t

Am

ox

icil

lin

sy

rup

Am

ox

icil

lin

ta

ble

t

Am

pic

illi

n p

ow

der

fo

r in

ject

ion

Asp

irin

ca

p/t

ab

Bet

a b

lock

er

Cef

tria

xo

ne

inje

ctio

n

Dia

zep

am

in

ject

ion

En

ala

pri

l ta

ble

t o

r a

lter

na

tiv

e A

CE

in

hib

ito

r

Ma

gn

esiu

m s

ulp

ha

te

inje

ctio

n

Met

form

in t

ab

let

Sim

va

sta

tin

ta

ble

t

Zin

c su

lph

ate

ta

ble

ts

“Rea

din

ess

ind

ex

(met

all

)”

PUSKEMAS

Simeulue 100 100 100 63 13 25 63 50 88 88 63 38 100 0 8

Aceh Jaya 78 100 100 56 33 11 44 78 100 86 89 100 89 0 9

Lhokseumawe 83 100 100 33 17 33 33 67 100 0 83 100 100 0 6

Tapanuli Selatan 79 100 100 29 36 43 14 86 100 73 43 79 100 0 14

Pesisir Selatan 73 100 100 7 20 40 7 73 87 54 87 0 73 0 15

Padang 100 100 100 0 76 53 12 59 100 57 100 94 94 0 17

Indragiri Hilir 95 100 100 25 45 65 70 90 95 58 100 100 95 5 20

Sungai Penuh 83 100 100 17 17 17 0 33 100 60 33 100 100 0 6

Cilacap 92 96 96 54 54 35 23 88 100 100 100 100 92 8 26

Semarang 100 100 100 21 74 47 32 84 100 70 95 100 84 0 19

Tegal 63 100 100 50 63 63 63 88 100 88 100 50 88 0 8

Pasuruan 88 100 100 0 50 25 0 63 100 20 100 100 100 0 8

Tangerang 91 100 100 0 35 48 4 52 100 50 78 100 78 0 23

Cilegon 50 63 63 38 0 75 13 63 63 100 63 50 38 0 8

Mataram 100 89 89 67 78 22 11 89 100 100 100 100 89 0 9

Bima 100 100 100 20 60 40 40 80 100 80 100 100 80 0 5

Banjar 89 100 100 11 6 61 28 83 100 60 100 100 100 0 18

Banjarmasin 100 95 95 16 95 74 11 68 100 42 79 100 95 0 19

Banjar Baru 100 100 100 29 71 29 14 71 100 50 100 57 100 0 7

Tomohon 100 100 100 0 43 14 0 71 100 0 100 100 71 0 7

Merauke 54 69 69 77 38 31 92 77 69 58 54 69 54 0 13

Yalimo 0 100 100 100 0 0 0 67 0 33 0 0 100 0 3

Puskesmas-urban 91 97 97 26 60 46 20 76 99 76 89 93 88 3 158

Puskesmas-rural 82 96 96 38 28 41 43 81 90 68 81 75 88 1 110

All Puskesmas 86 97 97 33 42 43 34 79 94 70 85 82 88 2 268

Private

Private-Rural n.a 65 65 12 n.a n.a n.a 23 n.a n.a n.a n.a 45 7 228

Private-Urban n.a 74 74 20 n.a n.a n.a 26 n.a n.a n.a n.a 41 5 61

Private-BPJS n.a 61 61 13 n.a n.a n.a 26 n.a n.a n.a n.a 45 7 121

Private- Non BPJS n.a 71 71 14 n.a n.a n.a 21 n.a n.a n.a n.a 43 5 168

All Private n.a 67 67 13 n.a n.a n.a 23 n.a n.a n.a n.a 44 6 289

Rifaskes-2011

Puskesmas - Rural 0 80 84 25 83 26 77 92 89 77 0 0 64 6 6617

Puskesmas - Urban 0 84 90 14 86 15 80 94 92 84 0 0 71 3 2364

All Puskesmas 0 81 86 22 84 23 78 92 90 79 0 0 66 5 8981

115

010

2030

4050

Per

cen

tage



Note : vertical solid line=mean; vertical dash line=medianComparing 5 components measured in both type of facility

General Service Readiness-Essential Medicinesby Type of Facility

010

2030

40P

erce

nta

ge




General Service Readiness-Essential Medicinesat Private GP/Clinic by BPJS Empanelment

05

1015

2025

Per

cen

tage

0 1 2 3 4 5 6 7 8 9 10 11 12 13Number of Component

Urban Rural


General Service Readiness-Essential Medicinesat Puskesmas by Urban/Rural

010

2030

40P

erce

nta

ge


Urban Rural


General Service Readiness-Essential Medicinesat Private GP/Clinic by Urban/Rural

116


F. GENERAL SERVICE READINESS

District/type of facilityBasic Amenities Basic Equipment

Standard Precaution

Basic DiagnosticEssential Medicine

General service readiness Number of

facilitymet all (%) met all (%) met all (%) met all (%) met all (%) met all (%)

PUSKEMAS

Simeulue 0 25 13 0 0 0 8

Aceh Jaya 0 11 22 0 0 0 9

Lhokseumawe 17 0 17 17 0 0 6

Tapanuli Selatan 7 21 7 0 0 0 14

Pesisir Selatan 7 27 13 0 0 0 15

Padang 53 29 76 12 0 0 17

Indragiri Hilir 30 30 0 20 5 0 20

Sungai Penuh 0 0 50 0 0 0 6

Cilacap 73 62 54 12 8 0 26

Semarang 58 37 42 11 0 0 19

Tegal 75 88 38 38 0 0 8

Pasuruan 13 63 88 25 0 0 8

Tangerang 96 9 74 0 0 0 23

Cilegon 88 38 38 0 0 0 8

Mataram 67 33 33 44 0 0 9

Bima 20 40 60 0 0 0 5

Banjar 11 56 28 6 0 0 18

Banjarmasin 58 53 32 11 0 0 19

Banjar Baru 29 43 14 29 0 0 7

Tomohon 29 14 0 0 0 0 7

Merauke 0 62 8 31 0 0 13

Yalimo 0 33 0 0 0 0 3

Puskesmas-urban 56 43 47 16 3 0 158

Puskesmas-rural 19 37 15 6 1 0 110

All Puskesmas 34 39 29 10 2 0 268

Private

Private-Rural 15 42 31 7 7 0 228

Private-Urban 23 20 10 7 5 0 61

Private-BPJS 27 56 37 8 7 0 121

Private- Non BPJS 9 24 18 6 5 0 168

All Private 17 37 26 7 6 0 289

Rifaskes-2011

Puskesmas - Rural 6 29 11 22 6 0 6617

Puskesmas - Urban 14 26 21 30 3 0 2364

All Puskesmas 8 28 13 24 5 0 8981

117

05

1015

Per

cen

tage

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34Number of Component


Note : vertical solid line=mean; vertical dash line=medianComparing 34 component measured in both type of facility

General Service Readiness-All Domainby Type of Facility

05

1015

Per

cen

tage




General Service Readiness-All Domainat Private GP/Clinic by BPJS Empanelment

05

1015

20P

erce

nta

ge

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44Number of Component

Urban Rural


General Service Readiness-All Domainat Puskesmas by Urban/Rural

05

1015

Per

cen

tage


Urban Rural


General Service Readiness-All Domainat Private GP/Clinic by Urban/Rural

118


Appendix 6Specific Services’ Readiness Index

A. FAMILY PLANNING


Staff & Training Equipment Medicines & CommoditiesFamily

Planning Supply Side

Number of facility

Gu

idel

ine

bo

ok

(%)

Tra

inin

g (%

)

“Rea

din

ess

Ind

ex

(all

met

)” (%

)

IUD

Kit

(%)

Imp

lan

t (%

)

BP

ap

pa

ratu

s (%

)

“Rea

din

ess

Ind

ex

(all

met

)” (%

)

Co

mb

ine

pil

l (%

)

Inje

cta

ble

co

ntr

ace

pti

ve

(%)

IUD

(%)

Imp

lan

t (%

)

Co

nd

om

(%)

“Rea

din

ess

Ind

ex

(all

met

)” (%

)

“Rea

din

ess

Ind

ex

(all

met

)” (%

)

PUSKEMAS

Simeulue 88 100 88 88 100 100 88 75 88 88 88 100 25 50 8

Aceh Jaya 33 89 33 56 67 78 56 78 78 56 56 67 33 11 9

Lhokseumawe 50 67 17 67 67 83 50 100 100 83 83 83 17 0 6

Tapanuli Selatan 31 62 14 38 38 100 36 77 69 46 31 77 21 7 13

Pesisir Selatan 67 87 60 73 80 93 60 80 87 53 47 20 7 7 15

Padang 94 88 82 94 94 94 88 94 94 100 100 100 0 71 17

Indragiri Hilir 55 90 45 60 75 95 50 90 90 80 100 75 15 15 20

Sungai Penuh 50 67 33 83 67 100 67 83 83 67 67 100 0 17 6

Cilacap 65 92 62 92 92 100 92 92 88 88 88 85 4 46 26

Semarang 58 89 47 84 89 100 84 89 89 84 84 58 0 26 19

Tegal 100 100 100 100 100 100 100 100 100 100 100 100 0 100 8

Pasuruan 88 100 88 100 100 100 100 100 100 100 100 75 0 63 8

Tangerang 70 78 57 100 96 100 96 96 96 96 96 52 0 30 23

Cilegon 75 100 75 100 100 75 75 75 63 63 75 50 0 38 8

Mataram 67 100 67 89 89 100 89 100 89 100 89 100 11 44 9

Bima 60 100 60 80 80 80 80 80 100 100 100 80 0 20 5

Banjar 89 72 67 67 83 100 67 89 94 56 94 72 11 33 18

Banjarmasin 68 68 42 89 89 95 84 100 95 79 89 74 16 21 19

Banjar Baru 86 71 57 71 71 100 71 86 86 86 86 43 0 14 7

Tomohon 14 86 14 57 71 100 57 71 57 71 43 14 0 0 7

Merauke 31 62 23 31 77 100 31 77 77 38 77 92 23 8 13

Yalimo 0 0 0 0 0 100 0 67 67 0 0 100 67 0 3

Puskesmas-urban 72 86 62 90 92 98 88 91 91 91 89 76 4 42 158

Puskesmas-rural 52 79 43 58 72 96 54 83 83 57 72 69 17 15 109

All Puskesmas 61 82 51 72 80 97 68 87 87 71 79 72 12 27 267

Rifaskes-2011

Puskesmas Rural 61 57 n.a n.a n.a 95 n.a 74 78 n.a n.a n.a n.a 29 6617

Puskesmas Urban 65 62 n.a n.a n.a 97 n.a 79 81 n.a n.a n.a n.a 33 2364

All Puskesmas 62% 58% n.a n.a n.a 96% n.a 76% 79% n.a n.a n.a n.a 30% 8981

010

2030

40P

erce

nta

ge

0 1 2 3 4 5 6 7 8 9 10Number of Component

National Urban Rural


Family Planning Readinessat Puskesmas

119

B. ANTENATAL CARE


Guidelines & Trainings

Equipment DiagnosticMedicines &

Commodities

“Antenatal Care

Supply Side”

