Is Indonesia Ready to Serve ? An analysis of Indonesia’s primary health care supply-side readiness Is Indonesia Ready to Serve ? An analysis of Indonesia’s primary health care supply-side readiness iv Is Indonesia ready to serve? v Acknowledgements This report was prepared by Vikram Rajan (Senior guidance. This report and the survey received Health Specialist), Anchita Patil (Consultant), Eko cofinancing from the Public Financial Management Setyo Pambudi (Research Analyst), and Junedi Multi Donor Trust Fund (supported by Canada, (Consultant) of the World Bank (WB). The team would European Union and Switzerland). Other sources of also like to thank WB colleagues Puti Marzoeki financing for the survey were: (Senior Health Specialist), and Pandu Harimurti (Senior Health Specialist), who provided valuable • The Gender Trust Fund (supported by the inputs on program-related aspects. The team also Department of Foreign Affairs and Trade (DFAT) received substantive inputs during the review (Australia); Royal Ministry of Foreign Affairs process from peer reviewers: Mickey Chopra (Lead (Denmark); Gesellschaft Fur Internationale Health Specialist, GHNDR), Jeremy Henri Maurice Zusammenarbeit (GIZ) (Germany); Ministry Veillard (Senior Health Specialist, GHNGE), and of Foreign Affairs (Iceland); Minister for Ajay Tandon (Lead Health Economist, GHN06). The Foreign Trade and Development Cooperation team would like to thank Christina Sukmawati (Netherlands); Ministry of Foreign Affairs (Program Assistant, WB, Indonesia Country Office) for (Norway); Swedish International Development formatting the report. The report was edited by Chris Cooperation Agency (Sida) (Sweden); Swiss Stewart. The layout was done by Indra Irnawan. Agency for Development and Cooperation (SDC); Department for International Development The Quantitative Service Delivery Survey (QSDS) (DFID) (United Kingdom); and United States was designed by Wei Aun Yap (Consultant WB) Agency for International Development (USAID); and Eko Setyo Pambudi and was conducted by • The Indonesia Integrating Donor-Funded Health SurveyMeter (Wayan Suriastini and team) and Programs, Multi-Donor Trust Fund (supported by Center for Health Policy and Management, Faculty DFAT and Bill and Melinda Gates Foundation); of Medicine, Gadjah Mada University (Laksono • The PNPM Generasi Trust Fund (supported DFAT; Trisnantoro and team). Royal Ministry of Foreign Affairs (Denmark); Commission of the European Communities The team would also like to thank Rodrigo A. (European Union); Millennium Challenge Chaves (Country Director, EACIF), and Toomas Account Indonesia; Minister for Foreign Trade Palu (Practice Manager, East Asia and Pacific and Development Cooperation (Netherlands); Health, Nutrition and Population) for their overall and DFID (United Kingdom). vi Contents 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 Is Indonesia ready to serve? vii 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 viii Abbreviations and Acronyms AD Auto-disable DOTS Directly Observed Treatment Short- AEFI Adverse Effects Following course Immunization DPT Diphtheria Pertussis Tetanus AIDS Acquired Immuno-Deficiency EPI Expanded Program on Immunization Syndrome FDC Fixed-dose Combination ANC Antenatal Care GDP Gross Domestic Product APBD Anggaran Pendapatan dan Belanja GoI Government of Indonesia Daerah (Regional Budget) GP General practitioner API Annual Parasite Index HCT HIV counseling and testing ARI Acute Respiratory Infection HDI Human Development Index ART Antiretroviral Therapy Hep-B Hepatitis B ATMI HIV and AIDS, Tuberculosis, Malaria HiB Hemophilus influenzae B and Immunization HIV Human Immunodeficiency Virus ATT Antitubercular Treatment HRH Human Resources for Health BCG Bacillus Calmette-Guérin (vaccine IDHS Indonesia Demographic and Health against tuberculosis) Survey BEmONC Basic Emergency Obstetric and IDR Indonesian Rupiah Neonatal Care IFA Iron and Folic Acid BKKBN Badan Kependudukan dan Keluarga IMCI Integrated Management of Childhood Berencana Nasional (National Family Illness Planning and Population Board) IMNCI Integrated Management of Neonatal BOK Bantuan Operasional Kesehatan and Childhood Illness (Health Operational Assistance) INA-CBG Indonesia Case-based Group BOR Bed Occupancy Rate IPT Intermittent Preventive Treatment (for BPJS Badan Penyelenggara Jaminan Sosial malaria) (Social Security Agency) IPV Inactivated Poliomyelitis Vaccine CI Confidence interval IYCF Infant and Young Child Feeding CVD Cardiovascular disease KAFKTP Komisi Akreditasi Fasilitas Kesehatan CST Care, Support and Treatment (for HIV) Tingkat Primer (Primary Care DAK Dana Alokasi Khusus (Special Accreditation Commission) Allocation Funds) KAP Key Affected Population DAU Dana Alokasi Umum (General LG Local Government Allocation Funds) LLIN Long-lasting Insecticidal Net DHO District Health Office LMIS Logistics Management Information Dinkes Dinas Kesehatan (District Health System Office) MCH Maternal and child health DM Diabetes Mellitus MDR-TB Multi-drug Resistant Tuberculosis Is Indonesia ready to serve? ix MMR Maternal Mortality Ratio QSDS Quantitative Service Delivery Survey MoF Ministry of Finance RDT Rapid diagnostic test MoH Ministry of Health Riset Fasilitas Kesehatan (Health Rifaskes MoHA Ministry of Home Affairs facility survey) MP-ASI Makanan Pendamping Air Susu Ibu RMNCH Reproductive Maternal Newborn and (Complementary food) Child Health MSS Minimum Service Standards SARA Service Availability and Readiness MUAC Mid upper arm circumference Assessment NCD Noncommunicable disease SBA Skilled Birth Attendant/Attendance NTT Nusa Tenggara Timur (East Nusa SDITK Stimulasi, Deteksi dan Intervensi Tenggara) Dini Tumbuh Kembang (Stimulation, OOP Out-of-Pocket (Expenditure) Early Detection and Growth OPD Outpatient Department Intervention) OPV Oral Polio Vaccine SHI Social Health Insurance ORS Oral Rehydration Solution SP2TP Sistem Pencatatan Pelaporan Terpadu PHBS Perilaku Hidup Bersih Sehat (Clean Puskesmas (Puskesmas Integrated and Healthy Life Behavior) Reporting and Recording System) PHC Primary Health Care STI Sexually Transmitted infection PHE Public Health Expenditure TB Tuberculosis PKK Pembinaan Kesejahteraan Keluarga THE Total Health Expenditure (Family Welfare Program) TT Tetanus Toxoid PMTCT Prevention of Mother-to-Child U5MR Under-five Mortality Rate Transmission UHC Universal Health Coverage Polindes Pos Bersalin Desa (Village Maternity UKBM Usaha Kesehatan Bersama Post) Masyarakat (Community-based PONED Pelayanan Obstetri Neonatal Health Services) Emergensi Dasar (Basic Emergency VCT Voluntary counseling and testing Neonatal and Obstetric Service) WHO World Health Organization Poskesdes Pos Kesehatan Desa (Village Health Post) Posyandu Pos Pelayanan Terpadu (Integrated Service Post) PPH Post-partum Hemorrhage Puskesmas Pusat Kesehatan Masyarakat (Community Health Center) Pustu Puskesmas Pembantu (Auxiliary Puskesmas) x Executive Summary This report brings out key findings from a underutilized levers to direct service-delivery Quantitative Service Delivery Study (2016) improvement at the local level. The majority of of public and private primary health care intergovernmental transfers are unconditional, providers in Indonesia. The report analyzes and those transfers that are conditional have weak primary health care supply-side readiness across performance orientation. There are multifaceted public and private facilities, rural and urban facilities, and competing mixtures of central and subnational private facilities empaneled by the national social regulations governing authority over key decisions health insurance agency (Badan Penyelenggara which complicates health service delivery. Another Jaminan Sosial – BPJS) versus those who have not, complication following decentralization in the amongst others. It also compares temporal changes health sector has been the disruption to, and varying in public-sector primary health care supply-side quality of, monitoring, reporting, and data systems. readiness since the last facility census, the Rifaskes (2011). The primary aim of the report is to present Indonesia has a mixed model of public-private findings from the survey that can inform policy provision of health care services. The public choices to improve primary health care service primary health care system is decentralized to the readiness as part of Indonesia’s path towards district level–with about 9,750 puskesmas1 forming achieving Universal Health Coverage (UHC). the backbone of the country’s health system. A similar number of private primary care clinics have Indonesia, the fourth most populous country been empaneled by BPJS; many nonempaneled in the world, has taken great strides in private clinics exist too, the count of which is not reduction of poverty and improvement of known. BPJS runs JKN–one of the largest single-payer health indicators. Life expectancy has increased social health insurance (SHI) programs in the world– from 67 in 2002 to 69 in 2015 and under-five under which health insurance coverage rates have mortality has declined from 46 per 1,000 live births increased from about 27 percent in 2004 and to about in 2002 to 32 per 1,000 live births in 2017, however, 70 percent in 2016. there are remaining challenges to be tackled. For example, the maternal mortality ratio (MMR), at Despite this large network of primary health 126 maternal deaths for every 100,000 live births, is care facilities, health service delivery is high compared to countries with a similar economic challenging. Indonesia has over 6,000 inhabited status and childhood malnutrition, as reflected islands, resulting in large geographical inequities by a stunting rate of 37 percent, continues to be a in access to health services and health outcomes. problem. The change in the population structure While JKN was designed to improve access to health due to the demographic transition is resulting in services by the poor by making health care more an epidemiological transition wherein the burden affordable, income-related inequities continue to of noncommunicable diseases (NCDs) is increasing abound as JKN is facing a number of implementation in the face of a persistent load of communicable challenges such as: (i) lack of clarity in institutional diseases leading to double burden of disease. roles; (ii) poor coverage of the “nonpoor” working in the informal sector; (iii) a nonexplicit benefits Health financing in Indonesia is marked package; and (iv) weak strategic purchasing of by low public health expenditures (PHE), services. The JKN is also poorly integrated with high out-of-pocket (OOP) expenditures and a supply-side financing to improve public sector complex and fragmented intergovernmental supply-side readiness and is also being underused to fiscal transfer system. Central government has harness private-sector provision. 1 Puskesmas: Pusat Kesehatan Masyarakat (Primary public health care center). Is Indonesia ready to serve? xi The last survey of health facilities–Rifaskes, The QSDS focused on the availability at, and which was conducted in 2011–was a census readiness of, the facility of not just general of only public-sector health facilities and health care services but also services in specific measured service availability and readiness. health care domains like maternal and child Rifaskes 2011 found gaps in multiple areas for health (MCH), communicable diseases like HIV general service readiness (such as some basic and AIDS,2 TB and malaria as well as NCDs. equipment, health care waste management and While the availability of services was assessed at patient safety systems) as well as for specific services all the sampled facilities (the only exception being (such as availability of guidelines and training, family planning and maternal health services),3 medicines and commodities and diagnostics). the readiness of the facility to provide the services Since Rifaskes 2011, the Government of Indonesia was examined in only those facilities where the (GoI) has put in substantive efforts to improve services were reported to be available. The survey the availability of health services. This includes also collected data regarding health-system issues introduction and expansion of the JKN, increased related to primary health care delivery like financing, availability of supply-side financing through special governance and management as well as human allocation funds (Dana Alokasi Khusus – DAK) to resources for health (HRH). provinces and districts for improving supply-side readiness, expanding access to health facilities in Recent studies (such as Leslie et al. 2017) have remote, lagging and border areas, as well as quality shown that availability of resources in facilities improvement and accreditation of primary health for provision of services (service readiness), is not care facilities. sufficient to improve quality of care outcomes by itself. Quality of care outcomes improve as a result of The current study, the Quantitative Service Delivery several other clinical process improvements, including Survey (QSDS) 2016, was conceptualized to address systems to increase adherence to standard protocols by the need to assess changes in the health service the facility staff. The availability of key inputs such as availability and readiness in the last five years since necessary infrastructure, equipment, diagnostics, and Rifaskes–it has these specific objectives: human resources are, however, necessary prerequisites to the provision of quality care. The results of this • To provide a baseline for the JKN in terms of study should not, therefore, be interpreted as a study its ability to improve supply-side readiness on quality of care outcomes at the public and private- • To include private-sector primary health sector primary health care facilities in Indonesia but as care supply-side readiness, that is an a measure of supply-side readiness as a necessary, but important provider of services but was not not sufficient, prerequisite to improve quality of care. covered in Rifaskes 2011 • To measure urban-rural differences This report primarily reflects data analysis • To measure factors that affect service on the service availability and readiness delivery at the facility level–such as components at the puskesmas and private- governance, health and health financing (but not sector clinics, along with additional analysis costing information) on governance, HRH and financing, for the • To measure any changes in supply-side nationally representative sample. Information readiness from Rifaskes 2011 given the on provider ability and patient satisfaction increased investments in supply-side readiness. 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). xii THE KEY FINDINGS FROM THIS REPORT ARE: For all the specific services, the puskesmas were better prepared than the private clinics A. The public-sector facilities (the to offer services. The difference between the public puskesmas) were readier to provide both and private sector varied across these specific services. general and specific primary health care The survey had no questions on the availability services when compared to the private (and readiness) of maternal health and services general practitioner (GP) clinics. To assess the related to facility planning in the private clinics, as facilities’ readiness for provision of general health maternity homes that provide such services were care services, this report analyzed the availability not included in the national sample. A separate of about 34 components– including basic amenities, sample was used for private maternity homes (see equipment, diagnostics, and essential medicines. Yap et al. 2017). Puskesmas were the main providers On average, the puskesmas had 26 components of childhood immunization services. Only 15 available compared to private GP clinics that had percent of the sampled private clinics provided any only 20 components (Figure 1). While the puskesmas immunization services. Even the few that provided outscored private clinics on all subdomains of immunization services, were found to be less “ready” general service readiness, the difference was than the puskesmas (Figure 2). In addition, unlike particularly stark in terms of availability of general the puskesmas, very few private clinics provided diagnostics–with the sampled puskesmas on outreach services. Newer vaccines like the rotavirus average having about four of the five items asked for, vaccine, the pneumococcal vaccine and even the compared to less than two at the private clinics. 5 injectable polio vaccine were, however, provided almost exclusively by the private sector. Figure 1. General Service Readiness (Availability of Components in Puskesmas and Private GP Clinics) Percentage 15 Puskesmas 10 5 Private GP/Clinic 0 0 2 6 10 14 18 22 26 30 34 Number of Component Note : vertical solid line=mean; vertical dash line=median Comparing 34 component measured in both type of facility 5 Details about the availability of individual items, as well as the subdomain scores, can be found in the main report in Appendix 5. Is Indonesia ready to serve? xiii Similarly, provision of care for diagnosis and B. Facilities located in urban areas management of communicable diseases like perform better on the service-readiness index malaria, TB and HIV was found primarily than rural facilities. The urban-rural divide in the puskesmas with significantly fewer in service availability and readiness was seen in private-sector clinics providing these both the public and private-sector facilities across services. In the private clinics that did provide general services and most of the specific services. these services, the quality of care in terms of There were a few specific domains, however, where adherence to standards was circumspect. For the availability of related services was higher in example, for both malaria and TB, the private clinics rural facilities compared to urban ones. For example, relied on clinical symptoms instead of laboratory only 58 percent of the urban puskesmas provided tests to make a diagnosis before initiating treatment. normal delivery care compared to 87 percent of Additionally, most of the private clinics neither the rural ones (the plausible reason for this was prescribed fixed dose combinations nor did they not explored as part of this survey). Similarly, 95 adhere to Directly Observed Treatment Short-course percent of the rural puskesmas provided malaria- (DOTS) for management of TB. 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. Figure 2. Immunization Service Readiness (Availability of Components in Puskesmas and Private GP Clinics) Percentage 30 20 Puskesmas Private GP/Clinic 10 0 0 2 4 6 8 10 12 Number of Component Note : vertical solid line=mean; vertical dash line=median Number of component = 12 xiv Of all the facilities that provided a certain C. Within the private sector, the clinics kind of service, the urban facilities fared that were empaneled with BPJS were more better than the rural ones for service likely to offer a wider spectrum of services readiness but the magnitude of the urban- and be service-delivery ready than those that rural difference varied with the type of were not empaneled. This suggests that linking service domain (or subdomain) that was the private sector with government programs being assessed and by the type of facility. For and provision of capitation payments for service example, on average, an urban puskesmas had provision can be a key strategy to strengthen about four additional components related to general private-sector engagement. The one exception to service readiness available in its facility compared this was the availability of Sexually Transmitted to its rural counterpart (Figure 3). On the other hand, Infection (STI) services where the nonempaneled the difference between an urban and rural private private clinics were slightly more likely (67 clinic was only of two such components (Figure 4). percent) to provide STI-related services compared Generally, the urban-rural difference was less stark to the ones working under the BPJS umbrella (64 for the private clinics compared to the puskesmas, percent). The service-readiness index was also probably because of the low overall service higher for the BPJS private clinics compared to the readiness at the private clinics, leaving less room for nonempaneled ones. For example, as can be seen the differences to show up. 