Number of Facilities

Gu

idel

ine

(%)

Tra

inin

g i

n t

he

last

2

yea

rs (%

)

“Rea

din

ess

ind

ex

(met

all

)” (%

)

Wei

gh

ing

sca

le (%

)

Do

pp

ler

Ult

raso

un

d

(%)

Stet

ho

sco

pe

(%)

Blo

od

Pre

ssu

re (%

)

“Rea

din

ess

ind

ex

(met

all

)” (%

)

Hem

og

lob

in T

est

(%)

Uri

ne

dip

stic

k-p

rote

in

(%)

“Dia

gn

ost

ic I

nd

ex

(all

ite

ms)

” (%

)

Iro

n-F

oli

c a

cid

(%

)

Teta

nu

s To

xo

id

Va

ccin

e (%

)

“Rea

din

ess

ind

ex

(met

all

)” (%

)

“Rea

din

ess

ind

ex

(met

all

)” (%

)

PUSKEMAS

Simeulue 100 75 75 100 75 75 100 50 100 38 38 88 100 88 13 8

Aceh Jaya 89 100 89 89 78 44 78 33 100 100 100 89 89 89 33 9

Lhokseumawe 100 83 83 100 83 100 83 67 83 83 67 83 83 83 33 6

Tapanuli Selatan 93 100 93 93 43 93 100 43 14 21 7 79 57 43 0 14

Pesisir Selatan 93 87 87 67 80 80 93 40 80 73 67 87 53 53 7 15

Padang 100 88 88 100 100 88 94 82 88 88 82 100 94 94 59 17

Indragiri Hilir 100 95 95 100 80 85 95 70 75 65 45 95 85 80 25 20

Sungai Penuh 100 100 100 100 83 83 100 67 83 67 67 83 67 50 17 6

Cilacap 96 96 92 96 85 85 100 73 88 96 85 100 92 92 54 26

Semarang 100 89 84 100 94 83 100 79 100 100 95 100 94 89 63 18

Tegal 100 100 100 100 100 100 100 100 100 100 100 100 88 88 88 8

Pasuruan 100 75 75 100 88 100 100 88 75 75 75 100 88 88 38 8

Tangerang 91 100 91 100 96 96 100 91 87 87 83 96 100 96 61 23

Cilegon 100 100 100 100 100 88 75 75 50 63 50 63 38 38 25 8

Mataram 100 100 100 100 100 67 100 67 100 100 100 89 89 78 67 9

Bima 100 100 100 100 80 80 80 60 100 100 100 80 80 80 60 5

Banjar 100 67 67 100 89 100 100 89 100 72 72 89 94 89 33 18

Banjarmasin 95 89 84 100 100 89 95 84 100 84 84 95 89 84 47 19

Banjar Baru 100 57 57 100 71 100 100 71 100 86 86 100 100 100 43 7

Tomohon 86 100 86 100 86 86 100 71 57 0 0 86 100 86 0 7

Merauke 100 69 69 100 77 100 100 77 85 62 62 92 92 85 31 13

Yalimo 100 67 67 100 100 100 100 100 0 0 0 100 100 100 0 3

Puskesmas-urban 99 88 86 100 92 88 98 81 94 91 87 95 89 85 51 157

Puskesmas-rural 96 88 85 93 76 85 96 61 74 62 53 91 84 79 25 110

All Puskesmas 97 88 85 96 83 86 97 69 82 74 67 93 86 81 36 267

Rifaskes-2011

Puskesmas Rural 54 n.a n.a 98 n.a 99 95 n.a 82 43 n.a 97 94 n.a 23 6617

Puskesmas Urban 51 n.a n.a 98 n.a 100 97 n.a 79 57 n.a 97 97 n.a 28 2364

All Puskesmas 53 n.a n.a 98 n.a 99 96 n.a 81 47 n.a 97 95 n.a 24 8981

010

2030

4050

Per

cen

tage

4 5 6 7 8 9 10Number of Component



Antenatal Care Readinessat Puskesmas

120


C. OBSTETRIC CARE



Equipments

Number of facility

Gu

idel

ine

bo

ok

(%)

Tra

inin

g (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Em

erg

ency

tra

nsp

ort

ati

on

(%)

Ex

am

ina

tio

n l

igh

t (%

)

Del

iver

y b

ed (%

)

Del

iver

y p

ack

(%)

Pa

rto

gra

ph

(%)

Do

pp

ler

ult

raso

un

d (%

)

Ma

nu

al

va

cuu

m e

xtr

act

or

(%)

Va

cuu

m a

spir

ato

r o

r D

&C

k

it (%

)

Neo

na

tal

ba

g a

nd

ma

sk (%

)

Res

usc

ita

tio

n t

ab

le (%

)

Incu

ba

tor

(%)

Dis

po

sab

le l

ate

x g

lov

es (%

)

Ster

iliz

er (%

)

Suct

ion

ap

pa

ratu

s (m

ucu

s ex

tra

cto

r) (%

)

Infa

nt

wei

gh

tin

g s

cale

(%)

Blo

od

pre

ssu

re a

pp

ara

tus

(%)

Soa

p a

nd

ru

nn

ing

wa

ter

OR

a

lco

ho

l b

ase

d h

an

d r

ub

(%)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

PUSKEMAS

Simeulue 63 100 63 100 100 100 88 88 75 13 0 50 25 88 88 100 38 100 100 88 0 8

Aceh Jaya 71 100 56 100 71 86 71 71 71 0 0 71 14 71 71 86 29 57 71 86 11 7

Lhokseumawe 100 100 17 100 100 0 0 100 100 0 0 0 0 0 0 0 0 100 100 100 0 1

Tapanuli Selatan 55 73 29 100 55 100 45 45 36 9 0 73 18 45 100 64 18 100 100 100 0 11

Pesisir Selatan 85 69 53 100 69 69 38 54 77 8 15 31 0 15 54 77 8 77 92 92 0 13

Padang 86 100 35 100 100 100 86 100 100 29 14 86 71 71 100 100 71 86 86 100 0 7

Indragiri Hilir 42 84 30 63 68 84 37 95 79 32 5 53 32 42 100 84 47 100 95 79 0 19

Sungai Penuh 40 100 33 100 80 100 60 80 100 20 20 60 40 80 80 80 60 100 100 100 0 5

Cilacap 70 96 58 91 96 100 74 96 83 17 4 74 91 78 100 96 43 87 100 100 0 23

Semarang 60 100 32 100 80 90 80 100 90 10 0 80 50 50 100 80 50 100 100 100 0 10

Tegal 88 100 88 100 100 100 75 100 100 13 0 88 63 50 100 100 75 100 100 100 0 8

Pasuruan 100 40 25 100 100 100 100 80 100 20 20 100 80 60 100 100 20 100 100 100 0 5

Tangerang 50 50 0 100 100 100 100 100 100 50 50 100 100 100 100 100 100 100 100 100 0 2

Cilegon 67 100 25 100 100 100 100 67 100 67 33 67 100 67 67 100 67 100 100 67 0 3

Mataram 57 100 44 100 71 100 86 100 100 57 43 71 100 100 100 57 57 86 100 100 0 7

Bima 100 80 80 80 80 100 60 80 80 80 60 80 60 0 100 100 40 100 80 100 0 5

Banjar 90 100 50 100 100 100 90 100 90 10 0 80 50 70 100 100 60 100 100 100 0 10

Banjarmasin 100 58 37 100 83 92 92 92 100 0 8 67 42 25 92 100 8 100 100 100 0 12

Banjar Baru 75 100 43 100 75 100 75 75 50 25 25 50 50 25 75 100 25 100 100 100 0 4

Tomohon 17 100 14 100 50 100 50 83 83 17 17 67 67 67 83 83 33 100 100 100 0 6

Merauke 17 17 8 100 67 100 67 92 75 8 0 58 33 33 75 100 25 100 100 67 0 12

Yalimo 0 67 0 33 33 33 33 67 100 0 0 0 33 33 67 67 33 100 100 67 0 3

Puskesmas-urban 71 95 38 97 84 92 72 95 89 16 7 67 58 67 96 93 43 96 99 95 0 86

Puskesmas-rural 56 76 40 88 77 91 60 80 75 15 5 61 39 48 87 85 35 91 96 89 1 95

All Puskesmas 61 82 39 91 79 91 64 85 79 16 5 63 45 54 90 88 38 93 97 91 0 181

Rifaskes-2011

Puskesmas Rural 71 53 45 81 83 n.a 92 n.a 36 30 n.a 39 n.a n.a 67 71 50 n.a 95 n.a 2 6617

Puskesmas Urban 66 50 40 87 90 n.a 91 n.a 33 23 n.a 31 n.a n.a 77 87 43 n.a 97 n.a 1 2364

All Puskesmas 70 52 44 82 85 n.a 92 n.a 35 29 n.a 37 n.a n.a 70 75 49 n.a 96 n.a 2 8981

05

1015

20P

erce

nta

ge

10 12 14 16 18 20 22 24 26 28 30 32 34 36Number of Component



Basic Obstetric Care Readiness

121

OBSTETRIC CARE (CONTINUED)


Medicines & CommoditiesBasic Obstetric Care

Supply Side

Nu

mb

er o

f fa

cili

ty

Ora

l E

rgo

met

rin

e (%

)

Erg

om

etri

ne

(In

ject

ab

le) (

%)

Ox

yto

cin

(in

ject

ab

le) (

%)

Ma

gn

esiu

m s

ulp

ha

te

Inje

cta

ble

s (%

)

Ca

lciu

m g

luco

na

te

(In

ject

ab

le) (

%)

Dia

zep

am

(In

ejec

tab

le) (

%)

Ora

l a

nti

hy

per

ten

siv

e d

rug

s (%

)

Inje

cta

ble

s a

nti

bio

tics

(%)

Met

ron

ida

zole

in

fusi

on

(%)

Ora

l a

nti

bio

tics

(%)

Ora

l a

na

lges

ics

(%)

Ad

ren

ali

n (I

nje

cta

ble

) (%

)

Dex

am

eth

aso

ne

(In

ject

ab

les)

(%

)

Intr

av

eno

us

solu

tio

n

(no

rma

l) s

ali

ne

(%)

Vit

am

in K

(In

ject

ab

le) (

%)

Skin

dis

infe

cta

nt

(%)

An

tib

ioti

cs E

ye

oin

tmen

t (%

)

"Rea

din

ess

Ind

ex

(met

all

)" (%

)

"Rea

din

ess

Ind

ex

(met

all

)" (%

)

PUSKEMAS

Simeulue 63 63 50 88 63 25 75 63 63 100 100 63 100 100 100 100 100 0 0 8

Aceh Jaya 86 86 86 71 29 29 86 43 71 100 100 71 86 100 86 86 86 0 0 7

Lhokseumawe 100 100 100 0 0 0 0 0 0 100 100 0 100 100 0 100 100 0 0 1

Tapanuli Selatan 45 73 45 64 45 82 100 36 9 100 100 0 55 100 100 91 91 0 0 11

Pesisir Selatan 77 92 85 31 15 69 85 46 54 100 100 46 85 100 85 100 92 0 0 13

Padang 86 43 100 57 29 43 86 43 29 100 100 100 71 100 100 100 100 0 0 7

Indragiri Hilir 89 84 89 42 11 68 68 58 32 100 100 79 95 100 95 100 95 0 0 19

Sungai Penuh 20 20 40 60 40 20 20 0 0 100 100 20 40 100 60 100 60 0 0 5

Cilacap 83 74 91 100 39 78 96 61 48 96 100 78 96 100 96 100 91 0 0 23

Semarang 70 90 70 60 60 80 60 30 40 100 90 100 70 100 70 100 100 0 0 10

Tegal 88 100 100 75 25 75 100 25 38 100 100 100 100 100 75 100 100 0 0 8

Pasuruan 40 60 60 20 0 60 100 20 0 100 100 80 80 100 40 100 80 0 0 5

Tangerang 50 50 100 50 100 0 100 0 0 100 100 50 100 100 100 50 100 0 0 2

Cilegon 67 67 33 67 67 67 67 67 33 67 67 67 67 100 67 100 67 13 0 3

Mataram 43 71 86 71 0 86 57 86 14 86 86 86 71 100 86 100 100 0 0 7

Bima 100 80 100 80 60 80 100 20 20 100 80 100 80 100 80 100 100 0 0 5

Banjar 90 100 100 50 0 80 90 40 0 100 100 90 100 100 100 100 100 0 0 10

Banjarmasin 58 75 75 33 25 58 100 17 25 92 100 83 50 92 75 100 100 0 0 12

Banjar Baru 75 75 75 50 25 100 50 50 25 100 100 100 50 100 50 100 75 0 0 4

Tomohon 33 17 83 0 0 0 100 33 33 100 100 17 50 67 67 100 67 0 0 6

Merauke 58 92 92 58 8 83 75 75 17 75 67 50 92 100 100 100 100 0 0 12

Yalimo 67 67 100 0 0 67 100 100 33 100 100 0 33 100 100 100 67 0 0 3

Puskesmas-urban 72 79 78 69 46 66 83 45 36 98 96 85 84 99 85 99 92 0 0 86

Puskesmas-rural 75 81 84 58 19 70 83 54 34 96 96 57 85 100 94 98 94 0 0 95

All Puskesmas 74 80 82 61 28 68 83 51 35 97 96 66 84 99 91 98 94 0 0 181

Rifaskes-2011

Puskesmas Rural n.a 39 38 43 n.a 60 n.a 38 n.a n.a n.a n.a n.a 18 n.a n.a 57 0 0 6617

Puskesmas Urban n.a 29 29 48 n.a 44 n.a 23 n.a n.a n.a n.a n.a 13 n.a n.a 52 0 0 2364

All Puskesmas n.a 36 36 44 n.a 55 n.a 34 n.a n.a n.a n.a n.a 17 n.a n.a 55 0 0 8981

122


D. CHILDHOOD IMMUNIZATION



Equipment Medicines & Commodities“Immunization

Supply Side”


Gu

idel

ines

(%)

Sta

ff T

rain

ned

(%)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Co

ld b

ox

/va

ccin

e ca

rrie

r w

ith

ice

pa

ck

(%)

Ref

rig

era

tor

(%)

Sha

rps

con

tain

er/

safe

ty b

ox

(%)

Au

to-d

isa

ble

sy

rin

ges

(%

)

Term

per

atu

re

mo

nit

ori

ng

dev

ice

in

refr

iger

ato

r (%

)

Ad

equ

ate

ref

rig

era

tor

tem

per

atu

re (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

med

icin

e: M

easl

es

Va

ccin

e (%

)

med

icin

e: D

PT-

Hib

+H

epb

Va

c in

e (%

)

med

icin

e: O

ral

Po

lio

v

acc

ine

(%)

med

icin

e: B

CG

va

ccin

e (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

PUSKEMAS

Simeulue 88 100 88 100 100 75 38 100 88 25 75 63 75 88 63 0 8

Aceh Jaya 67 100 67 78 100 89 56 89 89 33 78 89 89 78 67 22 9

Lhokseumawe 83 83 67 100 100 83 67 100 100 67 83 83 100 100 67 17 6

Tapanuli Selatan 50 93 50 86 86 71 43 93 64 21 71 57 64 64 57 7 14

Pesisir Selatan 67 53 40 93 100 80 67 87 87 47 87 80 87 80 67 20 15

Padang 100 59 59 100 100 100 76 100 100 76 88 88 88 88 82 35 17

Indragiri Hilir 75 90 70 90 85 85 40 75 65 15 70 75 75 75 70 5 20

Sungai Penuh 100 100 100 100 100 100 67 83 100 50 83 100 100 100 83 50 6

Cilacap 63 50 42 88 96 88 88 92 75 58 88 75 88 83 67 25 24

Semarang 83 72 67 94 100 94 89 100 100 83 94 94 94 94 94 50 18

Tegal 100 63 63 100 100 100 50 88 88 50 88 88 75 88 75 0 8

Pasuruan 88 50 38 88 100 88 75 100 75 50 75 63 75 75 63 25 8

Tangerang 74 100 74 100 100 100 74 91 100 70 96 96 96 96 96 52 23

Cilegon 75 100 75 100 100 100 63 100 100 63 50 50 50 50 50 38 8

Mataram 67 100 67 89 100 100 78 89 100 78 100 100 100 100 100 56 9

Bima 100 100 100 100 100 100 60 100 80 40 100 100 80 100 80 40 5

Banjar 100 89 89 100 100 100 100 100 100 100 100 100 100 94 94 83 18

Banjarmasin 74 89 63 100 100 100 95 100 84 79 89 89 89 84 84 42 19

Banjar Baru 86 100 86 100 100 100 57 86 71 43 86 86 86 71 71 43 7

Tomohon 29 100 29 86 100 100 57 86 57 29 86 86 86 100 57 0 7

Merauke 8 54 0 92 100 85 54 92 85 31 92 85 85 92 85 0 13

Yalimo 0 67 0 100 100 67 33 100 100 33 100 67 33 67 0 0 3

Puskesmas-urban 80 75 62 96 98 95 81 94 88 68 91 88 91 89 82 35 157

Puskesmas-rural 61 77 54 90 95 83 60 91 82 42 82 77 80 80 69 24 108

All Puskesmas 69 76 57 93 96 88 69 92 84 53 86 82 85 84 75 28 265

Private

Private-Rural 30 79 30 54 67 92 30 43 43 30 30 38 67 54 0 0 5

Private-Urban 34 43 23 67 93 94 59 54 42 22 47 36 45 48 26 3 36

Private-BPJS 36 50 27 62 88 93 49 55 40 22 46 36 45 47 26 4 31

Private- Non BPJS 26 34 14 78 98 100 80 46 48 26 44 35 55 55 12 0 10

All Private 34 47 24 65 90 94 56 53 42 23 46 36 47 49 23 3 41

Rifaskes-2011

Puskesmas Rural 69 45 n.a 97 87 82 93 79 n.a n.a 95 94 92 94 n.a 23 6617

Puskesmas Urban 73 46 n.a 99 91 91 95 86 n.a n.a 98 98 97 98 n.a 28 2364

All Puskesmas 70 45 n.a 98 88 84 94 81 n.a n.a 96 95 94 95 n.a 24 8981

123

010

2030

Per

cen

tage

0 1 2 3 4 5 6 7 8 9 10 11 12Number of Component



Immunization Service Readinessby Type of Facility

05

1015

2025

Per

cen

tage




Immunization Service Readinessat Private GP/Clinic by BPJS Empanelment

010

2030

40P

erce

nta

ge


Urban Rural


Immunization Service Readinessat Puskesmas by Urban/Rural

010

2030

Per

cen

tage


Urban Rural


Immunization Service Readinessat Private GP/Clinic by Urban/Rural

124


E. CHILD HEALTH



Equipment Diagnostic Medicines & Commodities

“Child Health

Services Supply

Side”

Number of

Facilities

Gu

idel

ines

fo

r IM

CI

(%)

Sta

ff t

rain

ed i

n I

MC

I (%

)

“Rea

din

ess

Ind

ex (m

et a

ll)”

(%)

Infa

nt

wei

gh

ing

sca

le (%

)

Ch

ild

wei

gh

ing

sca

le (%

)

Hei

gh

t m

easu

rem

ent

tap

e/M

icro

tois

e (%

)