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. Figure 3. General Service Readiness (Availability of Components in Urban and Rural Puskesmas) Percentage 20 15 Urban 10 Rural 5 0 0 4 8 12 16 20 24 28 32 36 40 44 Number of Component Note : vertical solid line=mean; vertical dash line=median Number of component = 44 Is Indonesia ready to serve? xv Figure 4. General Service Readiness (Availability of Components in Urban and Rural Private GP Clinics) Percentage 15 10 5 Rural Urban 0 0 2 6 10 14 18 22 26 30 34 Number of Component Note : vertical solid line=mean; vertical dash line=median Number of component = 34 Figure 5. General Service Readiness (Availability of Components in the BPJS-empaneled and Nonempaneled Private GP Clinics) Percentage 15 10 Empaneled Not empaneled 5 0 0 2 6 10 14 18 22 26 30 34 Number of Component Note : vertical solid line=mean; vertical dash line=median Number of component = 34 xvi D. When compared to Rifaskes 2011, most E. The availability of specific health care of the health services show an improvement services was very variable across domains, in QSDS 2016. There were, however, some areas and the lack of availability of certain specific that also saw regressions from Rifaskes 2011, services was a cause of concern. For example, such as availability of vaccines and training and while almost all the puskesmas provided antenatal guidelines for the malaria and TB program that are care (ANC) services, only three of four puskesmas a cause of concern. While interpreting the results, provided services for normal delivery, and this it must be borne in mind that the two surveys had proportion reduced further to just half when it came key methodological differences. First, the Rifaskes to the provision of basic emergency obstetric and was a census of public-sector facilities, while QSDS neonatal care (BEmONC)–the latter being a key to is a sample-based survey that captured only the reducing maternal mortality. primary health care facilities. In addition to the puskesmas, QSDS also sampled the private-sector Similarly, the lack of availability of HIV- GP clinics that were providing primary health care related services is a cause of concern. Only services. Given the different sample spreads, only two-thirds of the puskesmas and one-quarter of data for the puskesmas on commonly measured the private clinics provided these services. HIV indicators are comparable between the two surveys. counseling and testing (HCT) services, both for the general population as well as for pregnant The data shows that, in terms of general service women as part of the Prevention of Mother-to-Child readiness, the mean readiness index rose Transmission (PMTCT) program were primarily from 71 percent to 78 percent in the five years available in the puskesmas, while most of the following Rifaskes 2011. While some components private clinics referred these cases to public hospitals of general services readiness such as the availability and/or the puskesmas that were offering these of basic amenities and adherence to standard services. Provisions for special target groups such precautions show a major positive shift of about 9 as needle exchange and methadone maintenance percent or more, there was not much change in the programs for injecting drug users were available in availability of medicines and needed equipment in even fewer facilities. Availability of Antiretroviral the facility. In both surveys, lack of availability of Therapy (ART) for HIV-positive pregnant women basic diagnostics was a cause of concern. None of the and their newborn and people living with HIV was facilities met all the indicators for general service dismally low in the public sector and almost absent readiness in both surveys. For specific services, in the private-sector primary care facilities. the areas where puskesmas were performing well under the Rifaskes 2011, continued to do so even F. The logistics management information under the QSDS 2016. This included the availability system (LMIS) of most facilities was not of equipment for family planning or immunization functioning optimally–leading to frequent services, however, the actual availability of stock-outs of drugs and commodities. QSDS 2016 commodities (vaccines) for immunization services data revealed that the puskesmas had a system to dropped from 95 percent to 84 percent, showing that manage drug and diagnostics’ stock, which included the progress has not been uniform. 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. Is Indonesia ready to serve? xvii 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 • While staff at the puskesmas were more has, on an average, kept pace with the likely to be trained in the various technical growing population in Indonesia, however, guidelines than the private-sector staff, there is inequitable access to primary care, there were many facilities where none with wide variations in not only the population of the staff had received training (on the size served by the puskesmas (from less than 2,000 multiple themes enquired about) in the two to about 98,000), but also a five-fold difference in years preceding the survey. the minimum and maximum “time-to-reach care”. • The maximum capitation fee per registered • Almost all puskesmas had at least one member provided to a puskesmas was IDR6 functioning emergency transport vehicle 6,000, whereas it was IDR 10,000 for the for referral but only one-third (33 percent) of private facilities as puskesmas also receive the private clinics had such facilities, with other government budgetary financing. single-provider run clinics being far less likely to Some 43 percent of puskesmas and 46 percent have such a referral transport system ready, which of the private clinics received less than the indicates a need for a more systematic ambulance maximum capitation fee, the primary reason for system to be introduced for timely referrals. the same being lack of staff as mandated by BPJS. • About one-half of sampled facilities in There was no significant difference observed both the public and private sector were not between puskesmas that received maximum adhering to waste segregation guidelines for capitation versus those that did not in terms of infectious medical waste. Storage of sharp waste supply-side readiness for child care, diabetes and material too was an issue with the private sector. cardiovascular disease. There was a significant • Lack of privacy in the clinics for provider- difference observed (p<0.05), however, in the patient interaction, was a cause for concern, empaneled private clinics that received maximum especially in the puskesmas. This was of capitation versus those that did not in terms of greater concern in the facilities offering HCT supply-side readiness for child care, diabetes and services, where less than one-half of these cardiovascular disease. This indicates that JKN is facilities had these amenities. a key instrument that can be used to influence • When compared to the norms set by GoI, supply-side readiness for the private sector. there was an overall lack of nonmedical • About one-half of puskesmas revenue was staff such as the pharmacist and spent on providing monetary incentives nutritionist at the puskesmas. In contrast, to staff, with relatively little being spent the private-sector clinics, especially the single- on drugs and consumables. There was provider ones, were overly dependent on the a significant difference observed (at p<0.05) doctors and had significantly fewer nursing, between puskesmas that fully utilized JKN administrative and other support staff. Lack of funds versus those that did not and supply-side staff was also the main reason for the facilities readiness for child care but not for diabetes and receiving less than the mandated maximum cardiovascular disease. capitation fee per member as their staff strength • No clear link of increased operational did not meet the norms set by BPJS. expenditures with supply-side readiness • There was a positive correlation that is was observed. There was no significant statistically significant (at p<0.05) for difference observed between puskesmas that doctors/nonclinical staff and outpatient retained all revenue versus those that did not and visits at the puskesmas but not for nurses/ supply-side readiness for general services. midwives and outpatient visits. 6 IDR: Indonesian Rupiah. US$1 = approximately IDR 13,000. xviii • While regular monitoring visits from It is important that these findings are addressed the District Health Office (DHO) to the through key policy and implementation actions puskesmas and by the puskesmas staff related to health financing, service delivery and to the posyandu were being performed, governance. While this report itself does not cover the system of providing written feedback these recommendations, many of these have been needs improvement. There was no significant covered by other publications and will be covered difference between puskesmas that received in forthcoming work. As mentioned earlier, supply- regular monitoring and supervision versus those side readiness improvement is necessary, but that did not for supply-side readiness in various not sufficient, to improve service-delivery access specific health care areas. and outcomes. There needs to be a package of • Both the public and private-sector facilities policy interventions to improve performance and were using the SP2TP7 for recording and quality of primary health care quality, including reporting health information. While the strengthening performance monitoring and public-sector facilities were using computers to accountability, ensuring supply-side readiness maintain these records, the private sector was verification and improving managerial capacity more dependent on a paper-based system. 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. 7 SP2TP: Puskesmas Integrated Reporting and Recording System. Is Indonesia ready to serve? 1 Introduction 2 Country and Sectoral Background Indonesia, the fourth most populous country have increased significantly in recent years: from (approximately 250 million) in the world, has approximately 27 percent in 2004 to approximately made significant gains in economic growth 73 percent in 2017. By 2019, everyone in Indonesia and poverty reduction. Relatively strong should have coverage under the JKN. economic growth (5.5 percent per year since 2000) has been accompanied by a sustained decline in Key challenges remain, including slow poverty rates: about 31 percent and 6.8 percent of the progress on addressing inequalities in health population lived on US$3.10 a day and US$1.90 a outcomes, and access to primary and secondary day, respectively, in 2016, down from 82 percent and health care. The national maternal mortality 48 percent (respectively) in 1998 (World Bank 2017). ratio (MMR) is 126 per 100,000 live births, closer to With a Gross Domestic Product (GDP) per capita of low-income countries (World Bank 2017), while US$3,603 in 2016, Indonesia is currently classified as the MMR in Eastern Indonesia is even higher a lower-middle-income country and will transition (above 200 per 100,000 live births). Post-partum to an upper-middle-income country with continued hemorrhage (PPH), eclampsia and infections are economic growth. Its human capital indicators also the key causes of maternal death with underlying show impressive gains, with adult literacy at almost factors including: (i) lack of continuum of care; (ii) 95 percent, gross enrolment of 100 percent, 83 percent, adolescent pregnancies; (iii) unsafe abortions; and and 32 percent in primary, secondary and tertiary (iv) a stagnating family planning program. Similarly, education, respectively, with the share of female the U5MR in the Eastern Indonesian provinces of enrolment exceeding that of males at each level. East Nusa Tenggara (Nusa Tenggara Timur – NTT) and Maluku is close to 60 per 1,000 live births, much Health outputs and outcomes in Indonesia higher than the national average of 40 per 1,000.9 have improved in recent years. Life expectancy Large regional and income-related inequalities10 has increased from 67 years in 2002 to 69 years remain across the country, with the Infant Mortality in 2015 (World Bank 2017) and the under-five Rate in the poorest households being more than mortality rate (U5MR) has declined from 46 per double that in the richest. Chronic malnutrition or 1,000 live births in 2002 to 32 per 1,000 live births stunting rates remain very high at 37 percent at the in 2017 (Statistics Indonesia et al. 2013). The national level (Riskesdas 2013) and are even higher share of pregnant women receiving four or more in Eastern Indonesia. While overall coverage rates antenatal care (ANC) visits8 has also increased– of key maternal health services are high,11 it varies from 64 percent in 2002 to 77 percent in 2017. The widely across regions and income: there is a two-fold percentage of moderately/severely underweight difference in skilled birth attendance (SBA) across children under five years of age has decreased from some provinces and home delivery rates are six times 23 percent in 2002 to 19.6 percent in 2013. Landmark higher among women in the lowest income quintile legislation in 2004 and 2011 has helped realize a compared to the richest income quintile (Statistics potential pathway to Universal Health Coverage Indonesia et al. 2013). (UHC). Indonesia has one of the largest single- payer social health insurance (SHI) programs– Indonesia is facing a double burden of Jaminan Kesehatan Nasional (JKN)–in the world. disease, with new challenges rapidly Health insurance coverage rates in Indonesia emerging due to a demographic (ageing 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). Is Indonesia ready to serve? 3 population) and epidemiological transition remains endemic in some regions, including Papua. (persistent communicable diseases with rising At 66 percent, NCDs now account for the largest prevalence of noncommunicable diseases share of the burden of disease in Indonesia, almost (NCDs)). Indonesia is among a few countries in doubling since 1990 (Institute of Health Metrics and the world that reported an increase of Human Evaluation Metric Evaluation –IHME 2017). Immunodeficiency Virus (HIV) incidence among key affected population (KAP) groups (World Bank Indonesia has a mixed model of public-private 2018). Although the epidemic is concentrated in provision of health care services (Figure 1.1). KAP groups, there is a generalized HIV epidemic in Service delivery at all levels is challenging as Papua and West Papua. Indonesia has the second Indonesia has over 6,000 inhabited islands. The highest tuberculosis (TB) burden in the world– public sector is more dominant in provision of with the disease being the second most common inpatient services, especially in rural areas. Two- cause of premature deaths in Indonesia–and only thirds of outpatient care (for the poor and general one-third of the cases being detected (WHO 2017). population), about one-half of inpatient care for the In addition, new challenges such as Multi-drug general population and one-third of inpatient care Resistant TB (MDR-TB) have emerged, with the for the poor are provided by the private sector. There annual incidence now estimated to be 30,000 are approximately 2,400 hospitals in Indonesia–of cases, which poses a significant financial burden which about two-thirds are private. and program management challenge.12 Malaria Figure 1.1 Organization of Service Delivery in Indonesia Central Social government Security and BPJS Management parliament Agency Ministry of Ministry Central Home of Health hospitals Affairs Provincial Health Provincial Office Hierarchical government and Regulation parliament Provincial hospitals Public primary District care Health facilities District Office government and Private parliament clinics District and hospitals practice Source: Asia Pacific Observatory and WHO 2015. 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. 4 The public health care system is decentralized supply-side readiness of health facilities. It was to the district level with about 9,760 a census of all public-sector health facilities puskesmas13 forming the backbone of the and service delivery points (from posyandu to country’s health system. A similar number of puskesmas and up to the public-sector hospitals), private primary care clinics have been empaneled by and a sample of private-sector hospitals. The survey the Social Security Agency (Badan Penyelenggara revealed that not even one puskesmas had met Jaminan Sosial – BPJS Health). There is, however, all the 38 tracer indicators. There was significant no systematic information on the entire private- variation observed across districts; while almost all sector health system. The public primary care system puskesmas in Central Java met at least 80 percent of also includes 23,000 auxiliary puskesmas (pustu) the readiness indicators, only one-half of puskesmas for outreach activities in remote regions; village- in Papua and Maluku met this benchmark. Only level delivery posts (polindes, often the home of the 39 percent of public hospitals and 3 percent of the village midwife) and village health posts (poskesdes). 30 private hospitals surveyed maintained all 23 Frontline service delivery at approximately 75,000 basic obstetric care tracer items. Twenty percent of villages is also undertaken through posyandu14 and public hospitals and none of the sampled private by village midwives (who are formally part of the hospitals maintained all six blood transfusion tracer health system). Volunteer Kader15 are not part of the items, with a four-fold variation between districts. formal health system and do not get paid other than a A large majority of provinces (25 out of 33) had less minimal transport allowance. than 30 percent of public hospitals with all tracer items, including eight provinces where no hospitals Many Indonesians face significant physical reached this target. and time barriers to accessing health care, especially in Eastern Indonesia. Although the Despite having attained the minimum World median distance to a health facility in Indonesia Health Organization (WHO) norm, Human is only five kilometers, the median distance in Resources for Health (HRH) remains a key provinces such as West Papua, Papua, and Maluku challenge for Indonesia’s health sector, further is over 30 kilometers. Widely divergent geographic impeding the ability to provide equitable accessibility is correlated with the time taken to access to good quality health care services. The reach public health facilities. According to Riskesdas HRH-to-population ratio in 2013 was estimated at 2013, while about 18 percent of Indonesians took 2.3 per 1,000,17 equal to the minimum recommended more than one hour to reach a public hospital (using by WHO as necessary to attain an 80 percent SBA any travel means), over 40 percent of people in West rate. Multiple HRH-related issues remain, however, Sulawesi, Maluku, and West Kalimantan faced this including inequitable geographical distribution barrier to access. Measured in time, puskesmas were of health personnel, a shortage of specialists, and more accessible, as only two percent of the national inadequately skilled HRH. The physician-to- population took more than one hour to reach a population ratio in Maluku-NTT-Papua is one-third puskesmas, but the proportion of the population of that in the Java-Bali region, while the ratio for facing this travel time was much higher in Papua specialists is even worse than for general physicians (28 percent) and NTT (11 percent).16 (Indonesia Health Profile 2016). The shortage of nurses is especially acute in public facilities. Studies Rifaskes 2011 indicated wide variations in show that financial resources are often not enough health facility service readiness to provide to attract HRH in remote areas; good management good quality health care services. Rifaskes and better facilities have been found to be equally was the last survey that was conducted to study 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). Is Indonesia ready to serve? 5 Some of the key issues that need to be The Indonesian health financing system and the addressed to improve the performance, governance landscape, relevant to the Indonesian including quality, of primary health care are health sector, are described in Chapters 5 and 6, related to governance and accountability, respectively. Appendix 1 briefly describes the main service-delivery capacity, and low- GoI program to achieve UHC. performance orientation of health financing: An opportunity to improve the performance a. Lack of performance monitoring and of primary care has recently emerged with the accountability in a decentralized setting. establishment of a primary care accreditation Since 2001, decentralization has been accompanied commission (Komisi Akreditasi Fasilitas by increased complexity in fiscal transfers, diffuse Kesehatan Tingkat Primer – KAFKTP) that governance and accountability mechanisms, is based on the two decades of experience in and a fragmentation of monitoring systems. Most hospital accreditation. Accreditation will improve frontline health workers and local government quality of services by ensuring that not only the staff managing subnational health systems necessary inputs (such as infrastructure, equipment report to local governments–not to the Ministry and human resources) are in place but also certifies of Health (MoH). This has led to big variations that both clinical and managerial processes are in subnational capacity and the performance of improved. Accreditation involves a hands-on process local governments in delivering health services, of expert mentoring of facilities to improve their especially at the primary-care level. It has also managerial processes and primary health care (PHC) made it difficult for the MoH, or provincial and (clinical care and community health) standards. local leaders and citizens, to know how the system It also provides follow-up support for facilities to is performing and proactively address problems. address recommendations for continual quality b. Underdeveloped ability to enforce clinical improvement. The requirement to be reaccredited and managerial standards at the facility every three years provides an incentive to maintain and district level. The MoH has comprehensive standards. This is enhanced by Ministry of Health standards and guidelines that both districts and (MoH) policy that makes accreditation of PHC facilities must comply with to conduct health facilities by 2021 a prerequisite for empanelment by outreach, manage facilities, provide clinical care BPJS-Health as a JKN provider. While accreditation and run the subnational system. Standardization does not lead to improved clinical outcomes by itself, and compliance with managerial and health care it is an important part of a “package” of interventions guidelines and processes is weak at the district that would improve PHC performance. In addition and the facility level. to building capacity in the primary-care facilities, it c. Weak performance orientation of also provides a governance framework for the sector, intergovernmental fiscal transfers and JKN. directing investments, and signaling managerial and Special allocation funds (Dana Alokasi Khusus – clinical competence to beneficiaries and payers. 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. 