Len

gth

mea

sure

men

t b

oa

rd (%

)

MU

AC

mea

suri

ng

ta

pe

(%)

Gro

wth

ch

art

s (%

)

Blo

od

pre

ssu

re s

tra

p f

or

chil

dre

n (%

)

Stet

ho

sco

pe

(%)

Ther

mo

met

er (%

)

AR

I ti

mer

/sto

pw

atc

h (%

)

“Rea

din

ess

Ind

ex (m

et a

ll)”

(%)

Hem

og

lob

in (%

)

Test

pa

rasi

te i

n s

too

l (%

)

Ma

lari

a d

iag

no

stic

ca

pa

city

(%)

“Rea

din

ess

Ind

ex (m

et a

ll)”

(%)

Ora

l re

hy

dra

tio

n s

olu

tio

n p

ack

et (%

)

Am

ox

icil

lin

(dis

per

sib

le t

ab

let

25

0 o

r 5

00 m

g (%

)

Co

-tri

mo

xa

zole

sy

rup

(%)

Pa

race

tam

ol

syru

p (%

)

Vit

am

in A

ca

psu

les

(%)

Zin

c ta

ble

ts (%

)

“Rea

din

ess

Ind

ex (m

et a

ll)”

(%)

“Rea

din

ess

Ind

ex (m

et a

ll)”

(%)

PUSKEMAS

Simeulue 88 100 88 100 50 75 75 63 88 13 75 88 0 0 100 50 100 50 100 100 100 100 100 100 100 38 8

Aceh Jaya 56 100 56 78 78 67 33 67 56 22 44 56 33 0 100 22 100 22 100 100 100 100 89 89 78 0 9

Lhokseumawe 100 100 100 100 83 67 33 67 50 0 100 83 17 0 100 50 83 50 83 100 100 100 67 100 50 0 6

Tapanuli Selatan 50 36 14 93 71 79 57 64 64 7 93 71 29 0 14 29 71 7 93 100 100 100 79 100 79 14 14

Pesisir Selatan 80 53 47 87 67 73 60 73 73 20 80 67 73 7 93 27 73 27 93 100 87 100 53 67 33 20 15

Padang 100 82 82 100 100 94 94 94 94 53 88 100 94 47 100 65 41 35 100 100 94 100 94 94 88 12 17

Indragiri Hilir 95 90 85 100 75 95 90 90 75 20 85 90 50 15 95 45 90 45 100 100 100 100 80 90 70 20 20

Sungai Penuh 67 67 33 100 83 100 83 100 100 17 83 67 33 0 100 83 100 83 83 100 83 100 83 100 50 0 6

Cilacap 81 73 65 88 100 77 69 92 81 19 85 88 85 19 96 31 62 23 85 96 96 100 65 77 38 19 26

Semarang 79 89 68 100 84 100 74 95 79 47 84 100 58 16 100 74 53 47 100 100 100 95 100 84 79 5 19

Tegal 100 75 75 100 88 88 75 75 100 63 100 100 75 50 100 88 50 50 100 100 100 100 100 75 75 13 8

Pasuruan 88 88 75 100 100 100 100 88 88 63 100 100 100 63 88 63 25 25 88 100 88 100 100 100 88 13 8

Tangerang 83 30 26 96 96 100 96 96 87 39 96 100 87 39 91 30 0 0 96 100 100 96 100 78 74 9 23

Cilegon 88 63 50 75 88 88 75 75 75 38 88 75 75 38 100 13 0 0 63 63 63 63 63 38 38 13 8

Mataram 22 89 22 78 89 78 78 89 67 22 67 89 78 11 100 100 100 100 100 89 100 78 100 78 44 11 9

Bima 80 60 60 100 100 100 60 60 40 100 80 80 80 40 100 80 100 80 100 100 100 80 80 80 40 40 5

Banjar 83 33 33 100 100 100 94 100 94 28 100 100 100 28 100 78 94 72 100 100 100 100 100 100 100 6 18

Banjarmasin 79 26 26 89 100 100 84 79 79 74 89 89 84 53 100 95 89 84 95 89 100 100 95 95 79 0 19

Banjar Baru 86 14 14 100 100 100 100 100 86 57 100 100 100 57 100 57 100 57 100 100 100 100 100 100 100 0 7

Tomohon 0 57 0 100 71 86 86 86 71 43 86 100 57 14 57 43 100 29 100 100 86 100 71 71 43 0 7

Merauke 46 15 0 100 92 85 69 100 85 46 100 100 23 8 100 23 100 23 100 69 69 62 92 54 38 15 13

Yalimo 0 0 0 100 100 33 33 100 67 0 100 100 33 0 33 33 100 0 100 100 67 100 100 100 67 0 3

Puskesmas-urban 82 69 57 96 91 90 81 92 84 39 88 97 76 27 99 55 64 42 93 97 97 95 86 83 65 7 158

Puskesmas-rural 70 58 47 93 82 83 69 83 75 22 85 82 52 10 84 41 82 33 97 96 93 96 83 85 67 18 110

All Puskesmas 75 63 51 95 86 86 74 87 79 29 86 88 62 17 90 47 74 37 95 97 95 96 84 84 66 13 268

Private

Private-Rural 28 22 7 54 55 53 13 35 14 26 83 76 10 0 38 6 1 0 36 72 58 74 14 32 7 4 58

Private-Urban 27 15 5 63 80 72 22 36 25 34 87 93 33 4 29 9 4 2 45 62 53 68 12 43 9 3 209

Private-BPJS 34 15 5 81 81 86 32 56 35 35 82 94 36 7 40 8 6 2 49 61 56 64 17 42 13 4 116

Private- Non BPJS 21 18 7 45 69 52 11 19 13 30 89 86 21 0 23 8 1 1 38 67 53 74 9 40 6 3 151

All Private 27 17 6 61 74 67 20 35 23 32 86 89 28 3 31 8 3 1 43 64 54 69 12 41 9 4 267

Rifaskes-2011

Puskesmas Rural 71 42 n.a 34 n.a 74 n.a n.a 78 n.a 93 63 n.a n.a 47 22 54 n.a 92 80 79 89 62 64 n.a 0 6617

Puskesmas Urban 75 46 n.a 28 n.a 73 n.a n.a 78 n.a 96 64 n.a n.a 35 32 53 n.a 94 84 83 92 61 71 n.a 0 2364

All Puskesmas 72 43 n.a 32 n.a 74 n.a n.a 78 n.a 94 63 n.a n.a 44 24 54 n.a 92 81 80 90 62 66 n.a 0 8981

125

05

1015

20P

erce

nta

ge

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21Number of Component



Child Health Service Readinessby Type of Facility

05

1015

Per

cen

tage

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16Number of Component



Child Health Service Readinessat Private GP/Clinic by BPJS Empanelment

05

1015

20P

erce

nta

ge

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21Number of Component

Urban Rural


Child Health Service Readinessat Puskesmas by Urban/Rural

05

1015

20P

erce

nta

ge

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16Number of Component

Urban Rural


Child Health Service Readinessat Private GP/Clinic by Urban/Rural

126


F. MALARIA


Guidelines & Trainings Diagnostic Medicines & Commodities


Gu

idel

ines

Sta

ff t

rain

ed

Sta

ff t

rain

ed i

n I

PT

“Rea

din

ess

Ind

ex

(met

all

)”

Ra

pid

ma

lari

a t

esti

ng

Ma

lari

a s

mea

r te

st

Ca

pa

city

to

co

nd

uct

m

ala

ria

mic

rosc

op

y

“Rea

din

ess

Ind

ex

(met

all

)”

Fir

st-l

ine

an

tim

ala

ria

l in

sto

ck

Pa

race

tam

ol

cap

/ta

b

ITN

s o

r v

ou

cher

s

“Rea

din

ess

Ind

ex

(met

all

)”

“Rea

din

ess

Ind

ex

(met

all

)”

PUSKEMAS

Simeulue 63 75 50 25 100 100 88 88 25 100 13 0 0 8

Aceh Jaya 56 89 89 44 100 100 78 78 67 100 11 11 0 9

Lhokseumawe 17 50 50 0 67 67 83 50 33 100 17 17 0 6

Tapanuli Selatan 36 71 43 21 64 29 36 21 29 100 7 7 7 14

Pesisir Selatan 54 62 38 15 69 77 92 54 38 100 46 31 8 13

Padang 55 64 36 9 36 55 82 18 18 100 0 0 0 11

Indragiri Hilir 40 60 65 15 65 55 95 30 55 100 20 20 0 20

Sungai Penuh 17 67 17 0 100 100 100 100 17 100 0 0 0 6

Cilacap 42 46 13 8 33 54 75 17 8 100 4 4 0 24

Semarang 14 14 0 0 29 57 86 7 14 93 7 0 0 14

Tegal 20 0 20 0 0 80 100 0 0 100 0 0 0 5

Pasuruan 25 25 0 0 25 50 50 25 0 100 0 0 0 4

Tangerang 0

Cilegon 0 0 0 0 0 0 100 0 0 100 0 0 0 1

Mataram 22 89 11 0 22 100 100 22 0 78 0 0 0 9

Bima 60 40 20 20 40 80 100 20 60 80 0 0 0 5

Banjar 67 67 22 11 94 89 100 89 72 100 17 17 0 18

Banjarmasin 42 37 21 11 0 89 100 0 47 100 0 0 0 19

Banjar Baru 71 43 14 0 57 100 100 57 86 100 0 0 0 7

Tomohon 57 86 57 29 100 57 86 57 71 100 0 0 0 7

Merauke 31 62 31 15 100 77 100 77 92 62 100 54 0 13

Yalimo 0 0 33 0 100 0 67 0 100 100 100 100 0 3

Puskesmas-urban 47 47 26 15 39 70 92 26 28 96 10 3 0 111

Puskesmas-rural 39 60 38 13 78 64 80 51 50 96 28 22 2 105

All Puskesmas 42 55 33 13 63 66 84 41 42 96 21 15 1 216

Private : Combined Single & Multiple Provider

Private-Rural 14 10 n.a 3 3 0 16 0 14 59 0 0 0 15

Private-Urban 19 6 n.a 4 4 13 33 4 21 66 0 0 0 59

Private-BPJS 23 10 n.a 6 4 20 37 3 13 53 0 0 0 34

Private- Non BPJS 13 3 n.a 1 4 3 23 3 25 75 0 0 0 40

All Private 18 7 n.a 3 4 11 30 3 19 65 0 0 0 74

Rifaskes-2011

Puskesmas Rural 72 49 n.a n.a 54 n.a n.a n.a 45 89 n.a n.a 18 6617

Puskesmas Urban 68 42 n.a n.a 53 n.a n.a n.a 40 92 n.a n.a 18 2364

All Puskesmas 71 47 n.a n.a 54 n.a n.a n.a 44 90 n.a n.a 18 8981

127

010

2030

4050

Per

cen

tage




Malaria Service Readinessby Type of Facility

020

4060

Per

cen

tage




Malaria Service Readiness at Private GP/Clinicby BPJS-Empanelment

010

2030

40P

erce

nta

ge


Urban Rural


Malaria Service Readiness at Puskesmas by Urban/Rural

010

2030

4050

Per

cen

tage


Urban Rural


Malaria Service Readiness at Private GP/Clinic by Urban/Rural

128


G. TUBERCULOSIS


Guidelines & Trainings Diagnostic Items Medicine Items


Na

tio

na

l G

uid

elin

e fo

r TB

Dia

gn

osi

s a

nd

Tr

eatm

ent

Tra

inin

g o

n d

iag

no

sis

an

d t

rea

tmen

t o

f TB

Tra

inin

g o

n

ma

na

gem

ent

an

d

trea

tmen

t o

f M

DR

-TB

“Rea

din

ess

Ind

ex

(met

all

)”

TB d

iag

no

sis

by

cl

inic

al

sym

pto

ms

Pro

vis

ion

of

dru

gs

to

TB p

ati

ents

Spu

tum

sm

ear

an

d m

icro

sco

py

ex

am

ina

tio

n

TB M

icro

sco

py

HIV

dia

gn

ost

ic

cap

aci

ty

“Rea

din

ess

Ind

ex

(met

all

)”

Fir

st-l

ine

TB

med

ica

tio

ns

“Rea

din

ess

Ind

ex

(met

all

)”

“Rea

din

ess

Ind

ex

(met

all

)”

PUSKEMAS

Referral and Independent Laboratory 48 49 37 14 84 98 95 79 42 28 95 95 3 212

Referral and Independent Laboratory - urban 48 44 36 15 87 100 97 78 55 35 99 99 4 137

Referral and Independent Laboratory - rural 49 53 37 12 81 96 93 79 29 21 92 92 1 75

Satelite 47 40 32 11 42 97 n.a n.a n.a 42 88 88 6 55

Satelite - urban 60 26 46 14 32 100 n.a n.a n.a 32 80 80 3 21

Satelite - rural 44 43 28 10 45 97 n.a n.a n.a 45 90 90 7 34

Private

Private-Urban 15 19 15 3 26 37 n.a n.a n.a 14 38 38 1 111

Private-Rural 9 18 11 0 14 46 n.a n.a n.a 5 70 70 0 19

All Private 14 19 15 3 24 38 n.a n.a n.a 13 43 43 1 130

Rifaskes-2011

Puskesmas Rural 82 64 n.a n.a n.a n.a 73 n.a n.a n.a 46 n.a 0 6617

Puskesmas Urban 87 68 n.a n.a n.a n.a 75 n.a n.a n.a 55 n.a 0 2364

All Puskesmas 84 65 n.a n.a n.a n.a 73 n.a n.a n.a 48 n.a 0 8981

129

010

2030

Per

cen

tage




Tuberculosis Service ReadinessAt Independent/Referral Puskesmas

010

2030

40P

erce

nta

ge




Tuberculosis Service ReadinessAt Satellite Puskesmas

010

2030

40P

erce

nta

ge




Tuberculosis Service ReadinessAt Private GP/Clinic

010

2030

40P

erce

nta

ge


National Empaneled Not empaneled


Tuberculosis Service ReadinessAt Private GP/Clinic by BPJS-Empanelment

130


H. HCT


Guidelines & Training Equipment Diagnostic Commodities“HIV Counseling & Testing Supply

Side”


National guidelines

on HIV Counseling and Testing

(HCT),Others (%)

Training on HIV

counseling and testing (VCT and/or

PICT),Othres (%)

“Readiness Index

(met all)” (%)

Visual and

auditory privacy

(%)

“Readiness Index

(met all)” (%)

HIV diagnostic

capacity (%)

“Readiness Index

(met all)” (%)

Comdoms (%)

“Readiness Index

(met all)” (%)

“Readiness Index (met all)” (%)

PUSKEMAS

Simeulue 100 100 100 0 0 0 0 50 50 0 2

Aceh Jaya 20 0 0 0 0 40 40 0 0 0 5

Lhokseumawe 40 40 40 60 60 100 100 80 80 40 5

Tapanuli Selatan 0

Pesisir Selatan 33 100 33 33 33 100 100 0 0 0 3

Padang 63 63 38 63 63 88 88 100 100 38 8

Indragiri Hilir 17 83 17 50 50 100 100 33 33 0 6

Sungai Penuh 0 100 0 100 100 100 100 0 0 0 1

Cilacap 30 70 26 26 26 96 96 30 30 4 23

Semarang 14 57 0 43 43 86 86 43 43 0 7

Tegal 75 100 75 63 63 100 100 88 88 50 8

Pasuruan 75 63 50 25 25 100 100 63 63 0 8

Tangerang 50 69 50 75 75 75 75 75 75 25 16

Cilegon 25 63 13 75 75 100 100 75 75 13 8

Mataram 29 71 29 57 57 86 86 71 71 29 7

Bima 0 100 0 0 0 100 100 0 0 0 1

Banjar 50 50 0 50 50 100 100 0 0 0 2

Banjarmasin 60 70 50 10 10 80 80 50 50 0 10

Banjar Baru 14 43 0 29 29 100 100 86 86 0 7

Tomohon 0 100 0 50 50 83 83 67 67 0 6

Merauke 0 73 0 55 55 100 100 73 73 0 11

Yalimo 0 100 0 100 100 100 100 50 50 0 2

Puskesmas-urban 31 70 23 47 47 92 92 46 46 9 109

Puskesmas-rural 26 65 20 29 29 85 85 41 41 1 37

All Puskesmas 29 68 22 40 40 89 89 44 44 6 146

Private

Private-Rural 50 100 50 0 0 0 0 50 50 0 2

Private-Urban 2 27 2 46 46 10 10 13 13 0 19

Private-BPJS 0 37 0 54 54 0 0 16 16 0 11

Private- Non BPJS 14 21 14 26 26 26 26 14 14 0 10

All Private 5 31 5 44 44 9 9 15 15 0 21

131

010

2030

40P

erce

nta

ge




HIV-HCT Service Readinessby Type of Facility

020

4060

Per

cen

tage




HIV-HCT Service Readiness at Private GP/Clinicby BPJS-Empanelment

010

2030

40P

erce

nta

ge


Urban Rural


HIV-HCT Service Readiness at Puskesmas by Urban/Rural

010

2030

4050

Per

cen

tage


Urban Rural


HIV-HCT Service Readiness at Private GP/Clinic by Urban/Rural

132


I. HIV – CST


Guidelines & Trainings Diagnostic Medicines & Commodities

HIV Care Support and

Treatment Supply Side


Gu

idel

ines

fo

r cl

inic

al

ma

na

gem

ent

of

HIV

&

AID

S (%

)

Sta

ff t

rain

ed i

n

clin

ica

l m

an

ag

emen

t o

f H

IV &

AID

S (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Syst

em f

or

dia

gn

osi

s o

f TB

am

on

g H

IV +

cl

ien

ts (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Intr

av

eno

us

solu

tio

n

wit

h i

nfu

sio

n s

et (%

)

IV t

rea

tmen

t fu

ng

al

infe

ctio

ns

(%)

Co

-tri

mo

xa

zole

ca

p/

tab

(%)

Fir

st-l

ine

TB r

eatm

ent

med

ica

tio

ns

(%)

Pa

llia

tiv

e ca

re p

ain

m

an

ag

emen

t (%

)

Co

md

om

s (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

PUSKEMAS

Simeulue 0 100 0 100 100 100 100 100 100 100 100 100 0 1

Aceh Jaya 0 0 0 0 0 100 100 100 100 100 0 0 0 1

Lhokseumawe 0 0 0 100 100 100 100 100 100 100 100 100 0 1

Tapanuli Selatan n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Pesisir Selatan 0 50 0 50 50 100 100 100 100 100 0 0 0 2

Padang 67 67 33 100 100 100 100 100 100 100 100 100 33 3

Indragiri Hilir 100 100 100 100 100 100 100 100 100 100 100 100 100 1

Sungai Penuh 0 0 0 0 0 100 0 100 100 100 0 0 0 1

Cilacap 17 50 17 67 67 100 83 83 100 100 50 50 17 6

Semarang 100 100 100 100 100 100 100 100 100 100 100 100 100 1

Tegal 100 100 100 100 100 100 100 100 100 100 67 67 67 3

Pasuruan 0 0 0 100 100 100 0 100 100 100 100 0 0 1

Tangerang 0 100 0 100 100 100 67 100 100 67 0 0 0 3

Cilegon 25 75 25 100 100 75 75 75 75 75 75 75 25 4

Mataram 0 100 0 100 100 100 0 100 100 100 0 0 0 2

Bima n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Banjar 0 0 0 0 0 100 0 100 100 100 0 0 0 1

Banjarmasin 0 0 0 100 100 100 0 100 100 100 100 0 0 1

Banjar Baru 0 0 0 100 100 100 100 100 100 100 100 100 0 2

Tomohon 0 75 0 100 100 100 75 100 75 100 75 50 0 4

Merauke 0 33 0 100 100 100 50 100 100 83 50 17 0 6

Yalimo 0 0 0 100 100 100 100 100 100 100 100 100 0 1

Puskesmas-urban 27 57 25 83 83 99 88 99 97 96 47 43 23 30

Puskesmas-rural 9 42 9 75 75 100 59 91 100 93 61 44 9 15

All Puskesmas 18 50 17 79 79 99 74 95 98 95 53 44 16 45

Private : Combined Single & Multiple Provider

Private-Rural n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Private-Urban 0 77 0 77 77 89 11 89 77 89 0 0 0 3