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 There are four levels of accreditation for credibility of the KAFKTP and its processes PHC facilities, namely dasar (basic), madya need to be strengthened. Accreditation of PHC (medium), utama (excellent), and paripurna facilities began in 2015, with the enactment of (perfect), based on the scores achieved across Minister of Health Regulation No. 46/2015, and nine major standard areas. For the public sector, the establishment of the KAFKTP. While its current plans for accreditation of puskesmas include a capacity is limited (owing to its nascent stage), staggered approach, where at least one puskesmas in the vision is to expand its capacity, become fully each of 5,600 subdistricts is to be accredited by 2019. independent, cover both the public and private As per MoH, approximately 4,200 puskesmas have sector, and eventually get accredited by the been accredited as of December 2017, of which 30 International Society for Quality in Health Care percent have received accreditation at dasar level and (ISQua).18 It is also important that the commission 58.5 percent at madya level. While MoH has been develops credible quality assurance and validation focused on increasing coverage, from 2018 it will shift mechanisms, as well as making its standards and attention to increasing the proportion of puskesmas results transparent. 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. 18 International Society for Quality in Healthcare – an accreditor of accreditation agencies. Is Indonesia ready to serve? 7 The Need, Scope and Methodology for the Quantitative Service Delivery Survey (QSDS 2016) Given this background context, the Indonesia The main objectives for conducting this survey QSDS 2016 was envisioned as a PHC facility were as follows: and services survey, with a specific focus on nutrition, maternal and child (MCH), a. To provide a baseline for the JKN in terms of communicable diseases (particularly HIV and its ability to improve supply-side readiness; AIDS, TB, and malaria), and NCD services. The b. To include private-sector PHC supply-side survey captured information based on the WHO readiness, that is an important provider of Service Availability and Readiness Assessment services but was not covered in the Rifaskes 2011; (SARA) conceptual framework and was adjusted c. To measure urban-rural differences; per national guidelines. In addition, QSDS also d. To measure factors that affect service included modules on governance, HRH indicators, delivery at the facility level–such as health financing (without costing information), governance, health and health financing (but not provider ability, and patient satisfaction. Instruments costing information); were developed to survery various PHC facilities e. To measure any changes in supply-side (including puskesmas and polindes/poskesdes in the readiness from the Rifaskes 2011 given the public sector, and private clinics and maternal health increased investments in supply-side readiness. providers in the private sector), district health offices (dinkes), health workers, and conduct patient exit This report is not a study on quality of health interviews in DKI Jakarta. care outcomes in Indonesia but rather a study on an important prerequisite for improved This report primarily reflects data analysis quality of care, namely supply-side readiness. on the service availability and readiness Recent studies (such as Leslie et al. 2017) have components at the puskesmas and private- shown that availability of resources in facilities sector clinics, along with additional analysis for provision of services (service readiness), is not on governance, HRH19 and financing, for the sufficient to improve quality of care outcomes by nationally representative sample. Information itself. Quality of care outcomes improve because on provider ability and patient satisfaction of several other clinical process improvements, have been covered in thematic reports such as including systems to increase adherence to standard for maternal health and will be covered in a protocols by the facility staff. The availability of key forthcoming report on HRH. Appendixes 2 and inputs such as necessary infrastructure, equipment, 3 present in a fact sheet / tabular form the key diagnostics, and human resources are, however, a indicators used to measure service readiness. 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 As mentioned above, in addition to this report, sample sizes and instruments to measure two other reports focused on maternal health general and specific clinical services supply- as well as HIV and AIDS, TB, malaria and side readiness for both the puskesmas and the immunization (ATMI) will also be published private clinics (the exception being maternal with this report. These other reports use QSDS health and family planning services).20 Details 2016 sample and instruments focused on priority of the final sample are presented in Table 1.1 and program districts across public and private sectors. the detailed sampling and analytical methodology, In addition, there is separate policy brief covering with the trade-offs in sampling design, is discussed nutrition and community-related service delivery in Appendix 4. through the posyandu. In addition to data from the QSDS 2016, The remainder of this report is structured as secondary data on service utilization and follows: infrastructure availability in this report has been sourced from Rifaskes 2011, Indonesia • Chapter 2 covers overall service availability Health Profiles21 (MoH 2014; MoH 2016; MoH and utilization of primary care services; 2017), and IDHS 2012 (Statistics Indonesia et al. • Chapter 3 covers service readiness–both 2013) for correlation and comparison purposes. general and specific services at puskesmas Unless specified otherwise, the analysis referred to and private primary care providers. This in the document is based on the QSDS 2016 survey. chapter also shares the comparison in the key Changes in supply-side readiness between the findings between Rifaskes 2011 and QSDS 2016; QSDS 2016 (sample survey) and the Rifaskes 2011 • Chapter 4 focuses on availability of HRH as (census) are presented only for the national-level well as training; estimates for puskesmas-related indicators to ensure • Chapters 5 and 6 focus on financing and comparability. A comparison of the key findings governance of PHC facilities, respectively; between these surveys is presented in Chapter 3 • Chapter 7 summarizes the key findings from (Service Readiness), Chapter 7 (Summary of Key the report and lists down areas of concern Findings), and in Appendixes 5 and 6. that need attention from key policy makers. Table 1.1 The National PHC Facility Sample Used in QSDS 2016 All Urban Rural Type of Facility N % N % N % Puskesmas With bed 149 56 48 43 101 65 Without bed 119 44 64 57 55 35 Total 268 100 112 100 156 100 Private Facility GP 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. 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. Is Indonesia ready to serve? 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 Figure 2.1 Number of Puskesmas in Indonesia over the years, from 8,737 in 2009 to 9,767 in (2009–16) 2016 (Figure 2.1). The ratio of puskesmas per 30,000 population has remained stable, ranging from 1.13 9.731 9.754 9.767 to 1.17, indicating that the increase in the number of 9.655 puskesmas has kept pace with overall population 9.510 growth, however, there is wide variation in this ratio 9.321 between provinces (from 0.57 to 5.07). Provinces in Java have a relatively low puskesmas-to-population 9.005 ratio compared to provinces in Eastern Indonesia which can be explained by the difference in 8.737 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 2009 2010 2011 2012 2013 2014 2015 2016 a 50-fold difference between the minimum and Source: MoH 2014; MoH 2016; MoH 2017. maximum population catered to by a puskesmas in both 2013 (3,937 to 181,976), and 2015 (1,889 to The QSDS 2016 indicates that each puskesmas 97,890). Similarly, while the average number of had an average of about 33 posyandu in its villages served by a puskesmas was about 10, there catchment area, which translates to over 3.5 was a wide variation from just one village to as posyandu per village. This is very similar to the many as 95 villages served by one puskesmas. The Risfaskes 2011 data, indicating that the increase in rural puskesmas, on average, served about one-half the number of posyandu has kept pace with the of the population of what an urban puskesmas increasing numbers of puskesmas. Almost all the covered (21,699 for rural versus 40,378 for urban). posyandus were “active”.22 These posyandu are managed by the village kaders (community-based The most common form of transport used by workers). On average, there were about 17523 kaders people to reach a puskesmas was a motorbike working in the catchment area of one puskesmas, (87 percent), and the median time to reach a which translates to about 18 kaders per village, or puskesmas using this means was 15 minutes. one such worker per about 170 people. At the aggregate level, this is a good average “time to care”, as many medical emergencies can be Each puskesmas had about five polindes or handled within this time frame. When measuring poskesdes24 in their catchment area. While the time taken to reach the facility from the farthest these facilities are supposed to offer obstetric care village, the national average time doubled to about services, they are mainly used for ANC services 32 minutes, however, where the average time and are managed by the village midwives. There taken by a person to reach some puskesmas was were, however, quite a few facilities (48 of the five times longer. It took about double the time to 268 sampled puskesmas, most of which were in reach a rural puskesmas (41 minutes) compared urban areas) which did not have any polindes or to an urban puskesmas (23 minutes) from the poskesdes in their geographical catchment area. farthest village. Comparative data was not asked Given this situation, it probable that antenatal and for from the private-sector clinics as they do not basic obstetric care services, including delivery, in have a defined catchment area, nor do they have such areas take place either at home, in puskesmas, information on means of transport used by patients or private facilities. The QSDS 2016 also showed that visiting their facilities. there were about nine midwives on average in each puskesmas’ area, or about one in each village. 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). Is Indonesia ready to serve? 11 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. Table 2.1 Availability of Services at the Public and Private-sector Health Facilities Puskesmas Private Clinic/GP Opening Arrangements 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 Source: Indonesia QSDS 2016. Outpatient Services According to the QSDS 2016, all the Figure 2.2 Inpatient and Outpatient Puskesmas sampled puskesmas offer outpatient (2009-15) services and over one-half also offered Number of Puskesmas inpatient services. According to the 6.302 6.358 6.338 6.353 6.358 Indonesia Health Profile 2015 data (MoH 2016), 6.033 6.085 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 3.396 3.317 3.378 proportion of puskesmas offering inpatient 3.019 3.152 2.920 2.704 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 2009 2010 2011 2012 2013 2014 2015 puskesmas, and almost two-thirds (65 percent) of the rural puskesmas offered inpatient Inpatient Non-Inpatient services. Source: MoH 2014; MoH 2016. 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. 12 QSDS data in 2016 shows that the sampled26 puskesmas had an average monthly outpatient Inpatient Services 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 The QSDS 2016 showed that while all (monthly attendance of nearly 28,000 patients), which private-sector primary care facilities offered means that the outpatient load in such puskesmas outpatient services, only 13 percent had on any given day was much higher than what some inpatient facilities compared to about 50 other puskesmas were attending to in the whole year. percent for puskesmas. For both the puskesmas Attendance in urban facilities was found to be much and the private clinics, the proportion of facilities higher than those located in rural areas. For example, offering inpatient services was higher for rural in the year 2015, the median annual outpatient count centers than urban ones–65 percent versus 43 in urban puskesmas was about three times than that percent for the puskesmas and 23 percent versus 10 of a rural puskesmas (28,467 for urban puskesmas percent for private clinics. As this survey is focused versus about 10,956 for rural puskesmas). Possible on primary care facilities, there is very little data explanations for this variation in OPD attendance available on inpatient services. include variable population density in the catchment area, a higher population-to-puskesmas ratio in urban QSDS data shows that, while the average areas, geographical access, time taken to reach the number of beds in urban facilities offering facility, and community perception of quality of care inpatient care was more than in the rural available at the facility. facilities (11 versus eight beds for puskesmas and 10 versus eight beds for private clinics), the bed occupancy rates (BOR) were higher Figure 2.3 Annual Outpatient Attendance at in the rural areas. For puskesmas, the BOR was Puskesmas (by Location) 74 percent and 53 percent for rural and urban facilities respectively, with an overall average of 337.508 337.508 68 percent; while it was 64 percent and 49 percent 189.765 189.765 106.027 106.027 87.374 93.597 for private clinics respectively, averaging an 77.538 overall rate of 55 percent. 21.451 21.552 23.051 27.243 28.467 28.337 12.195 10.856 10.956 5.448 3.537 3.605 70 80 70 80 50 50 2013 2014 2015 2013 2014 2015 2013 2014 2015 All Urban Rural min max median Source: Indonesia QSDS 2016. 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. Is Indonesia ready to serve? 13 Specific Services 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 FAMILY PLANNING SERVICES than 97 percent) of the puskesmas. Both urban Family planning is an important intervention and rural puskesmas had negligible differences in that not only helps women, men and couples service availability for these services except for the achieve their reproductive goals, but is intra-uterine contraceptive device (IUD), which was also instrumental in improving maternal, available in 100 percent of the urban puskesmas but neonatal and child health. More than 80 percent in only 78 percent of the rural puskesmas. of couples use hormonal methods for women (injectable, oral pills and implants) to fulfil their Male sterilization services were conspicuous contraceptive needs (Figure 2.4). The uptake of male by their absence, with only 1 percent (three sterilization was found to be less than 1 percent, of 268 sampled puskesmas) offering this with female sterilization being higher at 3.5 percent method. Only one sampled puskesmas in each (BKKBN28 2016). As per Riskesdas 2013, almost 60 of Lhokseumawe, Pesisir Selatan and Banjar percent of married women in the reproductive age offered this service and all three facilities were group use some modern method of contraception. in rural areas. Most of the sampled districts and municipalities in this survey offered a wide range The QSDS 2016 shows that there was almost of contraceptive choice in one or more of their universal availability of family planning facilities. One district that stood out as an exception services in all the puskesmas (Figure 2.5).29 Of was Yalimo (in Papua province), where the three the 22 districts that were included in the sample, sampled facilities offered male sterilization and only one of the 14 sampled facilities in one district condoms, and one offered oral pills too, but none of (Tapanuli Selatan in North Sumatra Province) did these three facilities offered injectables, implants or not have any family planning services available. IUDs, thus severely limiting contraceptive choice More than three-quarters of puskesmas offered availability in this district. these services on all the days (six or seven days in a week) that the facility was open. Figure 2.4 Contraceptive Methods in “Active” Figure 2.5 Availability of Different Contraceptive Family Planning Users (2015) Methods in Puskesmas Female sterilization; 3,5% Male sterilization; 0,7% Condom; 3,2 % Family 99% planning 100% service 99% Pill 98% 99% contraceptives 98% Insertion of 78% IUD; 10,7% IUD/AKDR 100% 87% Injectable 99% 99% contraceptives 99% Implant; 10,6% Male 93% 95% condoms 94% Implant 94% Injection; 47,8% contraceptives 100% 97% Male 2% 0% sterilization 1% Rural Other 5% Urban services 1% Pill; 23,6% 3% All Source: BKKBN 2016. Source: Indonesia QSDS 2016. 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. 14 ANC SERVICES eclampsia were, however, provided in fewer All sampled puskesmas (except one in Semarang sampled puskesmas (84-91 percent) (Figure 2.6). district) offered some ANC services, and about While this is not a major cause of concern as they are three-quarters (72 percent) of the puskesmas on the higher side, averages hide regional variations. offered ANC on all reported working days of the Provision of these laboratory tests was higher in week (that is, 6-7 days a week). Most of the elements urban puskesmas compared to rural puskesmas. of ANC were available in the majority of puskesmas For example, blood grouping was available in 97 (Figure 2.6). Services that required relatively less percent of the urban puskesmas compared to just 77 skill and equipment such as weighing the pregnant percent of the rural puskesmas. This geographical woman or measuring her height were provided almost variation is a cause of concern–in some districts universally. The same was the case with abdominal within the sample, some of these laboratory facilities examination (measuring fundal height, assessing the were almost absent. For example, none of the three lie and presentation of the baby, and counting fetal sampled puskesmas in district Yalimo (in Papua heart rate) as well as administration of preventive care province), and only one of the 13 sampled facilities in such as Iron and Folic Acid (IFA) supplements and Tapanuli Selatan were performing blood grouping. Tetanus Toxoid (TT) vaccine. Given that hemorrhage continues to be one of the leading causes of maternal mortality in Indonesia, Basic laboratory tests like hemoglobin there is a need for this simple laboratory test (as a estimation, blood grouping, estimation of blood necessary precursor for a blood transfusion) to be sugar levels to rule out gestational diabetes and available–should a transfusion be needed to save the testing the urine for proteins to rule out pre- mother’s life. Figure 2.6 ANC Service Availability in Puskesmas (by Urban-Rural Areas) 100% Antenatal Care Service (ANC) 99% 99% 91% TB 96% 93% 38% HIV 68% 51% 29% Syphilis 56% 40% 73% Malaria 50% 63% 85% Blood sugar 99% 91% 76% Urine protein 96% 84% 84% Hemoglobin 97% 90% 77% Blood Typing 97% 86% Rural 98% Iron-folate supplementation 98% Urban 98% 98% All Tetanus Toxoid (TT) 100% 99% 100% Fetal presentation 98% 99% 99% Fetal heart rate monitoring 97% 98% 100% Fundal height measurement 98% 99% 100% Blood pressure measurement 100% 100% 99% MUAC measurement 100% 99% 98% Height measurement 99% 98% 100% Weight measurement 100% 100% 49% Intermittent preventive treatment for… 31% 41% Source: Indonesia QSDS 2016. Note: MUAC: Mid-upper arm circumference. Is Indonesia ready to serve? 15 Among all the elements of ANC surveyed under BASIC OBSTETRIC AND NEONATAL CARE SERVICES QSDS, the ones with the least availability were The QSDS 2016 shows that three out of four tests to detect concomitant diseases which are puskesmas were providing normal delivery important to manage to prevent an adverse services (Figure 2.7). This translates to over effect on the fetus. Only about one-half (51 percent) 7,000 puskesmas in the country offering normal of the surveyed puskesmas conducted tests to screen delivery care services. The proportion of puskesmas the pregnant woman for HIV, and the numbers were providing delivery care was higher in rural areas (87 even lower (40 percent) when it came to screening percent), and in those under a district administration for syphilis. As per the national guidelines, these tests (80 percent) compared to urban areas (58 percent), only need to be provided in high-risk areas, however, and areas administered by the municipality (50 and this could explain the low availability. The only percent), respectively. Those that were not offering disease for which screening tests were being provided normal delivery services or basic obstetric care by a majority of puskesmas (93 percent) was TB. The services cited lack of infrastructure, equipment and main reasons given for the lack of these laboratory medicines as the common reasons for the facility not services was the unavailability of equipment and providing these services. infrastructure as well as the lack of trained staff for this purpose. Another reason cited was that they did Most puskesmas providing delivery care not have the service available because no client had also performed basic obstetric and newborn ever requested it. care functions related to a normal delivery. Routine care required for a normal delivery, There was no significant urban-rural such as monitoring labor using a partograph, or differences in the availability of ANC. There is administering oxytocin immediately after birth no concomitant data for the private-sector clinics as to prevent PPH, was provided by almost all the private maternity homes–which are the key private facilities (97 percent and 99 percent respectively) sector facilities providing obstetric care–were not providing delivery care. In addition, elements of included in the QSDS national sample. There was essential newborn care such as early initiation of a different survey instrument under the QSDS that breastfeeding, thermal care (keeping the baby warm) was used for private maternity homes, data for which to prevent hypothermia and care of the umbilical has been analyzed and presented as a separate report cord were also available in 95 percent to 98 percent (Yap et al. 2017). 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) Thermal 99% 97% protection 98% Hygienic 98% 91% cord care 95% Rural Immediate 99% 96% Urban breastfeeding 98% All 87% Monitoring and management 97% 75% 97% of labor using partograph 97% 58% Administration of 99% 98% oxytocin injection 99% Assisted vaginal 100% 100% delivery 100% All Urban Rural Puskesmas location Source: Indonesia QSDS 2016. 16 Seventy five of the 268 puskesmas (28 percent) removal of retained products was offered in only 48 identified themselves as Basic Emergency percent of such BEmONC puskesmas, which means Obstetric and Neonatal Care (BEmONC) facilities that if PPH is due to retained placental fragments, the or PONED.30 One-half of the sampled puskesmas required management would not be available in over reported that they provide BEmONC services, one-half (52 percent) of the BEmONC puskesmas. however, which means that facilities beyond those Emergency care services which were the most officially labelled as PONED reported that they provide conspicuous by their absence were administration BEmONC services. of corticosteroids to the mother in preterm labor (17 percent) and provision of injectable antibiotics While over one-half of the sampled puskesmas to a child with neonatal sepsis (12 percent). The reported that they provide BEmONC services, administration of corticosteroids is a relatively new the nonavailability of all the BEmONC signal recommendation from WHO and is not yet part of the functions31 in these puskesmas was a cause of national guidelines on obstetric care. Unlike normal concern (Figure 2.8). For example, while 93 percent delivery care, there was an urban-rural difference of the puskesmas providing BEmONC services gave in the availability of various elements of BEmONC, a uterotonic drug in case a woman develops PPH, which varied across these elements. Figure 2.8 Availability of BEmONC Signal Functions at Puskesmas 61% Bimanual compression for post-partum hemorrhage 57% 60% 14% Injectable antibiotics for neonatal sepsis 9% 12% KMC (Kangaroo) mother care for 57% 66% premature/very small babies 60% 16% Corticosteroids in preterm labor 21% 17% Antibiotics for preterm or prolonged PROM 54% 62% (premature rupture of membranes) to prevent infection 57% Rural 71% Neonatal resuscitation with bag and mask 64% Urban 69% All 47% Removal of retained products of conception 50% 48% 88% Manual removal of placenta 77% 84% Parenteral administration of magnesium sulphate for 71% 76% management of preeclampsia and eclampsia (IV or IM) 73% Parenteral administration of oxytocic for 95% 90% treatment of post-partum hemorrhage (IV or IM) 93% Parenteral administration of antibiotics 51% 51% (IV or IM) for mothers 51% Source: Indonesia QSDS 2016. 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. Is Indonesia ready to serve? 17 IMMUNIZATION SERVICES on a more frequent basis, with about 82 percent of the While almost all (98 percent) of the sampled urban puskesmas providing immunization services puskesmas provided immunization services, on a daily or weekly basis compared to 55 percent for only 15 percent of the private facilities did. rural puskesmas. The frequency of immunization Within the private network, those registered services provided across facilities was very variable. under the National Health Insurance Agency or As very few private clinics had immunization BPJS network were more likely to provide these services available, the percentages shown in (Figure services than other private facilities (28 percent 2.10) should be interpreted with caution. versus 6 percent). Similarly, a greater proportion of multiprovider private facilities were providing Outreach sessions for immunization were immunization services compared to single-provider primarily organized by puskesmas. Outreach private facilities (27 percent versus 2 percent). sessions for the puskesmas are typically done through posyandus, which are organized monthly. There was a wide variation in the frequency of While almost all the puskesmas held outreach immunization sessions within the facilities, sessions for immunization–almost two-thirds of the from daily to weekly to even monthly; in puskesmas hold such sessions monthly–less than 15 addition, some facilities did not have a fixed percent of the private-sector facilities organized such schedule for the sessions (Figure 2.9). About two- sessions. This is not surprising given that the public thirds of the puskesmas offered the services within sector also focusses on delivery of preventive and their premises at least once a week, including 27 promotive programs, for delivery of public goods like percent of the puskesmas that provide it daily. The immunization, and have a delivery system (through urban puskesmas appeared to provide these services outreach workers) in place for the same. Figure 2.9 Frequency of Immunization Sessions at Puskesmas and Private GPs 3% 3% 3% 0% 0% 0% 4% 8% 11% 15% 16% 10% 16% 13% 19% 23% 24% 26% 54% 65% 40% 21% 33% 31% 34% 27% 29% 29% 25% 17% All Urban Rural All Urban Rural (N=265) (N=157) (N=108) (N=41) (N=36) (N=5) Puskesmas Private Daily At least once a week At least once a month Not regular Others Source: Indonesia QSDS 2016. 18 Almost all facilities (99 percent of the GoI has expanded the immunization program to puskesmas and 99 percent of the private also include four doses of Hep-B vaccine into the sector) where immunization services were complete immunization package. When Hep-B is available provided the basic vaccines that also added to the mix in data analysis, complete contain the six antigens that are part of the immunization rates dropped to only 37 percent original list of WHO’s Expanded Program on according to the IDHS 2012 data. The IDHS results Immunization (EPI) (Figure 2.10). These include pointed out that the real challenge lay in the high Bacillus Calmette-Guérin (BCG), Polio (Bivalent Oral drop-out rates between the first and third doses of Polio Vaccine - OPV) and Inactivated Polio Vaccine DPT (from 88 percent to 71 percent) and OPV (91 (IPV), Diphtheria-Tetanus-Pertussis (DTP/DPT) and percent to 75 percent). As many as 8 percent of the measles. DPT is now incorporated within either the children aged 12-23 months had not received any tetravalent (with Hep-B added to the mix) or the vaccine, which was a cause of concern. pentavalent (HiB also added to the mix) vaccines. Of the two variants, the current survey found that while While significantly fewer private-sector 96 percent of the puskesmas provided pentavalent, facilities had immunization services only 44 percent had the tetravalent vaccine. There available, those that did, also provided was no such difference in availability of these two the newer vaccines like IPV, and vaccines variants in the private sector. against rotavirus, pneumococcus, rubella and Japanese Encephalitis. In contrast, these Despite such high availability of basic EPI vaccines were conspicuous by their near absence vaccines through the public health sector, the from the puskesmas. The limited number of complete immunization32 rate for children puskesmas where these were available were almost aged 12-23 months was only 66 percent all located in urban areas. This variation between according to IDHS 2012 (Statistics Indonesia the public and private sector is probably because et al. 2013). This had increased substantially, most of these vaccines (exception for IPV) are not however, from only 59 percent in the previous IDHS yet included under the national immunization in 2007. Specifically, the measles vaccination rates program and have to be paid out of pocket by the for children at one year of age was 80 percent. The clients who wish to avail these services. Figure 2.10 Availability of Different Vaccines (as a Proportion of Those Providing any Immunization Services) Puskesmas Private HepB zero BCG Polio Oral(OPV) Polio SUntik(IPV) DPT-HepB(Tetravalent) Rural DTP-HepB-HiB(Pentravalent) Urban Measles All Pneumococcus Rotavirus Rubella Japanese encephalitis percent 0 20 40 60 80 100 0 20 40 60 80 100 Source: Indonesia QSDS 2016. 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. Is Indonesia ready to serve? 19 Almost all the facilities that provided of the private clinics that offer immunization), and immunization also counseled clients on the the management of these side-effects. Spontaneous relevant aspects like the potential side-effects responses on counseling people about the next due and their management, and the follow- date for immunization or the overall benefits of up schedule for the next doses (Table 2.2). immunization were far less. The rate of spontaneous Depending on the question, there was a variation responses from the public-sector facilities compared in spontaneous responses33 - from about one-half to the private sector ones varied from question to three-quarters of these facilities. The commonest to question. These apparent differences need to spontaneous response was counseling the parents be interpreted with caution, however, because of on the potential side-effects of immunization (76 the significantly fewer numbers of private clinics percent of the public-sector facilities and 83 percent offering immunization services. Table 2.2 Counseling Provided With Immunization Services Information provided during counseling Puskesmas (%) Private (%) Spontaneous 76 83 Possible adverse effect of Promted 22 16 vaccines No 2 1 Don’t know 0 1 Spontaneous 64 73 How to manage side effects Promted 36 25 at home No 0 0 Don’t know 0 1 Spontaneous 52 34 Next immunization Promted 45 64 schedule No 3 1 Don’t know 0 1 Spontaneous 66 34 Promted 34 65 Benefit of immunization No 1 1 Don’t know 0 1 Spontaneous 22 15 Promted 6 0 Others No 71 85 Don’t know 0 0 Source: Indonesia QSDS 2016. 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 SERVICES management, almost one-half of mothers had given The QSDS 2016 showed that all the puskesmas, either prepackaged oral rehydration solution (ORS) or and more than 90 percent of the private-sector recommended home fluids. While many medicines facilities provided some preventive and were also added to the treatment mix, including curative services for children under five years antibiotics and antimotility drugs, only 1 percent of age (Figure 2.11). There was not much difference in were given zinc supplements along with ORS. the provision of child care between single providers (90 percent) and multiple provider (93 percent) private More than 90 percent of puskesmas but only clinics, however, there was some difference between 75 percent of the private-sector facilities those within the BPJS network (96 percent) versus that provided child health-related services those not in the BPJS network (88 percent). There was included services for management of wide variation in terms of the spectrum of services pneumonia, including administration of available at different facility types (Figure 2.11). co-trimoxazole, and management of diarrhea with ORS and Zinc (Figure 2.12). There were Diarrhea and pneumonia continue to be fewer facilities offering Zinc supplementation for the primary causes of child morbidity and management of diarrhea compared to those that mortality. According to IDHS 2012, 5 percent of offer ORS; while the difference was insignificant children under five years of age had symptoms for the puskesmas–99 percent versus 100 percent–it suggestive of acute respiratory infection (ARI) in the was slightly higher for the private sector–78 percent two weeks preceding the survey. Of those who had versus 85 percent. The numbers suggest that, these symptoms, 75 percent sought medical help despite being a relatively new intervention, the at a health facility or from a health provider, but inclusion of zinc for the management of diarrhea only 39 percent were given antibiotics as part of the is now an integral part of public health services treatment. Similarly, 14 percent of children under and is also widely available from private-sector five years of age suffered from diarrhea in the two providers. Despite the almost universal availability, weeks preceding the IDHS 2012 survey, however, the low utilization of the same by mothers could only 65 percent of these children were taken to a be a reflection of the lack of knowledge, and its health facility or provider for care. As part of the conversion to behavior change, in the caregivers.34 Figure 2.11 Spectrum of Child Health Services Available at Puskesmas and Private GP Clinics Child Health Services Child Nutrition Services Preventive and curative care for Nutrition services for children underfive children under-five 100% 100% 80% Nutrition status Counseling on 80% surveillance breastfeeding Treatment of 60% Treatment of 60% malaria in children pneumonia under five 40% 40% 20% Class for mothers of 20% Counseling on MP-ASI children under five 0% 0% Provide zinc supplementation Administration of Early stimulation, Vitamin A for children with co-trimoxazole SDITK supplementation diarrhea Supplementary food Weighing for children recovery for PMT- Provide ORS for under-five Pemulihan children with diarrhea Puskesmas Private Source: Indonesia QSDS 2016. 34 IDHS 2012 showed that while the knowledge of use of ORS was 94 percent, only 39 percent actually used it. Is Indonesia ready to serve? 21 Within the spectrum of childhood diseases, The QSDS 2016 showed that 15 percent of service availability for management of puskesmas had no nutritionist. Most of the childhood malaria appeared to be a cause nutritionists that were there had a health-related of concern. Less than two-thirds (63 percent) of qualification, such as nursing, midwifery, or public puskesmas and one-third (28 percent) of private- health. Most (83 percent) of the available nutritionists sector facilities, offered management of malaria in were regular government staff (civil servants), while children. Within the public sector, there was a wide the remainder were honorary and contractual interdistrict variation in availability of malaria workers. Similar information is not available for treatment–districts like Tegal provided this service the private sector as the availability of a nutritionist in none of the puskesmas while, in stark contrast, is not mandated for private clinics and was not, districts like Banjar Baru, Tomohon and Yalimo therefore, part of the data collection tool for them. were providing treatment in all of their puskesmas. This regional difference can probably be attributed In addition to preventive and curative to the variable endemicity of the disease. care, QSDS also enquired about promotive health care activities for growth and Child nutrition-related services were almost development of children, such as the early universally available in the puskesmas. childhood stimulation (Stimulasi, Deteksi These included counseling on breastfeeding and dan Intervensi Dini Tumbuh Kembang or complementary feeding (MP-ASI)35 (99 percent), SDITK). The QSDS 2016 showed that SDITK were weighing the child (99 percent) or providing available in almost all (99 percent) the puskesmas supplementary food (Pemberian Makanan but only one-half (49 percent) of the private-sector Tambahan or PMT) for children aged 6-59 months facilities providing any child-care services. About (98 percent). In stark contrast, only one-third (35 three-quarters of the puskesmas also hold “Kelas percent) of the private-sector facilities offered ibu balita”,36 which are facilitated group discussions nutrition services for children under five years for mothers of children under five years of age. In of age; among those that did, nonequipment or these sessions, mothers share their experiences product-dependent services such as counseling on and opinions related to child care, health-service breastfeeding and complementary feeding were utilization, child nutrition, early childhood offered by almost all. stimulation and overall growth and development of the child. These classes are facilitated by the village According to QSDS 2016, Vitamin A Kader or the midwife. Concomitant data is not supplementation was provided primarily at available for the private clinics as no such classes puskesmas. Almost all (99 percent) puskesmas offer are mandated for the private sector. 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. 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 Communicable Diseases MALARIA Five of Indonesia’s 34 provinces–Papua, West Indonesia is characterized by complex Papua, East Nusa Tenggara, Maluku and North malaria epidemiology with more than 21 Maluku–have only 8 percent of the country’s confirmed mosquito vectors of malaria and population but 70 percent of its malaria cases. five Plasmodia species commonly infecting Most of the districts with sustained high transmission humans (WHO 2013). Malaria transmission in of malaria are located in this part of the country. Indonesia is unsurprisingly highly variable as well, Much of the region also happens to fall in the including across and within districts. Consequently, Australasian biogeographic zone which has more the National Malaria Program needs to be designed anthropophilic malaria vectors than elsewhere in to address these complexities. Over the decade Indonesia. Together with higher relative poverty, this to 2016, the MoH has made a concerted effort to leads to the high levels of malaria transmission. 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. Table 2.3 Distribution of Annual Parasite Index (API) (by Provinces and Districts) (2016) Sumatra, Kalimantan, East Nusa Number of Number of API Java-Bali Sulawesi, West Nusa Tenggara, Provinces/ Population Tenggara Maluku, Papua Districts Eliminated 2 0 0 2 14,477,697 <1 5 22 0 27 232,241,411 Provinces 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 Eliminated 113 134 0 247 178,715,165 <1 15 138 13 166 63,653,328 Districts 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. Is Indonesia ready to serve? 23 In the private sector, availability of malaria- Puskesmas and private-sector facilities used related services was marginally higher in those different methods to diagnose malaria. While the facilities that were part of the BPJS network puskesmas used both clinical symptoms (78 percent) (31 percent) compared to those that were not and the results of laboratory tests like microscopic (26 percent), however, significant interdistrict examination of peripheral smear of blood (73 percent) variation in service availability was noted and rapid diagnostic tests or RDT (54 percent) for (Figure 2.12). Of the 22 districts that were included diagnosis, the private sector relied almost exclusively in the national sample for QSDS 2016, 14 districts on clinical symptoms (94 percent) to diagnose malaria. had some malaria-related services available in all There was low availability of preventive management the puskesmas of their district. Another five districts of malaria in both puskesmas and private clinics– had these services in 63 percent to 92 percent of their fewer than one-half (46 percent) of the puskesmas puskesmas, however, there were three districts where and only one-fifth (20 percent) of the private facilities. less than one-half of the puskesmas were providing The availability of preventive malaria treatment was these services–that is, Pasuruan (50 percent), Cilegon higher in in rural puskesmas (51 percent) compared to (13 percent) and Tangerang (0 percent), all of which those in urban areas (38 percent). 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. 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 All Puskesmas 63% 88% Kab. Yalimo 100% 100% Kab. Merauke 85% 100% Kota Tomohon 100% 100% Kota Banjar Baru 100% 100% Kota Banjarmasin 84% 100% Kab. Banjar 89% 100% Kota Bima 80% 100% Kota Mataram 89% 100% Kota Cilegon 50% 13% Kota Tangerang 35% 0% Malaria services for children under five Kota Pasuruan 63% Malaria Service General 50% Kota Tegal 0% 63% Kab. Semarang 53% 74% Kab. Cilacap 54% 92% Kota Sungai Penuh 17% 100% Kab. Indragiri Hilir 65% 100% Kota Padang 59% 65% Kab. Pesisir Selatan 53% 87% Kab. Tapanuli Selatan 36% 100% Kota Lhokseumawe 67% 100% Kab. Aceh Jaya 78% 100% Kab. Simeulue 63% 100% Source: Indonesia QSDS 2016. 24 TUBERCULOSIS (TB) Almost all the puskesmas offered TB-related Indonesia has the second highest national TB services (Figure 2.14)–the two puskesmas burden in the world. In 2015, WHO estimated an that did not offer these services cited lack of incidence rate of 39537 per 100,000 population which trained staff as the reason. The services included translates to about 1,020,000 TB cases annually, diagnosis of the disease (89 percent) (passive case including new and relapse cases (WHO 2017). TB detection using microscopy, diagnostic kits like incidence and prevalence are, however, estimated to Mantoux test and physical examination of the be falling at a rate of 1 percent and 2 percent per year patient presenting with suspicious symptoms), respectively (Figure 2.13). prescribing antitubercular drugs (99 percent), and providing supervised administration of the medicines to patients (96 percent) (Directly Observed Treatment Figure 2.13 Trend of TB Incidence in Indonesia Short-course or DOTS). The puskesmas also offered active follow-up of the patients, including home Rate per visits, especially for defaulters (97 percent). While 100,000/year there was no urban-rural difference in the provision 600 of treatment, including DOTS, urban puskesmas were more likely to offer diagnostic services compared to Incidence, all forms rural ones (94 percent versus 85 percent). 