Private-BPJS 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Private- Non BPJS 0 87 0 87 87 100 13 100 87 100 0 0 0 2

All Private 0 77 0 77 77 89 11 89 77 89 0 0 0 3

010

2030

40P

erce

nta

ge




HIV-Care, Support & Treatment Readiness

133

J. HIV – ANTIRETROVIRAL THERAPY


Guidelines & Training

Medicines & Commodities

“HIV - ARV Prescrip-

tion Supply

Side”


Gu

idel

ines

fo

r a

nti

retr

ov

ira

l th

era

py

(%)

Sta

ff t

rain

ed i

n A

RT

pre

scri

pti

on

an

d

ma

na

gem

ent

(%)

“Rea

din

ess

Ind

ex (m

et a

ll)”

(%)

Fu

ll b

loo

d c

ou

nt

(%)

CD

4 o

r V

ira

l lo

ad

(%)

Ren

al

fun

ctio

n t

est(

seru

m c

rea

tin

ine

test

ing

or

oth

er) (

%)

Liv

er f

un

ctio

n t

est

(AL

T o

r o

ther

) (%

)

Dia

gn

ost

ics

In

dex

(mea

n) (

%)

Dia

gn

ost

ics

In

dex

(all

ite

ms)

(%)

Zid

ov

ud

ine

Ca

p/t

ab

(ZD

V, A

ZT)

(%)

Zid

ov

ud

ine

syru

p/s

usp

ensi

on

(ZD

V, A

ZT)

(%

)

Ab

aca

vir

Ca

p/t

ab

(AB

C) (

%)

La

miv

ud

ine

Ca

p/t

ab

(3TC

) (%

)

Ten

ofo

vir

Dis

op

rox

il F

um

ara

te c

ap

/ta

b(T

DF

) (%

)

Em

tric

ita

bin

e ca

p/t

ab

(FTC

) (%

)

Did

an

osi

ne

cap

/ta

b (D

DI)

(%)

Zid

ov

ud

ine

+ L

am

ivu

din

e ca

p/t

ab

(AZ

T +

3

TC) (

%)

Nev

ira

pin

e ca

p/t

ab

(NV

P) (

%)

Nev

ira

pin

e sy

rup

/su

spen

sio

n (N

VP

) (%

)

Efa

vir

enz

Ca

p/t

ab

(EF

V) (

%)

Lo

pin

av

ir +

Rit

on

av

ir C

ap

/ta

b (L

PV

/r) (

%)

Zid

ov

ud

ine

+ L

am

ivu

din

e +

Nev

ira

pin

e C

ap

/ta

b (A

ZT

+ 3

TC +

NV

P) (

%)

Sta

vu

din

e +

La

miv

ud

ine

+ N

evir

ap

ine

Ca

p/t

ab

(D4

T +

3TC

+ N

VP

) (%

)

“Rea

din

ess

Ind

ex (m

et a

ll)”

(%)

“Rea

din

ess

Ind

ex (m

et a

ll)”

(%)

PUSKEMAS

Simeulue n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Aceh Jaya n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Lhokseumawe n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Tapanuli Selatan n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Pesisir Selatan n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Padang 100 0 0 100 0 0 0 25 0 0 0 0 0 0 0 0 0 0 0 0 0 100 0 0 0 1

Indragiri Hilir 0 100 0 100 0 0 0 25 0 0 0 0 100 100 0 0 0 0 0 100 0 0 0 0 0 1

Sungai Penuh n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Cilacap 33 67 33 67 0 67 67 50 0 33 0 0 67 67 0 0 67 67 0 67 0 0 0 0 0 3

Semarang 100 100 100 100 0 0 0 25 0 100 100 0 100 100 0 0 100 100 100 100 100 100 100 0 0 1

Tegal 100 100 100 100 0 33 0 33 0 67 0 0 67 33 33 0 67 33 0 33 0 33 33 0 0 3

Pasuruan n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Tangerang 0 100 0 100 0 100 100 75 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Cilegon 50 0 0 100 0 0 0 25 0 0 0 0 0 0 50 50 50 50 50 50 50 50 50 0 0 2

Mataram n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Bima n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Banjar n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Banjarmasin n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Banjar Baru n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Tomohon n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Merauke 0 0 0 50 50 0 0 25 0 0 0 0 50 50 0 0 0 0 0 50 0 0 0 0 0 2

Yalimo 0 0 0 0 0 0 0 0 0 100 0 0 100 100 100 0 100 100 0 100 0 100 0 0 0 1

Puskesmas-urban 47 61 40 84 0 40 37 40 0 38 15 0 54 51 6 3 57 54 18 54 18 25 21 0 0 12

Puskesmas-rural 0 35 0 35 30 0 0 16 0 35 0 0 100 100 35 0 35 35 0 100 0 35 0 0 0 3

All Puskesmas 33 53 28 69 9 28 26 33 0 37 11 0 68 66 14 2 50 48 13 68 13 28 15 0 0 15

Private

Private-Rural n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Private-Urban n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Private-BPJS n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Private- Non BPJS n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

All Private n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

010

2030

40P

erce

nta

ge

0 2 4 6 8 10 12 14 16 18 20Number of Component



HIV-Antiretroviral Readiness

134


K. HIV – PMTCT


Guidelines & Training Equipment DiagnosticMedicines &

Commodities“PMTCT Service

Supply Side”


Gu

idel

ines

fo

r P

MTC

T (%

)

Gu

idel

ines

on

in

fan

t a

nd

yo

un

g c

hil

d

feed

ing

pra

ctic

es

(IY

CF

/PM

BA

) (%

)

Sta

ff t

rain

ed i

n P

MTC

T (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Vis

ua

l a

nd

au

dit

ory

p

riv

acy

(%)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

HIV

dia

gn

ost

ic

cap

aci

ty f

or

ad

ult

s (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Zid

ov

ud

ine

+

La

miv

ud

ine

+

Nev

ira

pin

e C

ap

/ta

b

(AZ

T +

3TC

+ N

VP

) (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

PUSKEMAS

Simeulue 100 100 0 0 0 0 0 0 0 0 0 2

Aceh Jaya 40 20 40 0 0 0 40 40 0 0 0 5

Lhokseumawe 0 50 50 0 50 50 100 100 0 0 0 2

Tapanuli Selatan 0 100 0 0 0 0 0 0 0 0 0 2

Pesisir Selatan 40 60 40 20 20 20 40 40 0 0 0 5

Padang 67 100 44 44 56 56 78 78 11 11 0 9

Indragiri Hilir 50 67 83 33 50 50 100 100 0 0 0 6

Sungai Penuh 100 100 100 100 100 100 100 100 0 0 0 1

Cilacap 56 83 72 28 28 28 100 100 0 0 0 18

Semarang 29 36 57 14 21 21 43 43 7 7 0 14

Tegal 88 38 100 38 63 63 100 100 13 13 0 8

Pasuruan 88 63 50 25 25 25 100 100 0 0 0 8

Tangerang 45 65 60 15 50 50 50 50 0 0 0 20

Cilegon 88 63 88 50 75 75 100 100 13 13 0 8

Mataram 89 56 67 33 44 44 67 67 0 0 0 9

Bima 50 100 0 0 0 0 50 50 0 0 0 2

Banjar 14 71 29 14 14 14 14 14 0 0 0 7

Banjarmasin 21 57 36 14 7 7 57 57 0 0 0 14

Banjar Baru 43 71 43 14 29 29 100 100 0 0 0 7

Tomohon 67 67 100 33 33 33 67 67 0 0 0 3

Merauke 36 0 45 0 55 55 91 91 9 9 0 11

Yalimo 100 0 100 0 100 100 100 100 100 100 0 1

Puskesmas-urban 48 61 67 25 40 40 75 75 3 3 0 122

Puskesmas-rural 40 49 38 8 19 19 56 56 5 5 0 40

All Puskesmas 45 56 56 18 31 31 67 67 4 4 0 162

Private

Private-Rural 26 0 38 0 0 0 0 0 0 0 0 8

Private-Urban 18 9 27 7 12 12 3 3 0 0 0 50

Private-BPJS 19 10 35 10 12 12 0 0 0 0 0 31

Private- Non BPJS 19 4 20 0 6 6 6 6 0 0 0 27

All Private 19 8 29 6 10 10 2 2 0 0 0 58

135

020

4060

Per

cen

tage




HIV-PMTCT Service Readinessby Type of Facility

020

4060

80P

erce

nta

ge




HIV-PMTCT Service Readiness at Private GP/Clinicby BPJS-Empanelment

010

2030

Per

cen

tage


Urban Rural


HIV-PMTCT Service Readiness at Puskesmas by Urban/Rural

020

4060

Per

cen

tage


Urban Rural


HIV-PMTCT Service Readiness at Private GP/Clinic by Urban/Rural

136


L. SEXUALLY TRANSMITTED INFECTIONS (STIS)


Guidelines & Training Diagnostic Medicines & Commodities

“STI Service Supply

Side”


Gu

idel

ines

fo

r d

iag

no

sis

& t

rea

tmen

t (%

)

Sfa

ff t

rain

ed i

n S

TI

dia

gn

osi

s &

tre

atm

ent

(%)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Syp

hil

is r

ap

id t

est

(%)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Co

nd

om

s (%

)

Met

ron

ida

zole

ca

p/

tab

(%)

Cip

rofl

ox

aci

n c

ap

/ta

b (%

)