400 In addition to patients who present to the facility with symptoms, the program also calls for “active case detection”, which is a key 200 Notified, all forms strategy to meet the case detection rate goals (70 percent of estimated new smear-positive Incidence, HIV+ cases) set by WHO. Active case detection for TB 0 was primarily carried out by the puskesmas (86 1990 1995 2000 2005 2010 percent) and by very few private-sector clinics (21 Source: WHO-led Joint External Monitoring Mission’s percent). The puskesmas facilities that conducted Indonesia TB Program report, January 2017. active case detection relied on the services of the TB kaders as well as other health facilities and even NGOs for this purpose. 37 A 95 percent confidence interval (CI) is 255-564 per 100,000 population (or 658,000-1,450,000 TB cases annually). Is Indonesia ready to serve? 25 Availability and quality of care for TB While almost 85 percent of the private- management in the private-sector clinics was sector facilities give prescriptions for TB a cause for concern. Only one-half (49 percent) patients, fewer than one-half of them (43 of the private-sector GPs provided TB-related percent) offered DOTS (Figure 2.14). In addition, services (Figure 2.14). Even among those that did, only one-quarter (26 percent) offered follow-up the modality for diagnosis was questionable, as services, presumably because of a lack of outreach less than one-third (27 percent) of the facilities used staff cadres. In the absence of DOTS and patient examination and tests to finalize the diagnosis–90 follow-up, compliance with treatment can become percent of the private clinics based their diagnosis one of the big challenges to complete successful on clinical symptoms, and only two-thirds used treatment. Many of the private-sector clinics sputum microscopy. This was in stark contrast to did not follow the recommended fixed-dose the puskesmas where more than 90 percent of combination (FDC) for TB. Almost all puskesmas the facilities used microscopy to diagnose TB. The provided FDCs for TB treatment, compared to about puskesmas that did not offer sputum microscopy one-third (38 percent) of the private-sector facilities cited patient-related issues (like refusal for that provide TB management. Combined with the diagnosis), whereas the private sector cited the low rates of DOTS, this can have adverse effects on absence of laboratory facilities as the primary reason treatment efficacy rates for patients receiving care for not offering diagnostic tests for TB. from the private clinics. Figure 2.14 TB Diagnosis, Management and Referral Services Available in Puskesmas and Private Clinics Facility Offer TB Services Spectrum of TB Related Services 100% 27% TB examination and TB diagnostic test 89% 80% 85% Prescription of TB treatment 99% 60% 43% DOTS for TB patients on treatment 96% 40% Treatment follow-up (home visit, 26% monitoring) for TB patients 97% 20% 21% Active TB case detection 86% 0% TB services 0% 20% 40% 60% 80% 100% Puskesmas Private Private Puskesmas Source: Indonesia QSDS 2016. 26 HIV PREVENTION OF MOTHER-TO-CHILD The availability of ART at the primary-care TRANSMISSION (PMTCT) facilities for HIV-positive pregnant women PMTCT-related services for HIV were available and/or their newborns was dismally low. The in only about one-half (54 percent) of the proportion of facilities offering various services puskesmas and one-fifth (19 percent) of the included under the PMTCT umbrella was variable private-sector facilities (Figure 2.15). Provision (Figure 2.15). While counseling for HIV testing was of PMTCT services usually requires additional available in almost all the puskesmas that offer equipment (for laboratory testing) and medicines PMTCT services, the actual testing for HIV was (antiretroviral therapy/ART), and those that did available in only 70 percent of these puskesmas. not offer these services cited various supply- ART for both the pregnant women who test positive side deficiencies such as the lack of necessary and their neonates was available in only 18 percent infrastructure, equipment or trained staff for this of the puskesmas and in almost none (1 percent) of lack of service provision. the private sector clinics offering PMTCT. In fact, the private sector fared much worse than the puskesmas In addition to supply-side issues, quite a few on all the parameters of PMTCT care. 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 HIV CARE and 27 percent of the private clinics not Availability of HIV-related services was a providing PMTCT services). Such responses are an cause of concern, especially in the private indirect reflection of the quality of care being provided sector. Only about two-thirds of the puskesmas in this arena as the national guidelines mandate and one-quarter of private-sector clinics offer HIV screening of all pregnant women for HIV, and diagnosis, care and treatment-related services for provision of ART should she be positive, be conducted the general (nonpregnant) population (Figure 2.16). in all high-risk areas. Providing these tests only when HIV care and support services and special services the woman asks for it is not part of the recommended directed towards target groups–such as a needle clinical protocol. The fact that only 16 percent of exchange program and methadone maintenance the puskesmas and 24 percent of the private-sector therapy for injecting drug users–were provided by facilities refer all pregnant women to other facilities for even fewer puskesmas. The situation in the private HIV counseling and testing (HCT), while most of the sector was even worse, and the services meant for others refer only select cases also gives credence to this special target groups were conspicuous by their apparent nonadherence to clinical protocols. absence in the private sector. Figure 2.15 Spectrum of PMTCT Services Available at Puskesmas and Private GP Clinics Facility Offer PMTCT Services Spectrum of PMTCT Related Services 100% Counseling to all pregnant women on reproductive health, STI, and HIV 80% 100% 80% Family planning counseling to 60% HIV counseling and testing HIV positive pregnant women 40% services to pregnant women 60% 54% 20% 0% 40% Nutritional counseling for HIV Provide ARV as treatment for positive pregnant women and HIV positive pregnant women 19% their infants 20% Provide ARV prophylaxis for neonates of HIV positive 0% pregnant women Preventing mother-to-child transmission (PMTCT) Puskesmas Private Puskesmas Private Source: Indonesia QSDS 2016. Is Indonesia ready to serve? 27 Within the spectrum of HIV care, “general” counseling (PITC). The availability was higher in services like counseling and testing and the urban puskesmas (82 percent) compared to the PMTCT were available in a large proportion rural ones (62 percent). In contrast, HCT services of facilities offering HIV care (Figure 2.16). HCT were available in very few private-sector facilities services were available in almost three-quarters (21 percent) and most of these were located in (73 percent) of the puskesmas that offered any HIV urban areas. Data specific to DKI Jakarta shows that services. Most of these facilities (86-87 percent) only 4 percent of the private-sector facilities in that provided both voluntary counseling and testing area offer any ART services–compared to 26 percent (VCT) as well as provider-initiated testing and of the puskesmas. Figure 2.16 Spectrum of HIV-related Services Available at Puskesmas and Private GP Clinics Facility Offer HIV/AIDS Services Spectrum of HIV Related Services 70% HIV Counseling adn testing services (HCT) 60% 90% 80% 70% Methadone 60% 50% Maintenance 50% Care Support and Therapy (MMT) 40% Treatment (CST) 30% 20% 40% 10% 0% 30% Needle Syringe Program (NSP) PMTCT 20% 10% Diagnose and treatment for STI 0% Puskesmas Private Puskesmas Private Source: Indonesia QSDS 2016. 28 The facilities–both puskesmas and private As mentioned above, very few facilities clinics–which did not offer these services offered HIV care and support services, and referred cases most commonly to the public within these limited numbers too, none of the hospitals that provided HIV services, and facilities offered the complete range of services sometimes to other puskesmas. In fact, about (Figure 2.17). One of the most concerning issues was two-thirds of the puskesmas that offered counseling the relative lack of facilities providing ART–only 10 and testing services had received referrals from percent of the puskesmas–and none of the private other facilities. The fact that: (i) very few (less than 30 clinics provided ART. The others referred patients to percent) of the private-sector clinics that offered HCT either public or–at times–private-sector hospitals to services received referrals from other facilities; and (ii) receive treatment. This would impact access in terms private clinics also referred cases to public hospitals, of both distance and time taken to reach the facility. add to the evidence indicating the relative lack of counseling and testing services in the private sector– probably including private hospitals (Figure 2.17). Figure 2.17 Availability of HIV Care, Support and Treatment (CST) Services in Puskesmas and Private38 Sector Facility Offer HIV-Care Support & Treatment Services Spectrum HIV-Care Support & Treatment Related Services 100% Treatment of opportunistic infections 100% 80% Nutrition 80% Provide or prescribe services treatment for TB 60% 60% 40% Prescription of Provision of male 20% micronutrient condoms to prevent supplementation for further transmission 0% people living 40% of HIV with HIV Family planning 20% Screening or testing counseling for for TB among people people living living with HIV with HIV 0% Prescription of ARV for people living HIV/AIDS Care, Support and Treatment services with HIV Puskesmas Private Puskesmas Private Source: Indonesia QSDS 2016. 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. Is Indonesia ready to serve? 29 SEXUALLY TRANSMITTED INFECTIONS (STIS) absence of a confirmed laboratory-based “diagnosis” According to QSDS 2016, about 73 percent indirectly indicates that these health facilities of the puskesmas and 66 percent of the may be following the syndromic management sampled private-sector facilities offered some approach for treatment of STIs. These interpretations STI-related services (Figure 2.18). While over cannot be generalized across the country, however, 90 percent of these facilities offered treatment because there was a wide interdistrict variation in services, only about one-half had laboratory-based the availability of these laboratory tests–from the diagnostic services available. The availability of lowest to the highest possible, that is in 0 percent these laboratory services for STIs was significantly of the sampled facilities in districts like Pesisir lower in the rural facilities compared to the urban Selatan district in West Sumatra to 100 percent of the ones, for the puskesmas (38 percent vs. 67 percent) sampled facilities in districts like Yalimo district in but was the reverse for the private sector (19 percent Papua and Banjar Baru in South Kalimantan. vs. 51 percent). The availability of treatment in the Figure 2.18 Availability of STI Diagnosis and Management Services in Puskesmas and Private Facilities Facility offer sexually transmitted infections (STI) service 82% 73% 93% 70% Rural Private 67% 66% 64% 51% Urban 100% 19% All 94% 43% 93% Puskesmas Rural 38% Urban 92% 67% All 93% 52% All Urban Rural All Urban Rural Provide or prescribe treatment for STIs available Puskesmas Private Diagnosis of STIs that is confirmed by laboratory test available Source: Indonesia QSDS 2016. 30 Non Communicable of the facilities) for the diagnosis of the other three conditions that were enquired about. There are two Diseases (NCDs) 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. This survey studied the availability of Additionally, the diagnosis of DM and hypertension services for the five most common NCDs and does not need the availability of a skilled doctor conditions. These include three diseases: Type and can be provided by a laboratory technician 2 diabetes mellitus (DM), cardiovascular diseases and/or nursing staff in a health facility. In contrast, (CVDs), and chronic respiratory diseases (CRDs) conditions like CVD and CRDs need examination by as well as two risk factors–hypertension and a qualified doctor, while that for dyslipidemia needs dyslipidemia–the presence of which predisposes the advanced laboratory equipment. patient to other NCDs, most notably CVDs. National health programs, including standards and protocols, The proportion of facilities providing are available for the management of NCDs. treatment and/or prescribing medicines for the management of the five NCDs was Diagnostic service availability for DM and variable. The management of DM was available hypertension was almost universal (96-99 in over 90 percent of the facilities in both the public percent of the facilities) with negligible and private sector, while treatment for CVDs was difference between the availability rates in available in only 73 percent of the puskesmas and the puskesmas and the private sector (Figure 80 percent of the private clinics. This is probably a 2.19). There was no significant difference between reflection of the high priority accorded to addressing the private rural and urban facilities, however DM and hypertension in MoH’s strategic plan. there was a relative lack of services (67-81 percent Figure 2.19 Availability of Diagnostic and Treatment Services for NCDs in Public and Private-sector Health Facilities Diagnosis of type 2 diabetes melli tus 100% Prescription of dysl ipidemia Diagnosis of cardiovascular without complication 80% diseases treatment 60% Prescription of primary 40% Diagnosis of chronic hypertension treatment respi ratory diseases 20% 0% Prescription of chronic Diagnosis of primary respi ratory diseases hypertension treatment Prescription of Diagnosis of dyslipidemia cardiovascular diseases without complication treatment Prescription of type 2 diabetes mellitus treat ment Puskesmas Private Source: Indonesia QSDS 2016. Is Indonesia ready to serve? 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 Services 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. COMMUNICATIONS was available in less than one-half (46 percent) of The puskesmas were found to be lacking in the facilities, followed by the cell phone (29 percent) availability of the means of communication– and the radio (12 percent) (Figure 3.1). In comparison, such as telephones and radios. A health facility the availability of cellular mobile phones was far needs communication systems to interact with higher in private-sector clinics (69 percent), while patients and other beneficiaries, other health landline phone availability was similar to that of the facilities as well as the health administration system puskesmas (43 percent). (such as the district health office – DHO) to be able to function optimally. While communication services There was a wide interdistrict variation in the are needed for multiple purposes, one key area that availability of communication in puskesmas. it impacts is referral, as prior information to a facility In six of the 22 sampled cities and districts, only can facilitate better preparedness to receive and one-third or fewer puskesmas had any means treat emergency cases without delay. The sampled of communication40, with none of the sampled facilities were asked about the availability of various puskesmas in Simeulue district having a telephone communication means such as a telephone (landline or a radio within their premises. In contrast, there and/or cellular) and/or a radio39 for this purpose. The were six other cities and districts where all the most common means of communication available sampled puskesmas had at least some means of for puskesmas was the landline phone, but even this communication. Figure 3.1 Availability of Communication Services at Puskesmas and Private-sector Facilities 79% 79% 69% 67% 46% 47% 43% Land line 29% 28% 29% Cellular phone 23% 25% Short-wave radio 15% 12% 7% 6% 2% 1% All Rural Urban All Rural Urban Puskesmas Private GP/Clinic Type of Facility Source: Indonesia QSDS 2016. 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. Is Indonesia ready to serve? 33 Puskesmas in urban areas were almost twice REFERRAL TRANSPORT as likely to have communications systems PHC facilities often offer not just routine compared to those in rural areas. For example, health care, but also basic management of while 88 percent of the urban puskesmas had some emergencies. For definitive management of means of communication, less than one-half (49 emergencies and other complications, patients need percent) of the rural ones did (Appendix 5A). The to be referred to secondary- or tertiary-care facilities. primary difference was in the availability of a Time to care is of essence here, and delay in reaching landline telephone, wherein only 23 percent of the the appropriate facility is one of the biggest causes rural puskesmas had a landline phone compared of mortality. Every primary care facility, therefore, to 79 percent of the urban facilities. The cell phone needs functional referral services, including the penetration was almost similar (28 percent and 29 availability of a vehicle for this purpose. percent respectively) (Figure 3.1). The rural facilities, in contrast, depended more than the urban ones on Most of the puskesmas (as many as 93 percent) radios to communicate. A similar trend was seen had access to their own emergency transport with the private-sector facilities too. (referral) vehicle. Of these, the majority (98 percent) were four-wheeled vehicles, which is the ideal Unlike the private sector, computer form of emergency transportation, although a few availability was almost universal in the also had motorbikes (18 percent), and motor boats (1 puskesmas. Computers allow for communication percent). Almost all (98 percent) of the puskesmas through emails, maintain the facility-related also had fuel for their transport vehicles/s. There was records in a soft format, and use different no significant difference between rural puskesmas applications and information systems to transmit (90 percent) and urban puskesmas (98 percent) in information. Almost all the puskesmas (98 percent) vehicle access. Besides their own vehicles, 42 percent had a computer at the facility, however, significantly of the puskesmas also had access to emergency fewer (68 percent) private-sector clinics have this transportation vehicles stationed at nearby facilities. facility. There was no major difference between urban and rural areas for both puskesmas and In contrast, only one-third (31 percent) of private sector. There was, however, a difference the private sector facilities had their own between a private-sector facility that is part of the functional emergency transportation. About BPJS network (97 percent) compared to those not in one-half (48 percent) of the private-sector facilities the BPJS network (46 percent). shared access to vehicles owned by nearby health facilities. Among those facilities that had their Of those having a computer, only 82 percent own vehicle, the most common vehicle available of the puskesmas and 86 percent of the was a four-wheeled vehicle (27 percent), followed private-sector facilities had access to emails by motorbikes (14 percent). Almost all (96 percent) or Internet. While almost all (99 percent) urban private-sector facilities had fuel to run the same. puskesmas had access to the Internet, only about Within the private sector, single doctor run clinics two-thirds (68 percent) of the rural puskesmas were far less likely to own an emergency transport did. While there was no significant urban-rural vehicle (14 percent) compared to those with multiple difference in Internet availability for the private- practitioners (46 percent). Rural private facilities were sector facilities, almost all facilities (97 percent) that more likely to have an ambulance than an urban were part of the BPJS network had Internet access one (43 percent versus 30 percent); there was almost compared to only about half (46 percent) of those no difference between those in the BPJS network (33 facilities that were not part of the BPJS network percent) versus those who were not (30 percent). (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. 34 ELECTRICITY SUPPLY In a large proportion (about four-fifths) of both All the facilities, both puskesmas and puskesmas and private clinics, the electricity private, had an electricity supply (except supply was without any interruption. Less one puskesmas in district Tapanuli Selatan, than 10 percent of facilities, puskesmas or private, North Sumatra). Almost all (97 percent) of the had frequent prolonged interruptions (more than puskesmas used the electricity supply to fulfil all two hours a day) to the electricity supply. A slightly the electrical needs of the facility, be it for general greater proportion of rural facilities, both for the lighting, to power medical devices or to maintain puskesmas and private facilities, cited prolonged the cold chain. This proportion is less for the private interruptions than their urban counterparts (11 sector, where only 86 percent of the facilities used percent versus 6 percent for puskesmas, respectively). the power supply to provide for all electricity needs of the facility. WATER, SANITATION AND HYGIENE Almost all the private-sector facilities (99 More than 90 percent of the facilities, percent) and the majority (95 percent) of the puskesmas and private, had a water supply puskesmas received their supply from the from an “improved water source”. Water central source (government supply) (Figure 3.2). supply is essential at any medical facility–not only Among the very few that relied on alternate sources for drinking but also for sanitation and cleaning such as generators or solar panels for their primary purposes. There were only three of the total 557 source of electricity, it was largely the puskesmas in sampled facilities that did not have any water the rural areas. Nearly three-quarters (72 percent) supply in the facility, one puskesmas and two of the puskesmas and about one-half (53 percent) private-sector clinics. 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. Figure 3.2 Source of Primary and Secondary Electricity Supply in the Sampled Facilities 1% 2% 1% 2% 25% 99% 47% No Secondary 1% Others 1% 95% Solar system 71% 52% Generator Central supply of electricity (e.g. PLN) 4% 1% Primary Secondary Primary Secondary Puskesmas Private clinic/doctor Source: Indonesia QSDS 2016. Note: Due to rounding errors, the breakdown may not total to 100%. Is Indonesia ready to serve? 35 While a piped water supply into the facility Almost all sampled facilities, puskesmas and was the commonest source of water (42 percent private, also had a functioning toilet for the and 47 percent of the puskesmas and private patients attending the OPD. The proportion was facilities respectively), a significant proportion slightly less in the private sector compared to the also relied on tube-wells, bore-wells or covered puskesmas (92 percent vs. 97 percent), and within dug-wells for their water (Figure 3.3). Of the the private sector, it was the single GP run clinics various water sources, 63 percent of the puskesmas that were the least likely to have toilets (only 84 had this source within the facility itself, while in percent). Most of the private-sector facilities that did another 28 percent puskesmas, the water source not have their own toilets had their patients/clients was within the facility premises. The water source use the services in nearby facilities or houses. 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. Figure 3.3 Source of Water Supply for the Sampled Puskesmas and Private-sector Facilities Puskesmas Private Clinic/Doctor 2% 42% 47% 1% 4% 7% 93% 2% 98% 4% 4% 25% 1% 13% 19% 30% Not improved Piped into facility Protected spring Not improved Piped onto facility grounds Piped onto facility grounds Public tap/standpipe Piped into facility Public tap/standpipe Tubewell/borehole Protected dug well Source: Indonesia QSDS 2016. 36 PRIVACY puskesmas, but more than one-half (54 percent) of It is a cause of concern that almost half (48 the private-sector clinics had rooms or consulting percent) of the puskesmas did not have any chambers that permitted both auditory and visual room that offered any privacy for the health privacy (Figure 3.4). provider-client interactions. Visual and auditory privacy in a health facility is essential to not only INFECTION PREVENTION AND WASTE DISPOSAL allow the patient the comfort of discussing his/ Only about one-quarter of the facilities (26 her problems with the health provider, and be percent of private clinics and 29 percent of examined in complete privacy, but also to ensure puskesmas) met all the criteria regarding that confidentiality is maintained. Rural puskesmas infection prevention and waste disposal. were twice (60 percent) as likely to have no privacy Infection prevention is key to patient and health compared to urban ones (31 percent). Comparatively, worker safety as it helps prevent nosocomial only one-fifth (19 percent) of private facilities did (health facility acquired) infections. Figure 3.5 not have any privacy, although urban private shows the gaps in both puskesmas and private clinics were again twice as likely to not have facilities in terms of infection prevention and waste privacy compared to rural clinics (29 percent versus management equipment, systems and supplies. 16 percent). Only one-quarter (25 percent) of the Figure 3.4 Privacy in Consulting Rooms in Sampled Puskesmas and Private-sector Facilities Both Auditory Auditory Visual only Both only (0%) & Visual (28%) Auditory (54%) Auditory Visual only only (2%) & Visual (25%) (25%) Source: Indonesia QSDS 2016. Figure 3.5 Availability of Infection Prevention-related Equipment and Supplies at Sampled Puskesmas and Private-sector Facilities 86% Latex gloves 95% Standard Precaution Component Supplies 89% Soap and running water or alcohol based… 90% 86% Single use of standard disposable syringe 95% 77% Disinfectant 85% 49% Appropriate storage of infection waste 44% Private 62% Public Equipment Appropriate storage of sharps waste 89% 88% Safe final disposal or infectious wastes 86% 87% Safe final disposal or sharps 78% 64% Sterillizer 87% Percentage of Facility Source: Indonesia QSDS 2016. Is Indonesia ready to serve? 37 At least one item of sterilizing equipment In contrast to storage of waste, the facilities was available in 87 percent and 64 percent of performed well in terms of final disposal of the puskesmas and private-sector facilities these wastes (Figure 3.6). More than one-half respectively. The most common equipment in (51 percent) of the puskesmas and three-quarters both these places was the electric dry heat sterilizer, (77 percent) of the private-sector clinics used while the electric autoclave, that uses both heat and the services of a third-party professional waste pressure to sterilize equipment, and is considered management agency for final disposal of the sharps- the best of all sterilization equipment, was hardly related waste; the second most common disposal seen in the sampled facilities. The various supplies method for puskesmas (11 percent) was burying required for direct patient care such as running their used sharps in a pit or covered ground. The use water and soap (or disinfectant) to clean hands, of third-party services for nonsharps medical waste latex gloves, or disposable syringes were generally was much less common–with only about one-third available in over 80 percent of the facilities. Even (34 percent) of the puskesmas and just over one-half this seemingly minimal gap is a cause of concern, (56 percent) of the private-sector facilities using their however, as lack of infection control can lead services. The facilities that did not use these services to adverse and even fatal patient outcomes. The appear to dispose their waste on the ground, with puskesmas were slightly better equipped than the about one-fifth (18 percent) of the puskesmas not private-sector facilities for these supplies. even covering the ground or pit that contained these medical wastes. More than three-quarters of Inappropriate storage of biomedical waste is a the puskesmas and about one-half of the private- cause of concern. Appropriate storage of infectious sector clinics had infection-prevention guidelines waste (in a plastic-lined waste receptacle) was available at the facility. 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). Figure 3.6 Waste Disposal Methods Used by Sampled Puskesmas and Private GP Clinics 1% 2% 5% Never have 7% 8% 1% Others 34% 56% Have the third party Stored unprotected 51% Stored in other protected environment 2% 3% 77% Stored in covered container 1% 5% Protected ground or pit 1% 1% Open-pit - no protection 1% 25% 1% 7% 8% Covered pit or pit latrine 2% 1% 4% 2% Pit or protected ground 3% 1% 11% 1% 2% Flat ground - no protection 17% 2% 11% 4% 1-chamber drum/brick 3% 10% 9% 7% 2% 1% 2-chamber industrial (800-1000+° C) 3% 1% 2% 1% Sharps waste Medical waste Sharps waste Medical waste Puskesmas Private GP/Clinic Source: Indonesia QSDS 2016. 38 EQUIPMENT MEDICINES Basic health equipment like The SARA guidelines list 20 essential sphygmomanometer (blood pressure medicines, the availability of which is used apparatus), stethoscope, oxygen cylinder, to assess the readiness of the facilities for and intravenous (IV) infusion kits, amongst provision of general services (Appendix 2). It others, was available in most of the includes antibiotics, steroids, anti-inflammatory puskesmas (Figure 3.7). The availability of this drugs, ORS and zinc for diarrhea management, equipment was slightly less in the private sector. anti-hypertensives, and drugs for diabetes and for For emergency management-related equipment– management of asthma. The private clinics were like IV kits and oxygen cylinders, the private sector asked about the availability of very few as these lagged the puskesmas significantly. Compared to clinics are required to keep only emergency or the puskesmas, very few (56 percent vs. 93 percent) lifesaving drugs, while the others can simply be private-sector facilities had the infant weighing prescribed by the practitioner and the patient can scale available in their premises. X-ray view boxes purchase the same from a pharmacy. 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. Figure 3.7 Availability of Basic Medical Equipment in Puskesmas and Private-sector Facilities Light source 59% 94% Blood pressure apparatus 97% 79% Stethoscope 86% 81% Thermometer Private 87% 56% Public Infant scale 93% 67% Child scale 85% Adult scale 95% Source: Indonesia QSDS 2016. Is Indonesia ready to serve? 39 The availability of essential medicines was very DIAGNOSTICS variable across drug types (Figure 3.8). While basic As is the case with medicines, SARA guidelines antibiotics were readily available, higher-end ones also list about eight diagnostic tests as part of the like ceftriaxone were available in less than 40 percent assessment for general service readiness (Appendix 2). of the puskesmas. Most of the drugs for NCDs were also relatively readily available; their availability Most of the puskesmas offered a wide variety matches the availability of diagnostic and treatment of diagnostic services. Some of the infrequently services for NCDs (Figure 2.21). As expected, the used tests like rapid diagnostic tests for syphilis or availability of drugs in the private clinics was far less for HIV were, however, less commonly available than in the puskesmas. (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. Figure 3.8 Availability of Basic Medicines in Puskesmas and Private GP Clinics 44% Zinc sulphate tablets 88% Simvastatin tablet 82% Metformin tablet 85% Magnesium sulphate injection 70% Enalapril tablet or alternative ACE… 94% 23% Diazepam injection 79% Ceftriaxone injection 34% Private Beta blocker 43% Puskesmas Aspirin cap/tab 42% 13% Ampicillin powder for injection 33% 67% Amoxicillin tablet 97% 67% Amoxicillin syrup 97% Amlodipine tablet 86% Source: Indonesia QSDS 2016. Figure 3.9 Availability (on-site) of Common Diagnostic Tests in Puskesmas and Private GP Clinics 46% Urine test for pregnancy 83% Syphilis rapid test 20% HIV diagnostic capacity(RDT kit) 38% Private 21% Urine disptick-glucose 79% Public 16% Urine dipstick-protein 74% Malaria diagnostic capacity 74% 66% Blood Glucose 80% 25% Hemoglobin 82% Source: Indonesia QSDS 2016. Note: Syphilis rapid test, HIV diagnostic capacity and malaria were not asked for in private facilities. 40 While 91 percent of the puskesmas had a located outside the facility (off-site). Most of the tests diagnostic laboratory within their premises, offered by a greater proportion of private clinics– only 39 percent of the private-sector facilities such as blood glucose using a glucometer or urine did. Private facilities that are part of the BPJS tests using dipsticks–are those that do not need a network were more diagnostic “ready” than those sophisticated laboratory set-up but can easily be done that were not (47 percent versus 33 percent). There in an outpatient setting. This is linked to the fact that is not much difference between rural and urban most of the private clinics, unlike the puskesmas, did puskesmas (88 percent vs. 96 percent) or between not have an in-house laboratory. In contrast, a much rural and urban private-sector facilities (38 percent greater proportion of the puskesmas offered a wider versus 40 percent). variety of tests and most of the tests were conducted within the facility (on-site). The management of a A large proportion of the private-sector clinics laboratory requires space, equipment and human did not offer basic laboratory tests (Figure 3.10). resources, many of which may be outside the Among those that did, many basically acted as budgetary and management capacities of private sample collection centers, and the laboratory was 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 Availability of On-site Diagnostic Availability of On-site Diagnostic Capacity at Puskesmas Capacity at Private Clinic/GP 47% 96% 40% 39% 38% 33% 91% 88% Urban Rural All Urban Rural BPJS Non-BPJS All Puskesmas Private Clinic/GP Renal function creatinin test 15% 1% 84% 12% 8% 80% Renal function ureum test 17% 1% 82% 12% 9% 80% Liver function SGPT test 16% 1% 83% 12% 8% 80% Liver function SGOT test 16% 1% 83% 12% 8% 80% Cholesterol test 96% 4% 0% 73% 4% 23% General microscopy/wet-mounts 47% 1% 52% 8% 6% 86% Thrombocyte testing 48% 2% 50% 14% 8% 78% White blood cell testing 47% 2% 51% 13% 8% 79% Hemoglobin testing 90% 1% 9% 31% 7% 62% Blood glucose tests using a glucometer 86% 1% 14% 78% 3% 20% Urine ketone dipstick testing 50% 1% 49% 15% 9% 77% Urine glucose dipstick testing 79% 1% 20% 21% 8% 71% Urine protein dipstick testing 83% 2% 16% 21% 8% 71% Urine rapid tests for pregnancy (PP test) 93% 5% 2% 60% 3% 38% On-site Off-site No Source: Indonesia QSDS 2016. Is Indonesia ready to serve? 41 Specific Services 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 There are four broad themes against which service puskesmas (48 percent) had the TB diagnosis readiness was assessed: (i) (trained) staff and and treatment guidelines available on the day of guidelines; (ii) equipment; (iii) diagnostics; and (iv) the survey, but only 17 percent had the national medicines and commodities (Appendix 3). guidelines for HIV and TB coinfection–thus reducing the “average” availability rate for the TB STAFF TRAINING AND GUIDELINES guidelines to just about one-third of the facilities. Puskesmas were significantly more likely to have the technical guidelines available Staff at the puskesmas were also more likely in the facilities compared to the private than the private-facility staff to be trained sector. Technical guidelines are one way of in the RMNCH and communicable diseases ensuring quality of services as they list standard arena (Table 3.1). The gap between the puskesmas management protocols based on most recent and the private sector reduces, to some extent, for evidence. For almost all the thematic areas, the NCDs. The one exception where a greater proportion puskesmas were more likely than private-sector of the private-sector staff appears to be trained is facilities to have the guidelines available at the HIV treatment, however, this is misleading because facility (Table 3.1). The probable reason is because of inadequate sample size. There were only three the government publishes these guidelines and is private-sector facilities offering these services in this mandated to share those with the puskesmas. sample, the staff in two of which were trained. Between the various special services, the puskesmas were more likely to have EQUIPMENT FOR SPECIFIC SERVICES reproductive, maternal, neonatal and child Equipment availability for most specific health (RMNCH) related guidelines compared services was close to 90 percent for most to ones for communicable diseases and 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) Guidelines Training in Last 2 Years THEMATIC AREA Puskesmas Private Puskesmas Private Family 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% | 44% 50 51 14% 49% | 43% 64 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 facilities (Table 3.2). Maintenance of cold-chain A low proportion of puskesmas (69 percent) immunization services in the private sector was a and private-sector facilities (56 percent) had cause of concern as an ineffective cold chain can lead auto-disable (AD) syringes. While AD syringes to rapid degradation of vaccine potency and efficacy. are not essential to ensure infection prevention (and While most (90 percent) of the private facilities even disposable syringes with disposable needles offering vaccines in their services had refrigerators, are good enough), AD syringes help to reduce only two-thirds (65 percent) had vaccine carriers repeat use which is sometimes seen even with the with ice packs. The probable reason for this could be disposable syringes and needles. relative lack of need for this because of low rates of outreach immunization sessions in these facilities The private sector lacked equipment needed which is where the carrier is required. The real for anthropometric measurements, especially concern, however, was the lack of care in ensuring for infants and younger children (Figure 3.11). the temperature of the refrigerators. About one-half For example, while three-quarters (74 percent) of (53 percent) of the private facilities had thermometers private-sector facilities had weighing scales for in their refrigerators, and only 42 percent of the children, only 61 percent of the clinics had the refrigerators in the private clinics had maintained infant weighing scale. Similarly, while two-thirds correct temperature for storage of vaccines. (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 86% 86% 87% 79% 74% 74% 67% Public Private 35% 20% 23% Child Height Length MUAC Growth weighing measurement measurement measuring charts scale tape/Microtoise board tape Source: Indonesia QSDS 2016. 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). Is Indonesia ready to serve? 43 one-fifth (20 percent) had the equipment to measure The lack of auditory and visual privacy for the length (lying down) of infants and younger clients seeking HCT services is another cause children. One probable reason for this could be that for concern, in both the puskesmas (available maternity clinics, which are the key centers dealing in only 40 percent of facilities) and the with newborn and infant care, were not included in private sector (available in only 44 percent of the QSDS national sample. In contrast, over three- facilities). A lack of privacy has an adverse impact fourths of the puskesmas had the infant weighing on the quality of counseling services. scale and equipment to measure length of infants (95 percent and 74 percent) respectively. Other While the availability of equipment for anthropometry and growth monitoring related diagnosis and management of some NCDs, equipment like MUAC tapes and growth charts like diabetes and CVDs, is sufficient, especially were available in about one-third or less (35 percent in the public sector, there is a shortage of and 23 percent) of the private-sector clinics offering needed equipment for CRDs. Peak flow meters, child health services, respectively. Even within which are required to diagnose disorders like the private sector, fewer single-provider clinics had asthma, were available in only 13 percent and 3 the necessary equipment compared to multiple- percent of the public and private-sector facilities provider ones. 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. Table 3.2 Specific Services Readiness of Puskesmas and Private Facilities (Availability of Equipment) Mean Availability For All Proportion of Facilities With THEMATIC AREA Equipment (Domain Score) All Equipment Available Puskesmas Private Puskesmas Private Family 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 CST HIV/AIDS ART Prescriptions & Client Management HIV/AIDS PMTCT 31% 10% 31% 10% STIs Diabetes 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. 44 DIAGNOSTICS clinics compared to those managed by multiple The readiness of the facilities in terms of providers. For example, hemoglobin estimation for availability of diagnostics is a weak link. The children was found in 44 percent of the multiple- availability of diagnostic tests does not exceed 90 provider private clinics that offer child-health percent in any thematic area (Table 3.3). In those services, compared to only 14 percent of the single- areas where a battery of diagnostics is required provider clinics. The one area where the proportions to fulfil the readiness index, such as for STIs, the suggest a better performance by the private sector average rates are much lower. is for HIV care and support. The high proportions are misleading, however, as the number of private The private sector fared significantly worse facilities offering CST services is very low. than the public sector in availability of diagnostics (Table 3.3); and within the private The low rate of diagnostics for diabetes care sector those managed by single providers were in the private sector is mainly due to the even less diagnostic “ready”. The probable reason lack of availability of dipsticks for protein for this gap is the measurement standard used by and ketone testing of urine. The private sector the survey, wherein availability of diagnostics is significantly lagged the puskesmas for these two required within the facility. As mentioned earlier, tests (15 percent and 10 percent respectively for the while 91 percent of the puskesmas have onsite private sector compared to 77 percent and 45 percent laboratories, only 39 percent of the private clinics do. for puskesmas). The situation is worse for single-provider run private Table 3.3 Specific Services Readiness of Puskesmas and Private Facilities (Availability of Diagnostics) Mean Availability For All Proportion of Facilities With THEMATIC AREA Diagnostics (Domain Score) All Diagnostics Available Puskesmas Private Puskesmas Private Family Planning ANC 78% 67% Basic Obstetric and Newborn Care Immunization 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 Management HIV/AIDS PMTCT 67% 2% STIs 33% 3% 24% 2% Diabetes 67% 31% 37% 6% CVDs CRDs 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. Is Indonesia ready to serve? 