Cef

tria

xo

ne

inje

ctio

n

(%)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

PUSKEMAS

Simeulue 50 25 0 25 13 0 100 25 25 0 0 4

Aceh Jaya 40 20 11 20 11 0 80 80 40 0 0 5

Lhokseumawe 0 67 0 100 50 33 100 67 0 0 0 3

Tapanuli Selatan 14 0 0 57 29 0 100 29 14 0 0 7

Pesisir Selatan 22 44 0 0 0 0 100 44 11 0 0 9

Padang 50 57 29 36 29 21 100 100 14 12 6 14

Indragiri Hilir 0 36 0 50 35 7 93 86 79 5 0 14

Sungai Penuh 50 75 33 25 17 25 100 0 0 0 0 4

Cilacap 45 40 19 25 19 20 65 100 30 4 4 20

Semarang 25 38 11 25 21 6 94 88 31 5 0 16

Tegal 100 100 100 75 75 38 100 100 63 38 25 8

Pasuruan 88 50 38 88 88 13 100 100 0 0 0 8

Tangerang 48 52 30 26 26 9 91 96 4 0 0 23

Cilegon 25 88 25 100 100 38 63 63 13 13 13 8

Mataram 44 67 33 78 78 22 100 89 11 0 0 9

Bima 50 50 0 100 40 0 100 100 50 0 0 2

Banjar 25 19 6 6 6 6 100 94 31 6 0 16

Banjarmasin 33 33 5 39 37 6 94 89 11 0 0 18

Banjar Baru 17 0 0 50 43 17 100 100 17 0 0 6

Tomohon 0 83 0 33 29 17 50 50 0 0 0 6

Merauke 0 0 0 56 38 44 67 100 89 23 0 9

Yalimo 100 100 33 100 33 100 100 100 0 0 0 1

Puskesmas-urban 36 49 19 45 37 16 86 92 21 6 3 137

Puskesmas-rural 24 22 4 22 14 11 89 75 46 4 0 73

All Puskesmas 29 35 10 33 24 13 88 83 34 5 1 210

Private

Private-Rural 17 18 3 0 0 0 59 67 30 0 0 43

Private-Urban 21 11 2 4 3 0 51 58 15 0 0 145

Private-BPJS 23 17 4 5 3 0 51 52 19 0 0 76

Private- Non BPJS 17 9 1 2 1 0 53 66 18 0 0 112

All Private 20 12 3 3 2 0 53 60 18 0 0 188

137

010

2030

40P

erce

nta

ge


Urban Rural


STI Service Readiness at Private GP/Clinic by Urban/Rural

010

2030

40P

erce

nta

ge




STI Service Readinessby Type of Facility

010

2030

40P

erce

nta

ge




STI-PMTCT Service Readiness at Private GP/Clinicby BPJS-Empanelment

010

2030

40P

erce

nta

ge


Urban Rural


STI Service Readiness at Puskesmas by Urban/Rural

138


M. NCDS – DIABETES



Equipment Diagnostic Medicines & Commodities

“Diabetes Service Supply

Side”


Gu

idel

ine

(%)

Sta

ff T

rain

ed (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Blo

od

pre

ssu

re

ap

pa

ratu

s (%

)

Ad

ult

sca

le (%

)

Hei

gh

t m

easu

rem

ent

tap

e/M

icro

tois

e (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Blo

od

glu

cose

(%)

Uri

ne

dip

stic

k-

pro

tein

(%)

Uri

ne

dip

stic

k-

ket

on

es (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Met

form

in c

ap

/ta

b (%

)

Gli

ben

cla

mid

e ca

p/

tab

ale

t (%

)

Glu

cose

in

ject

ab

le

solu

tio

n (%

)

Gli

piz

ide

tab

let

(%)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

PUSKEMAS

Simeulue 63 63 50 100 100 75 75 75 38 0 0 63 88 13 88 0 0 8

Aceh Jaya 44 89 44 78 89 67 56 78 100 56 33 89 100 22 100 22 0 9

Lhokseumawe 67 50 50 83 100 67 50 100 83 83 83 83 100 67 100 50 33 6

Tapanuli Selatan 54 77 50 100 92 77 71 54 23 0 0 46 85 31 85 21 0 13

Pesisir Selatan 64 50 40 93 64 71 40 57 71 0 0 93 93 29 93 13 0 14

Padang 88 82 76 94 100 94 88 82 88 59 53 100 94 24 94 24 0 17

Indragiri Hilir 40 70 20 95 100 95 90 85 65 50 50 100 100 25 100 25 5 20

Sungai Penuh 50 100 50 100 100 100 100 67 67 50 50 33 33 0 33 0 0 6

Cilacap 38 58 31 100 96 77 77 73 96 46 31 100 96 50 96 50 12 26

Semarang 47 63 26 100 95 100 95 95 100 74 68 95 84 16 84 16 0 19

Tegal 63 50 25 100 100 88 88 88 100 75 75 100 100 0 100 0 0 8

Pasuruan 75 13 0 100 100 100 100 100 75 75 75 100 100 0 100 0 0 8

Tangerang 57 91 57 100 100 100 100 91 87 83 78 78 61 4 61 0 0 23

Cilegon 50 88 38 75 100 88 63 50 63 13 0 63 63 13 63 13 0 8

Mataram 67 56 56 100 100 78 78 89 100 100 89 100 100 22 100 22 11 9

Bima 80 40 40 80 100 100 80 60 100 80 40 100 100 20 100 20 0 5

Banjar 72 78 61 100 100 100 100 94 72 44 39 100 61 0 61 0 0 18

Banjarmasin 53 68 37 95 100 100 95 95 84 79 74 79 100 5 100 5 0 19

Banjar Baru 57 57 29 100 100 100 100 86 86 86 71 100 100 0 100 0 0 7

Tomohon 71 86 57 100 100 86 86 86 0 0 0 100 100 0 100 0 0 7

Merauke 0 22 0 100 100 100 69 100 78 33 23 78 89 22 89 8 0 9

Yalimo n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a n.a 0

Puskesmas-urban 58 72 44 98 99 90 87 89 91 61 56 89 87 23 87 18 2 158

Puskesmas-rural 44 60 30 96 92 86 73 74 66 31 23 89 88 23 88 19 3 101

All Puskesmas 50 65 36 97 95 88 79 81 77 45 37 89 88 23 88 19 3 259

Private

Private-Rural 40 55 27 88 n.a 51 43 62 18 4 2 73 68 30 68 23 0 58

Private-Urban 32 47 18 96 n.a 65 60 67 15 12 8 66 65 10 65 8 1 213

Private-BPJS 37 63 25 92 n.a 84 76 65 20 18 11 59 55 14 55 8 2 113

Private- Non BPJS 31 38 16 95 n.a 45 42 67 12 4 3 74 73 15 73 13 0 158

All Private 33 49 20 94 n.a 62 56 66 15 10 6 68 66 14 66 11 1 271

Rifaskes

Puskesmas Rural n.a n.a n.a 95 98 59 n.a 51 43 n.a n.a n.a n.a 84 n.a n.a 20 6617

Puskesmas Urban n.a n.a n.a 97 98 60 n.a 63 57 n.a n.a n.a n.a 66 n.a n.a 21 2364

All Puskesmas n.a n.a n.a 96 98 59 n.a 54 47 n.a n.a n.a n.a 79 n.a n.a 20 8981

139

05

1015

2025

Per

cen

tage




Diabetes Service Readinessby Type of Facility

05

1015

20P

erce

nta

ge




Diabetes Service Readiness at Private GP/Clinicby BPJS-Empanelment

010

2030

Per

cen

tage


Urban Rural


Diabetes Service Readiness at Puskesmas by Urban/Rural

05

1015

2025

Per

cen

tage


Urban Rural


Diabetes Service Readiness at Private GP/Clinic by Urban/Rural

140


N. NCDS – CARDIOVASCULAR DISEASES (CVDS)



Equipment Medicines & Commodities“Cardiovascular

Service Supply Side”


Gu

idel

ine

(%)

Sta

ff T

rain

ed (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Stet

ho

sco

pe

(%)

Blo

od

Pre

ssu

re

Ap

pa

ratu

s (%

)

Ad

ult

Sca

le (%

)

Ox

yg

en (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

AC

E I

nh

ibit

or

(%)

Hy

dro

chlo

roth

iazi

de

(%)

Bet

a B

lock

er (%

)

Ca

lciu

m C

ha

nn

el

Blo

cker

s (%

)

Asp

irin

ca

p/t

ab

s (%

)

Met

form

in c

ap

/ta

bs

(%)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

PUSKEMAS

Simeulue 67 83 50 100 100 100 100 75 83 67 17 100 17 67 13 13 6

Aceh Jaya 50 88 44 38 75 88 88 33 100 88 13 75 38 88 11 0 8

Lhokseumawe 75 75 50 100 100 100 100 67 100 100 0 75 25 75 0 0 4

Tapanuli Selatan 67 83 57 100 100 92 92 71 100 67 8 83 33 33 0 0 12

Pesisir Selatan 55 55 27 82 91 73 100 33 100 91 18 82 27 91 7 0 11

Padang 85 85 59 85 100 100 92 59 100 69 54 100 77 100 29 24 13

Indragiri Hilir 47 65 20 82 94 100 94 60 94 94 76 94 41 100 35 0 17

Sungai Penuh 25 100 17 100 100 100 100 67 100 50 25 75 0 25 0 0 4

Cilacap 39 48 23 87 100 96 96 69 100 74 52 91 57 100 27 8 23

Semarang 31 63 16 88 100 94 100 68 100 88 56 100 69 94 42 11 16

Tegal 71 57 38 100 100 100 100 88 100 100 71 57 57 100 13 0 7

Pasuruan 80 0 0 100 100 100 100 63 100 100 0 100 40 100 0 0 5

Tangerang 64 91 61 95 100 100 100 91 100 91 64 91 36 77 13 9 22

Cilegon 33 100 25 83 67 100 50 38 67 67 33 50 0 50 0 0 6

Mataram 67 56 56 67 100 100 100 67 100 89 11 100 78 100 11 0 9

Bima 75 50 40 75 75 100 100 40 100 50 25 100 50 100 0 0 4

Banjar 73 73 50 100 100 100 100 83 100 73 60 87 7 100 0 0 15

Banjarmasin 50 72 32 89 94 100 89 74 100 100 83 100 94 83 63 21 18

Banjar Baru 57 57 29 100 100 100 100 100 100 100 14 100 71 100 0 0 7

Tomohon 43 86 43 86 100 100 100 86 100 86 14 100 43 100 14 0 7

Merauke 0 14 0 100 100 100 100 54 100 57 29 71 43 86 0 0 7

Yalimo 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Puskesmas-urban 57 71 37 87 99 98 98 70 99 79 49 90 57 88 22 8 135