45 Stock-out of RDT kits for various diseases institutions, does not have a logistics management (malaria, syphilis and HIV) was common in information system (LMIS) in place to regularly both puskesmas and private-sector facilities assess the availability of diagnostics and order (Figure 3.12). It should be noted, however, that the replacement stock in a timely manner. By and large, number of private-sector facilities offering these stock availability of diagnostics appears to be better tests–especially for syphilis and malaria–were very in rural facilities than the urban ones. few (one and six, respectively) and comparisons with the puskesmas should, therefore, be done cautiously. MEDICINES AND SUPPLIES MANAGEMENT AND Stock-outs at the puskesmas generally tended STOCK-OUTS to be for longer durations (>14 days). One of the An LMIS was used by the puskesmas to order reasons that the puskesmas gave for this was the resupplies of medicines and commodities. QSDS inability of the warehouse (national, provincial data shows that in almost two-thirds of the puskesmas, or district level) to send the needed stocks on time. the responsibility for ordering the medicine stocks lay In some cases, the puskesmas also stated that they with the pharmacist or his/her assistant. The facilities received a higher than expected case load of patients were using a mix of the push and pull systems for leading to stock-out of the test kits. restocking of supplies; the system probably varies with the category of the drug being ordered or the In contrast, stock-outs at the private clinics program the drug falls under. Most (85 percent) of the were usually for less than a week; and the puskesmas reported using some formula to assess the reason given was that the facility forgot to need for medicines and commodities at their facility. order the same on a timely manner. These differences suggest that, while the public sector does The products were usually sourced from the have a system in place for indent of diagnostics, district-level warehouses; in more than one- it is not an efficient one, and suffers from delays. third of puskesmas the facility went to the On the other hand, the private sector, while not warehouse to collect the medicines, while in dependent on external-to-the-facility factors and 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 100% 100% 51% 51% 47% 42% 36% Stock out for Malaria RDT Kits Stock out for Syphilis RDT Kits 16% 13% 13% Stock out for HIV RDT Kits 11% 7% 3% 0% 0% 0% 0% 0% All Rural Urban All Rural Urban Puskesmas Private 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). 46 transporting the supplies to the puskesmas percent) placed them every two or three months. lay with the warehouse. The system was such This variation in frequency probably reflects the that about 68 percent of puskesmas received their variation in buffer stock levels maintained by supplies within two weeks of ordering them and the facilities (which also varied from one to three another 20 percent within one month. Almost 90 months) and the time taken to receive the supplies. percent of the puskesmas, therefore, received their supplies within one month of placing the order. The efficacy of the LMIS is questionable given While three-fifths (59 percent) of the puskesmas the frequent stock-outs. Given the frequency of placed their orders every month, two-fifths (39 ordering, the system for maintenance of buffer stock Table 3.4 Specific Services Readiness of Puskesmas and Private Facilities (Availability of Medicines and Commodities) Mean Availability of Proportion of Facilities Proportion of All Essential Medicines With All Medicines Facilities With Stock- THEMATIC AREA / Commodities (Domain / Commodities outs in Last 3 Months Score) Available Puskesmas Private Puskesmas Private Puskesmas Private Family 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 95% Laboratory 7% 10% Puskesmas: Satellite 88% HCT 44% 15% 10% HIV CST 86% 59% 44% 0% HIV/AIDS ART Prescriptions & Client 31% 0% 9% Management 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. Is Indonesia ready to serve? 47 and quick time frames for supply, it is surprising that The facilities used different mechanisms to 70 percent of the puskesmas reported stock-outs of deal with stock-outs depending on the product at least one (or more) product one month prior to the that was out of stock and whether it was a survey. The stock-out rates for individual drugs and puskesmas or a private clinic. In case of stock- commodities were generally low–from 2 to 8 percent outs, one of the commonest actions taken by the but at the collective level (that is availability of all puskesmas was to give the patient a substitute of the listed drugs and commodities) the stock-out rate the item or drug that was not available. The private was very high. sector, on the other hand, said that they purchased new items. In many other cases, however, both the The duration of stock-outs was very variable– puskesmas and the private clinics asked the patient/ from less than two weeks to more than two user to purchase the drug from an off-site pharmacy. months. As with the diagnostics, the common reason reported for these stock-outs was the Unlike the case with other drugs, in the case of inability of the warehouse to provide the supply. stock-out for HIV ART, the facilities referred the Districts procure most of their own drugs using patient to another facility with ART or reordered an e-catalogue, except for specific programs such the drugs from the DHO. The reason for this is as ART for HIV management. This points out to obvious– ART is not available in the open market an issue of supply-chain management (SCM) and cannot be purchased from a pharmacy like other between the districts and the suppliers under the drugs. Similarly, when puskesmas faced shortages of e-catalogue system. Another relatively common antitubercular drugs, they tended to borrow from other reason mentioned was an increased patient load; facilities or reordered supplies from the DHO. In this this reflects the need to develop a scientific system case, the private-sector facilities also reordered from the to calculate demand and an adequate buffer stock DHO and fewer facilities asked patients to purchase to cover any increase in the number of patients that the drugs from a pharmacy. may occur. Table 3.5 Overall Readiness of Puskesmas and Private-sector Facilities to Provide Specific Services Service Index Proportion of Facilities THEMATIC AREA (Mean Proportion of Facilities) With All Indicators Puskesmas Private Puskesmas Private Family 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. 48 Overall, the puskesmas seemed better prepared to provide the specific services than Understanding the private-sector facilities (Table 3.5). They not only had higher average (mean) availability scores Temporal Trends: but were also more likely to have all the needed components measured under readiness, especially Comparison of QSDS in the RMNCH arena. 2016 with Rifaskes 2011 The puskesmas were most ready to provide the RMNCH services compared to other This section compares similar indicators thematic areas. The average scores for most of the measured under Rifaskes in 2011 to the QSDS RMNCH services were around 75 percent or more 2016. Only some results are comparable because compared to around 50 percent or lower for the of different methodologies–while Rifaskes 2011 communicable diseases. was a census of all public-sector health facilities, QSDS 2016 is a sample-based survey. Rifaskes The low levels of readiness for provision of also covered public-sector hospitals; while QSDS HIV-related services is cause for concern. Not covered the private clinics, which were not included only were the overall mean scores for HIV service in the Rifaskes survey. This section, therefore, readiness low, reflecting a smaller proportion of only compares the puskesmas, which is the only facilities that are ready to provide these services, but common facility type between these two surveys. the readiness for ART was even lower. While the There were also other methodological differences in private sector is involved in counseling and testing data collection and analysis, such as the data fields services for HIV, HIV care and management seem captured and the various elements that contributed to be the exclusive domain of the public sector; only towards calculating an index. three private-sector clinics stated that they provide these services, and even here, none of them was The tables below compare “like with like”– ready in terms of supplies and other logistics. 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. Table 3.6 General Service Readiness (Comparison Between Rifaskes 2011 and QSDS 2016) Basic Basic Standard Basic Essential Readiness Readiness Survey Amenities Equipment Precaution Diagnostic Medicine Index Index – All Instrument (Mean %) (Mean %) (Mean %) (Mean %) (Mean %) (Mean %) met (%) Rifaskes 2011 (Puskesmas 74% 84% 71% 61% 70% 71% 0% N= 8,981) QSDS 2016 (Puskesmas 83% 86% 83% 66% 71% 78% 0% N=268) 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. Is Indonesia ready to serve? 49 Table 3.7 Spesific Service Readiness (Comparison Between Rifaskes 2011 and QSDS 2016) Thematic Survey Type / Guidelines and Medicines and Equipment71 Diagnostics72 Area Elements Captured Trainings70 Commodities72 Rifaskes 2011 60% 96% 78% Family QSDS 2016 71% 97% 87% Planning Elements captured Guidelines Training BP apparatus Combined pill Injectable contraceptive Rifaskes 2011 53%72 98% 64% 96% QSDS 2016 93% 93%73 78% 89% ANC Elements captured Guidelines Training73 Weighing scale Hb estimation IFA Stethoscope Urine dipstick for Tetanus toxoid injection BP apparatus protein Rifaskes 2011 61% 65% 40% QSDS 2016 72% 70% 77% Elements captured Guidelines Training Emergency transportation Ergometrine Examination light Oxytocin Delivery pack Magsulf Obstetric Care Doppler ultrasound Diazepam Manual vacuum aspirator Injectable antibiotics Neonatal bag and mask IV fluid Disposable latex gloves Antibiotic eye ointment Sterilizer Mucus extractor BP apparatus Rifaskes 2011 58% 89% 95% QSDS 2016 73% 88% 84% Elements captured Guidelines Training Cold box Measles vaccine Immunization Refrigerator Pentavalent vaccine Temperature monitoring device OPV in refrigerator BCG vaccine Sharps container AD syringe Rifaskes 2011 58% 68% 41% 79% QSDS 2016 69% 87% 70% 92% Elements captured Guidelines (IMCI)74 Infant weighing scale Hb estimation ORS Child Health Training (IMCI) Tape (for height) or microtoise Stool for parasite Tab amoxicillin Growth chart Malaria tests Syp co-trimoxazole Stethoscope Syp paracetamol Thermometer Tab Zinc Cap Vitamin A Rifaskes 2011 59% 54% 67% Malaria QSDS 2016 49% 63% 69% Elements captured Guidelines Training RDT for malaria Antimalarial (first line) Paracetamol Rifaskes 2011 75% 73% 48% TB QSDS 2016 49% 95%75 95% Elements captured Guidelines Training Sputum microscopy Antitubercular Treatment - ATT (first line) Rifaskes 2011 - 76 84% 51% 79% QSDS 2016 93% 79%77 23%78 Diabetes Elements captured BP apparatus Blood glucose Injectable glucose solution Adult weighing scale Urine dipstick for Tape (for height) / microtoise protein Rifaskes 2011 -76 94% 84% QSDS 2016 94% 98%79 CVDs Elements captured Stethoscope ACE inhibitor BP apparatus Adult weighing scale Oxygen Rifaskes 2011 -76 90% 84% CRDs QSDS 2016 91% 82% Elements captured Stethoscope Antiasthmatic Oxygen Oral 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 Within each of these broad domains of general service readiness at the puskesmas general service readiness, there were when compared to the Rifaskes 2011 data (Table multiple elements that were asked for and the 3.6). While the average (mean) of some components difference with Rifaskes was variable. As an of general services readiness such as the availability example, (Figure 3.13) shows in detail the various of basic amenities and adherence to standard subelements captured under “basic equipment” precautions show a major positive shift of about and “standard precautions”. There was significant nine percentage points or more, there was not much improvement in the availability of some (such change in the availability of medicines and needed as child and infant weighing scales in the basic equipment in the facility. In both the surveys, equipment); while issues such as safe disposal of lack of availability of all basic diagnostics was a infectious waste continued to be an area of concern cause of concern. The average (mean) availability even in the QSDS survey. of individual components, however, varied much more (Appendix 5). None of the facilities met all the In terms for readiness for provision of specific indicators for general service readiness in both the services, the QSDS 2016, by and large, showed surveys. an improvement over the Rifaskes 2011 results (Table 3.7). The areas where the puskesmas were Figure 3.13 General Service Readiness: Basic Equipment and Standard Precautions Subdomains (Comparison Between Rifaskes 2011 and QSDS 2016) Basic Equipments Standard Precaution Adult scale Sterillizer 100% 100% Latex 80% Safe final Child gloves 80% disposal for sharps Light source 60% scale 60% 40% 40% Soap and Safe final disposal 20% running water 20% for infectious wastes 0% or alcohol… 0% Infant Blood pressure scale apparatus Single use of standard disposable Appropriate storage syringe of sharps waste Stethoscope Thermometer Disinfectant Appropriate storage of infection waste QSDS-2016 Rifaskes-2011 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. Is Indonesia ready to serve? 51 performing well under the Rifaskes Figure 3.14 Specific Service Readiness: Obstetric Care 2011, continued to do so even under Subdomain (Comparison Between Rifaskes 2011 the QSDS 2016, such as the availability and QSDS 2016) of equipment for family planning or Guideline book immunization services. 100% Antibiotics Eye ointment Training 90% Intravenous solution 80% Emergenc Obstetric care was one thematic (normal) saline 70% transportation area, where the overall indexes 60% Injectables antibiotics 50% Examination ligth showed significant improvement. 40% Averages hide variations, however, and, 30% Diazepam (Inejectable) 20% Delivery pack even with this well-performing specific 10% Doppler service domain, there were elements– Magnesium sulphate 0% ultrasound Injectables such as the availability of a manual Manual vacuum vacuum aspirator for provision of Oxytocin (injectable) extractor comprehensive abortion care, including Neonatal bag the management of incomplete abortions Ergometrine (Inejectable) and mask in the first trimester; or the availability Blood pressure apparatus Disposable latex gloves of delivery packs/kits–that had dropped below Rifaskes 2011 levels (Figure 3.14). Suction apparatus (mucus extractor) Sterilizer QSDS-2016 Rifaskes-2011 Moreover, there were other complete indexes, where services have worsened since Rifaskes 2011 (Table 3.7). The most important Figure 3.15 Specific Service Readiness: Childhood amongst these were availability of Immunization Subdomain (Comparison Between commodities for ANC (IFA tablets and Rifaskes 2011 and QSDS 2016) injectable tetanus toxoid) and vaccines for childhood immunization; there Guidelines was a significant reduction in the 100% BCG availability of all the basic vaccines Vaccine Staff Trainned when compared to the previous survey 80% (Figure 3.15). Similarly, availability 60% Oral Polio of guidelines for important programs Vaccine Cold box 40% like TB and malaria have also shown reductions. 20% 0% The large reduction seen in DPT-Hib+HepB Vaccine Refrigerator commodities for diabetes management is probably more of a measurement issue. As Rifaskes 2011 asked for the availability of Measles Sharps container only injectable glucose solution, this Vaccine was the only item that lent itself for comparison under this head. So, while Termperatur monitoring Auto-disable syringes QSDS 2016 showed a much greater availability of other diabetes related QSDS-2016 Rifaskes-2011 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. 52 Is Indonesia ready to serve? 53 Human Resources for Health 54 Staff Availability 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. Table 4.1 Minimum Staffing Norms at Puskesmas Puskesmas in Urban Rural Remote and Very Puskesmas Puskesmas No HEALTH WORKER Remote Areas Without With Without With Without With Beds Beds Beds Beds Beds 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). Minister of Health Regulation No. 75/2014. 80 This cadre was not inquired about in the QSDS 2016 tool. 81 Is Indonesia ready to serve? 55 When compared with the norms, the puskesmas The gap between staff requirement according were found to be short on nonmedical staff. On to norms and the actual staff on-board is greater average, the puskesmas had adequate numbers of in the rural puskesmas compared to the urban general physicians, nursing and midwifery personnel puskesmas. Even medical staff like the general (Table 4.2), however, these averages hide variations. physician and the dentist were fewer in number than For example, the number of doctors available at a mandated in terms of average availability in the rural puskesmas ranged from zero to as many as ten; the areas, while they were in sufficient numbers in the range for the availability of nurses and midwives was urban ones. For some cadres like the pharmacists and even higher–zero to 50, and zero to 61 respectively– the nutritionist, where there were gaps in both the reflecting that despite having a higher than required urban and rural puskesmas, the difference was wider average HRH, there were puskesmas with insufficient in the rural puskesmas. 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. Table 4.2 Human Resource Availability in Puskesmas Compared to Minimum Staffing Norms Urban Rural HEALTH WORKER82 Staff Positions Filled Staff Positions Filled Norm83 Norm83 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. 56 Compared to the puskesmas, the private thus reducing the need for nursing staff. Laboratory clinics had fewer nursing, paramedical and analysts or technicians were also not available at support staff. The average number of physicians these private facilities, which correlates with a lower per private clinic in the overall sample was slightly availability of on-site laboratory services in the higher than the availability at the puskesmas private-sector facilities compared to puskesmas. (Table 4.3). There is, however, a striking lack of nursing and midwifery staff at the private clinics, The overall pattern of availability of staff in when compared to the puskesmas. Compared to the private clinics reflects a relatively heavy an average of over nine nurses in a puskesmas, reliance on doctors. This is probably the case in a private clinic had less than two. While one most single-GP run clinics, where the burden of all puskesmas had as many as 50 nurses on-board, the medical tasks, including those that can be delegated maximum any private clinic had was 11 nurses. to nursing staff and paramedical workers, as well as the administrative and management load of the Some of these differences are probably a clinic are handled by the doctor himself/herself. reflection of the spectrum of services as well as This situation is probably due to the financial and the patient load catered to by the puskesmas logistical challenges of maintaining a larger staff and private facilities. For example, in the present strength in the private sector. In a few facilities, private-sector sample, maternity centers were not especially in the private sector, other specialists were included, and that could explain the relative lack also employed. The availability of specialists was of midwives. Similarly, private-sector clinics in the seen more in the multiple-GP run clinics compared sample were also less likely to offer inpatient care, to single GP ones. Table 4.3 Human Resources Mean Availability in Puskesmas and Private-sector Facilities Urban Rural All HEALTH WORKER Private Private Private Puskesmas Puskesmas Puskesmas Clinics Clinics 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. Causes of legitimate absenteeism included authorized leave, off shift hours, on administrative duty, on outreach activities (which 84 was the most common reason for being absent), and others. Is Indonesia ready to serve? 57 Absenteeism amongst puskesmas staff does These numbers were slightly higher for nurses and not seem to be an issue in either the urban midwives (in urban puskesmas). On deeper analysis or the rural puskesmas, across all cadres of of the responses to differentiate between those who staff. Some 26 percent and 31 percent of the doctors were “legitimately”84 not present at the clinic and on the sampled puskesmas’ payrolls in the urban those who were “absent” without cause, at the time and rural areas, respectively, were not available of the survey there was almost no unauthorized at the facility on the day of the survey (Table 4.4). absenteeism amongst staff (Table 4.5). Table 4.4 Absenteeism Rate Among Puskesmas Staff on the Day of the Survey Urban Rural Staff Staff Staff Staff HEALTH WORKER Position Attendance Absenteeism Position Attendance Absenteeism Filled on Survey rate (%) Filled on Survey Rate (%)85 (Mean) Day (Mean) (Mean) Day (Mean) 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. Table 4.5 “Legitimate Absenteeism” and “Absenteeism Without Cause” in Puskesmas Rural Puskesmas Urban Puskesmas HEALTH Staff not Absent Staff not Absent Number Legitimately Number Legitimately WORKER present on without present on without of Staff absent of Staff absent survey day cause survey day cause General 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. Absenteeism rate = {(Staff in position – Staff present on day of survey)/Staff in position}*100 85 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. Figure 4.1 Correlation Between Availability of Human Resource Cadres and OPD Attendance at Puskesmas 3 3 3 Outpatient visit per person/year Outpatient visit per person/year Outpatient visit per person/year 2 2 2 r=0.1683 (p<0.05) 1 1 1 r=0.0917 (p>0.05) r=0.414 (p<0.05) 0 0 0 0 5 10 15 0 20 40 60 80 100 0 5 10 15 Number of GP/ Number of Number of Other Dentist/Specialist Nurse/Midwife Health Care Worker Source: QSDS 2016. Is Indonesia ready to serve? 