Puskesmas-rural 45 59 26 88 95 93 95 59 97 82 43 89 33 88 17 2 86

All Puskesmas 50 64 31 88 97 95 96 64 98 81 46 90 44 88 19 5 221

Private

Private-Rural 35 46 17 81 88 n.a 42 29 75 68 45 73 49 72 26 3 50

Private-Urban 31 47 18 80 95 n.a 58 40 70 56 34 65 43 66 21 3 185

Private-BPJS 33 63 23 81 93 n.a 75 53 59 51 33 59 38 58 19 6 99

Private- Non BPJS 31 34 14 80 95 n.a 39 26 80 65 38 73 49 74 24 1 136

All Private 32 47 18 81 94 n.a 55 38 71 59 36 67 44 67 22 3 235

Rifaskes-2011

Puskesmas Rural n.a n.a n.a 99 95 98 82 n.a 83 n.a n.a n.a n.a n.a n.a 26 6617

Puskesmas Urban n.a n.a n.a 100 97 98 74 n.a 86 n.a n.a n.a n.a n.a n.a 13 2364

All Puskesmas n.a n.a n.a 99 96 98 81 n.a 84 n.a n.a n.a n.a n.a n.a 22 8981

141

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Per

cen

tage

0 1 2 3 4 5 6 7 8 9 10 11Number of Component


Note : vertical solid line=mean; vertical dash line=medianCompared 11 components measured in both facility type

Cardiovascular Service Readinessby Type of Facility

05

1015

2025

Per

cen

tage




by BPJS-Empanelment

010

2030

40P

erce

nta

ge


Urban Rural


Cardiovascular Service Readiness at Puskesmas by Urban/Rural

010

2030

Per

cen

tage


Urban Rural


Cardiovascular Service Readiness at Private GP/Clinic by Urban/Rural

142


O. NCDS – CHRONIC RESPIRATORY DISEASES (CRD)


Guidelines & Training Equipment Medicines & Commodities

“Chronic Respiratory

Service Supply Side”


Gu

idel

ine

(%)

Sta

ff T

rain

ed (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

Stet

ho

sco

pe

(%)

Pea

k fl

ow

met

ers

(%)

Spa

cer

for

inh

ale

r (%

)

Ox

yg

en (%

)

Ele

ctro

card

iog

ram

(%)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

An

tia

sth

ma

tic

ag

ent

for

acu

te a

tta

ck (%

)

Ora

l co

rtic

ost

ero

id (%

)

Inje

cta

ble

co

rtic

ost

ero

id (%

)

Ep

inep

hri

ne

inje

cta

ble

(%)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

“Rea

din

ess

Ind

ex

(met

all

)” (%

)

PUSKEMAS

Simeulue 63 75 63 75 0 0 88 0 0 38 100 100 63 25 0 8

Aceh Jaya 44 78 33 44 11 56 89 0 0 78 100 100 56 44 0 9

Lhokseumawe 67 50 50 100 33 17 100 17 0 83 100 83 33 17 0 6

Tapanuli Selatan 55 73 43 100 18 18 91 27 0 45 100 55 0 0 0 11

Pesisir Selatan 69 54 40 77 23 23 100 15 7 77 92 85 54 40 0 13

Padang 93 80 71 87 47 40 100 53 18 53 100 73 80 18 6 15

Indragiri Hilir 50 61 20 83 6 50 89 44 0 83 100 89 83 60 0 18

Sungai Penuh 50 100 50 83 83 17 100 67 0 17 100 0 17 0 0 6

Cilacap 40 52 23 84 8 44 96 40 4 56 96 80 80 42 0 25

Semarang 33 61 11 89 6 28 100 39 0 67 94 78 83 47 0 18

Tegal 57 57 25 100 14 43 100 57 0 86 100 57 100 50 0 7

Pasuruan 83 0 0 100 17 17 100 0 0 50 100 67 67 13 0 6

Tangerang 62 86 48 95 29 38 100 29 0 38 95 33 67 13 0 21

Cilegon 67 83 38 100 0 33 83 50 0 50 67 50 67 25 0 6

Mataram 71 57 44 71 29 43 100 0 0 100 86 57 71 22 0 7

Bima 75 25 20 75 25 25 100 50 0 100 100 100 100 80 0 4

Banjar 67 78 56 100 11 17 100 6 6 83 100 78 72 67 6 18

Banjarmasin 47 71 26 88 29 24 88 18 0 82 100 65 82 47 0 17

Banjar Baru 57 43 29 100 29 43 100 29 14 71 100 86 86 57 0 7

Tomohon 33 83 29 83 0 17 100 83 0 67 100 33 17 0 0 6

Merauke 0 40 0 100 0 60 100 40 0 100 80 100 60 15 0 5

Yalimo 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Puskesmas-urban 56 70 36 89 14 38 97 37 3 59 97 69 77 35 0 140

Puskesmas-rural 47 59 26 84 12 29 94 22 2 74 97 85 61 41 1 93

All Puskesmas 51 64 30 86 13 33 96 29 2 67 97 78 68 38 1 233

Private

Private-Rural 27 40 9 88 0 25 35 6 0 56 73 45 27 10 0 45

Private-Urban 29 44 14 81 4 23 56 8 1 48 69 43 36 18 1 185

Private-BPJS 30 59 18 82 7 26 75 5 1 44 61 35 31 14 1 97

Private- Non BPJS 28 30 9 83 0 21 33 9 0 54 77 49 37 17 0 133

All Private 28 43 13 82 3 23 52 7 0 50 70 43 34 16 0 230

Rifaskes-2011

Puskesmas Rural n.a n.a n.a 99 n.a n.a 82 n.a n.a 77 87 n.a n.a n.a 22 6617

Puskesmas Urban n.a n.a n.a 100 n.a n.a 74 n.a n.a 84 89 n.a n.a n.a 12 2364

All Puskesmas n.a n.a n.a 99 n.a n.a 81 n.a n.a 79 88 n.a n.a n.a 19 8981

143

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CRD Service Readinessby Type of Facility

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CRD Service Readiness at Private GP/Clinicby BPJS-Empanelment

05

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Urban Rural


CRD Service Readiness at Puskesmas by Urban/Rural

05

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Per

cen

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Urban Rural


CRD Service Readiness at Private GP/Clinic by Urban/Rural

144


Asia Pacific Observatory and WHO. 2015. “Health System in Transition, Country Report: Indonesia.” Final draft, unpublished. Country Team, Asia Pacific Observatory and WHO.

Efendi, F., C-M Chen, N. Nursalam, N.W.F. Andriyani, A. Kurniati, and S. Nancarrow. 2015. “How to attract health students to remote areas in Indonesia: a discrete choice experiment.” International Journal of Health Planning and Management. http://dx.doi.org/10.1002/hpm.2289

Grafström, A., and L. Schelin. 2014. “How to Select Representative Samples.” Scandinavian Journal of Statistics.

Hansen, B.B., and S. Klopfer Olsen. 2006. “Optimal full matching and related designs via network flows.” Journal of Computational and Graphical Statistics 15(3): 609-627.

Heywood, P., and N.P. Harahap. 2009. “Health facilities at the district level in Indonesia.” Australia and New Zealand Health Policy Vol. 6(13).

Institute for Health Metrics and Evaluation (IHME). 2017. IHME database. http://www.healthdata.org

Kruk, M.E., H.H. Leslie, S. Verguet, G.M. Mbaruku, R.M.K. Adanu, and A. Langer. 2016. “Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys.” The Lancet Global Health 4(11): e845–e855.

Leslie, H.H., Z. Sun, and M.E. Kruk. 2017. “Association between infrastructure and observed quality of care in 4 healthcare services: A cross-sectional study of 4,300 facilities in 8 countries.” PLoS Medicine 14(12). http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002464

Ministry of Health (MoH). 2012. “Riset Fasilitas Kesehatan (Rifaskes) 2011.” (http://labdata.litbang.depkes.go.id/riset-badan-litbangkes/menu-riskesnas/pemanfaatan-data/menu-riskesnas/menu-data-rifaskes/371-pelayanan-rifaskes-2011)

References

———. 2014. “Indonesia Health Profile 2013.” Jakarta: MoH. http://www.depkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/Indonesia%20Health%20Profile%202013%20-%20v2%20untuk%20web.pdf

———. 2016. “Indonesia Health Profile 2015.” Jakarta: MoH. (http://www.depkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/indonesian%20health%20profile%202015.pdf )

———. 2017. “Indonesia Health Profile 2016.” Jakarta: MoH. http://www.depkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/Profil-Kesehatan-Indonesia-2016.pdf

Rokx, C., G. Schieber, P. Harimurti, A. Tandon, and A. Somanathan. 2009. “Health Financing in Indonesia: A Reform Road Map”. Washington, DC: World Bank.

Rokx, C., J. Giles, E. Satriawan, P. Marzoeki, P. Harimurti, and E. Yavuz. 2010. “New Insights into the Provision of Health Services in Indonesia: A Health Workforce Study.” Washington, DC: World Bank.

Statistics Indonesia, National Population and Family Planning Board, and Ministry of Health (MoH). 2013. “Indonesia Demographic and Health Survey (IDHS) 2012.”

United Nations Development Group. 2003. “Indicators for Monitoring the Millennium Development Goals. Definitions, Rationale, Concepts and Sources.” New York: United Nations.

World Bank. 2014. “Universal Maternal Health Coverage: Assessing the Readiness of Public Health Facilities to Provide Maternal Health Care in Indonesia.” Washington, DC: World Bank.

———. 2016. “Indonesia Health Financing System Assessment: Spend More, Right and Better.” Jakarta: The World Bank.

———. 2017. “World Development Indicators 2017.” Washington, DC: The World Bank.

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World Health Organization. 2013. “Service Availability and Readiness Assessment (SARA). An annual monitoring system for service delivery. Reference Manual.” Geneva: World Health Organization.

———. 2016. “WHO-led Joint Malaria Program Review report, November 2016.” Geneva: World Health Organization

———. 2017. “Global Tuberculosis Report 2017.” Geneva: World Health Organization.

Yap, W.A., E.S. Pambudi, P. Marzoeki, J.S. Cain, and A. Tandon. 2017. “Revealing the Missing Link: Private Sector Supply-Side Readiness for Primary Maternal Health Services in Indonesia.” Washington, DC: World Bank.

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