59 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 Puskesmas are mandated to conduct mini- (Figure 4.2). Both of these workshop topics were workshops in their premises for their staff. mentioned by over 99 percent of the puskesmas and The topics are related to overall management of the were the most spontaneous of all responses. There puskesmas and are meant for all staff. On average, was no specific urban-rural trend seen in the conduct the puskesmas had conducted over 12 workshops of these workshops–whether a workshop was more (rural - 12.4; urban - 12.8) in the 12 months preceding common in the urban or the rural area varied from the QSDS survey. topic to topic. Figure 4.2 Mini-workshop Topics Held in Puskesmas in the 12 months Preceding the Survey 1% 0% 0% 0% 0% 0% 0% 0% 0% 2% 1% 1% 4% 1% 5% 6% 6% 15% 35% 58% 58% 70% Dknow 63% 71% 75% 81% No 84% 64% 16% Prompted 36% 28% 32% Spontaneous 26% 24% 26% 14% Pharmacy Staffing Data Program, Plan of Financing Minimum Local Area Other Coverage, Action Service Monitoring Output Standard Source: QSDS 2016. 60 In addition to the mini-workshops, puskesmas community empowerment was conducted at only staff are also mandated to receive training 55 percent of the puskesmas. Of the seven predefined on various themes. From the preventive and training topics, only about one-third (31 percent) of promotive health care basket, the most common the puskesmas had one or more persons from their theme on which puskesmas staff had received staff who had attended all of them. The reasons training was “Counseling on Clean Behavior” cited for staff members not attending these training (Perilaku Hidup Bersih Sehat – PHBS), which was sessions included not being selected as participants received by at least one staff member from three- or, in some cases, the training not being conducted quarters (76 percent) of the puskesmas in the year in their district. preceding the survey (Figure 4.3). Training on Figure 4.3 Training Related to Health Promotion and Preventive Programs Received by Puskesmas Staff in the 12 Months Preceding QSDS 76% 73% 67% 63% 58% 59% 55% 44% Counseling Development Community Drinking/ Food/ Garbage or PKPR Any other on Clean of health post empowerment clean water beverage wastewater (Program training on Behavior development and sanitation treatment Kesehatan health (PHBS) and/or village mobilization Peduli Remaja) promotion allert / Health Programs for Source: QSDS 2016. Adolescence Table 4.6 Reasons Given by Puskesmas Staff for Not Receiving Training on Specific Health Services Themes86 Not No Such Training Never Heard Training Not Thematic Area Selected as in This District/ of Such Available in the Participant City Training 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. Denominator for calculating the proportions is those facilities who mentioned not having received any training listed under that 86 specific health theme. Is Indonesia ready to serve? 61 The most common reason mentioned by In contrast, the main reason given in the puskesmas staff for not receiving training on private sector for not receiving training on specific health themes was that none of their specific health themes was because they were staff members was selected as a participant unaware of the same (Table 4.7). From a practical (Table 4.6). This was similar to the reasons given for viewpoint, it is difficult for private practitioners, not receiving training on preventive and promotive especially those managing their OPDs in single- care. Many puskesmas shared that they were not provider settings, to excuse themselves from their aware of some of the training, even on RMNCH- work for the training duration, as that would mean related topics, which is surprising given that this shutting down the services completely for that time, training has been going on for many years. which may not be feasible. All these responses indicate the need to In the absence of formal training on specific strengthen the training system such that all health themes, the health facilities, both puskesmas are given a chance for their staff to puskesmas and private clinics, resorted to be trained on various issues. Training needs to convening discussion forums within the be held close to the facility to avoid travel and other facility to share information related to the logistical issues that may hinder participation in various specific services, or relied on the staff the training. Training closer to the facility will also themselves to upgrade their own knowledge reduce the time that the staff is absent from facility, and skills (Table 4.8 and Table 4.9). The latter thus reducing the disruptive impact staff training was used even more for the comparatively newer sometimes has on staff attendance at the facility. The technical services like HIV and AIDS care or local government that is responsible for conducting management of NCDs. Such a relatively heavy training needs to streamline the system. 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. Table 4.7 Reasons Given by Private Clinic Staff for Not Receiving Training on Specific Health Services Themes86 Not No Such Never Heard Training Not Thematic Area Selected as Training in This of Such Available in the Participant District/City Training Last Two Years Family Planning ANC Basic Obstetric and Newborn Care Immunization 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 62 Table 4.8 Action Taken by Puskesmas to Make Up for Lack of Training on Specific Services Thematic Area Provide Convene Arrange internal Support staff to Motivate staff book or coordination training systems attend seminar, to improve module meeting or where the senior workshop, or knowledge/ to read discussion staff train junior other capacity- skills session/ staff (on-the-job building independently forum to share training) activities information Family Planning 18% 41% 10% 20% 26% ANC 20% 43% 11% 20% 30% Basic Obstetric and 25% 37% 14% 25% 32% Newborn Care 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. Table 4.9 Action Taken by Private Clinics to Make Up for Lack of Training on Specific Services Thematic Area Provide Convene Arrange internal Support staff to Motivate staff book or coordination training systems attend seminar, to improve module meeting or where the senior workshop, or knowledge/ to read discussion staff train junior other capacity- skills session/ staff (on-the-job building independently forum to share training) activities information Family Planning ANC Basic Obstetric and Newborn Care Immunization 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. Is Indonesia ready to serve? 63 Financing of Puskesmas 64 Health Financing close to 9.4 percent of the district health budget, and is an important source of capital spending (Figure Landscape 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); Health financing in Indonesia is marked puskesmas accreditation; and hospital accreditation by low public health expenditures (PHE), (DAK akreditasi).90 In 2018, the total DAK Non-Fisik high out-of-pocket (OOP) expenditures and a allocation is IDR 8.55 trillion. Neither DAK Fisik nor complex and fragmented intergovernmental DAK Non-Fisik have been strongly linked to results. fiscal transfer system (World Bank 2016). PHE at Both are allocated based on formulas that ascertain 1.5 percent of GDP (IDR 118 trillion or US$9.1 billion) need, with DAK Fisik also based on proposals from is amongst the lowest in the world and forms only provinces and districts. More importantly, DAK 41 percent of total health expenditures (THE). THE forms a pivotal source of resources for the health constituted 3.6 percent of GDP or US$126 per capita sector in underdeveloped districts, such as those in in 2014. Government revenue as a share of GDP is Eastern Indonesia. also low at 17 percent and PHE is only 5.3 percent of national government expenditure. OOP is very high Figure 5.1 Sources of District Revenue for Health (as % of at 46 percent of THE and is 1.2 percent of GDP. Total Revenue) (2013–15) Both supply-side financing of public-sector 10% 9% provision and demand-side financing through 23% 10% 9% the JKN exists. On the supply-side financing, several intergovernmental fiscal transfer mechanisms (from 1% the Ministry of Finance (MoF) to local governments 18% (LGs)87 exist. The main ones are general allocation 17% 24% funds (Dana Alokasi Umum, DAU), revenue sharing (Dana Bagi Hasil, DBH), and special allocation funds (DAK). About 75 percent of DAU is allocated to 19% Dekon-TP spending on personnel, limiting districts’ flexibility on their annual budgets. Indonesia’s health sector DAK 42% 28% has low dependency on external financing except for BPJS some health programs.88 12% Social security fund Province DAK is the largest conditional transfer and an 10% Other interfiscal transfers important lever for the national government 20% 4% User fees to influence subnational service-delivery 9% 5% Other PAD outcomes (World Bank 2016). There are two 12% forms of DAK: DAK Fisik is focused mainly on 8% 9% infrastructure, equipment and medicines; and DAK 2013 2014 2015 Non-Fisik finances some operational expenditures (largely for outreach and accreditation). DAK Fisik Source: Indonesia QSDS 2016. increased more than four-fold between 2014 and Note: Data is based on a nationality representative sample 2018, to IDR 17.45 trillion (US$1.29 billion).89 It forms of 22 districts 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. Is Indonesia ready to serve? 65 JKN Program Strategic purchasing92 under JKN will provide an opportunity for increased efficiency and accountability in service delivery. Primary care The JKN (BPJS), with expenditures at about is currently paid through capitation and hospitals IDR 53 trillion84 (approximately US$4.1 are reimbursed based on diagnosis-related groups billion) or 42 percent of the district health known as INA-CBGs (Indonesia Case-based Group). budget in 2015 (Figure 5.1), is an underused In 2016, the GoI implemented Kapitasi Berbasis financial lever to improve health outcomes Komitmen (KBK)–a capitation payment to primary- and supply-side readiness. Key challenges health facilities that is linked to agreed performance include clarifying institutional roles, covering the indicators.93 In its first year of implementation, up informal nonpoor, a nonexplicit benefits package, to 25 percent of the capitation payment could be and weak strategic purchasing of services. The JKN deducted if targets or criteria were not met–offering is also poorly integrated with supply-side financing puskesmas’ a significant financial incentive. Since to improve public-sector supply-side readiness then, the payment deduction has been scaled and is also being underused to harness private- back–ranging from 2.5 percent to 10 percent. The sector provision. JKN needs to ensure the poorest choice of indicators is also reflective of the current 40 percent of the population are targeted better, needs of BPJS Health, which is more focused on and that contribution collection among nonpoor cost containment and general oversight rather than informal workers increases.91 JKN implementation health system performance overall. The scheme is done through BPJS Health, which is not well presents an opportunity to develop an additional set integrated with other health authorities across all of indicators that would meet both BPJS and MoH levels. About 65 percent of the expenditure claims performance-monitoring objectives. in 2014 have been hospital-based and another 20 percent were used for noncapitated fee-for-service In line with the goals of the JKN program, payments to facilities. Claims for NCDs dominate, all puskesmas surveyed under the national with CVDs, kidney failures and stroke being among sample in QSDS 2016 were empaneled with the top five diseases accounting for most of JKN BPJS Health. The average number of members expenditures. Even though JKN capitation forms covered by puskesmas was 11,729 with a range from a large source of revenue for puskesmas, its use for 1,929 to 43,250. The average number of members supply-side readiness continues to be problematic covered by a rural puskesmas was 8,698 (ranging due to a lack of clarity on capitation spending at the from 1,929 to 35,618) while that for the urban puskesmas level. 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 empanelment was inability of the facility to fulfil facilities were empaneled by BPJS, with a big the BPJS requirements (22 percent), with more rural difference between urban (47 percent) and private-sector facilities (28 percent) being unprepared rural (30 percent) facilities. One-third (35 percent) than urban private-sector facilities (20 percent). of private-sector facilities were “not interested” in being empaneled, with urban private-sector facilities The average number of members covered being twice more than twice as likely to cite this by a private clinic was 4,150–with a wide reason than rural ones (40 percent vs. 19 percent) range from 142 to 25,000. The average number of (Figure 5.2). This disinterest is probably linked to members covered by a rural private GP was 1,240 the capitation amount, which about 11 percent of with a range from 200 to 4,750 and the average providers stated was lower than their expectation. number of members covered by an urban private GP The second most common reason for non- was 4,400 with a range from 142 to 25,000. Figure 5.2 Reasons for Nonempanelment of Private Clinics with BPJS Percentage 18 The capitation amount is too small 8 11 9 Non-capitation claim is too small 2 4 There is limited partnership quota 4 for health facility empanelled with BPJS 6 6 Drastic increase in workload because 5 of high patient volume 9 8 19 Not interested 40 35 Has proposed, but didn’t 9 pass credentialing... 8 8 Has not proposed yet because 28 of unfulfilled requirement 20 22 Does not know JKN 4 partnership mechanism 3 3 4 Rural Urban All Other 3 3 Source: Indonesia QSDS 2016. Table 5.1 Reasons for Puskesmas Not Getting Maximum Capitation of IDR 6,000 REASONS FOR NOT GETTING MAXIMUM PREMIUM ALL URBAN RURAL Number 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% Source: Indonesia QSDS 2016. 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. Is Indonesia ready to serve? 67 The capitation received per member per month There was no significant difference observed at the puskesmas ranged from IDR 3,000 to IDR between puskesmas that received maximum 6,000, and 43 percent of puskesmas received capitation versus those that did not in terms less than the maximum capitation of IDR 6,000 of supply-side readiness for child health, per member per month. The main reasons for not diabetes or CVDs (Table 5.2). While the mean getting maximum capitation payments were lack of service index for some selected components of adequate HRH (in terms of numbers and/or cadres) as specific services was lower for the facilities that had mandated by BPJS (cited by 43 percent of the facilities), not received the complete/maximum allowable followed by deficiency in services in comparison to the capitation fee, the difference was not statistically BPJS requirement (cited by 30 percent of the facilities) significant. This indirectly indicates that availability (Table 5.1). The reasons varied between the urban and of funds may not be a critical barrier for improving rural facilities; for example, availability of providers service readiness of facilities (puskesmas). was a reason for lower capitation in 48 percent of the rural puskesmas compared to only 29 percent of the In 2015, over 85 percent of the puskesmas were urban ones. 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 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Puskesmas Received Maximum Capitation No 88 16.51 0.29 2.70 15.94 17.08 -0.63 -1.70 0.09 Yes 180 17.14 0.22 2.91 16.71 17.57 All 268 16.93 0.17 2.85 16.59 17.28 Supply-side Readiness Score for Diabetes 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Puskesmas Received Maximum Capitation No 80 8.80 0.19 1.70 8.42 9.18 -0.26 -1.13 0.26 Yes 179 9.06 0.13 1.68 8.81 9.30 All 259 8.98 0.10 1.69 8.77 9.18 Supply-side Readiness Score for CVDs 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Puskesmas received maximum capitation No 65 8.35 0.19 1.55 7.97 8.74 -0.23 -0.99 0.33 Yes 156 8.58 0.13 1.59 8.33 8.83 All 221 8.52 0.11 1.58 8.31 8.72 Source: Indonesia QSDS 2016. 68 There was a negative correlation observed The average capitation received per member (at p=0.05) between puskesmas utilization of per month at the private-sector facilities was JKN funds and supply-side readiness for child IDR 8,000 (with a range from IDR 4,000 to IDR health, however, no such linkages were seen 10,000), while 46 percent of the private-sector for diabetes and CVDs. Contrary to expectations, facilities received less than the maximum puskesmas that are unable to expend all the funds capitation of IDR 10,000 per member per received from BPJS have marginally better service- month. The maximum capitation amount for readiness scores than those that are able to manage private-sector facilities (IDR 10,000 per member 100 percent expenditure (Table 5.3). These differences per month) is more than the maximum capitation need to be interpreted with caution, however, as amount received by the puskesmas (IDR 6,000 per not only is the difference not statistically significant member per month) because the latter also receives (other than for child health), the number of other government budgetary sources of revenue. puskesmas in one comparative arm is very small. Rural private-sector facilities were twice as likely As most of the capitation is used to fund operational to receive less than the maximum capitation of costs (paragraph 160), its ability to impact service IDR 10,000 than urban private-sector facilities (82 readiness at the facility is also relatively limited. percent vs. 42 percent). Table 5.3 Correlation Between Utilization of JKN Capitation Fees and Service Readiness (for Selected Specific Services) of Puskesmas Supply-side Readiness Score for Child Health 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Able to use all fund received from Capitation No 252 17.02 0.18 2.85 16.67 17.37 1.46 1.99 0.05 Yes 16 15.56 0.65 2.61 14.17 16.95 All 268 16.93 0.17 2.85 16.59 17.28 Supply-side Readiness Score for Diabetes 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Able to use all fund received from Capitation No 250 8.99 0.11 1.70 8.78 9.20 0.44 0.76 0.45 Yes 9 8.56 0.47 1.42 7.46 9.65 All 259 8.98 0.10 1.69 8.77 9.18 Supply-side Readiness Score for CVDs 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Able to use all fund received from Capitation No 214 8.53 0.11 1.59 8.32 8.75 0.53 0.88 0.38 Yes 7 8.00 0.38 1.00 7.08 8.92 All 221 8.52 0.11 1.58 8.31 8.72 Source: Indonesia QSDS 2016. Table 5.4 Reasons for Private-sector Facilities Not Getting Maximum Capitation of IDR 10,000 REASONS FOR NOT GETTING MAXIMUM PREMIUM ALL URBAN RURAL Number 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% Source: Indonesia QSDS 2016. Is Indonesia ready to serve? 69 A large proportion (49 percent) of the providers Overall, the private clinics empaneled under who did not get the full capitation fee cited BPJS were more service ready than the reasons others than the ones prelisted in the nonempaneled ones (Figure 5.3). The average data collection tool (Table 5.4). The other reasons score for general service readiness increased from an were similar to the ones cited by the puskesmas availability of less than 19 items in non-empaneled such as shortage of human resources, and inability private clinics to about 22 items (out of a total possible to provide the services as required under BPJS. As score of 34) in BPJS-empaneled private clinics. BPJS is the case with puskesmas, lack of infrastructure empanelment resulted in the average readiness scores was the lowest ranked reason for receiving lower for child health shifting from about 8 to 10. Further amounts of capitation, indicating once again that details on this for various subdomains of general shortage of human resources is a bigger bottleneck service readiness and for other themes under specific than infrastructure–even for the private sector. The services can be found in Appendix 5 and 6 respectively. difference in services not meeting BPJS requirements The only two areas, where BPJS-empaneled private between rural and urban private-sector facilities was clinics appear to perform slightly better than three-fold (49 percent vs. 16 percent). 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 Percentage 15 10 Not empaneled Empaneled 5 0 0 2 6 10 14 18 22 26 30 34 Number of Component (34) Child Health Service Readiness Percentage 15 Not empaneled 10 Empaneled 5 0 0 2 4 6 8 10 12 14 16 18 20 Number of Component (21) Note : vertical solid line=mean; vertical dash line=median Source: Indonesia QSDS 2016. 70 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. Table 5.5 Correlation Between Receipt of JKN Capitation Fees and Service Readiness (for Selected Specific Services) of the BPJS-empaneled Private Clinics Supply-side Readiness Score for Child Health 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Private facility received maximum capitation No 77 8.87 0.41 3.59 8.05 9.69 -3.16 -4.18 0.0001 Yes 39 12.03 0.69 4.29 10.63 13.42 All 116 9.93 0.38 4.11 9.18 10.69 Supply-side Readiness Score for Diabetes 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Private facility received maximum capitation No 74 5.07 0.27 2.33 4.53 5.61 -1.57 -3.45 0.0008 Yes 39 6.64 0.36 2.25 5.91 7.37 All 113 5.61 0.23 2.41 5.16 6.06 Supply-side Readiness Score for CVDs 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Private facility received maximum capitation No 65 5.85 0.38 3.06 5.09 6.60 -1.77 -2.87 0.0050 Yes 34 7.62 0.45 2.62 6.70 8.53 All 99 6.45 0.30 3.02 5.85 7.06 Source: Indonesia QSDS 2016. Is Indonesia ready to serve? 71 Puskesmas Revenue The puskesmas revenue patterns from 2013-15 As a proportion, revenue from OOP has also indicate an approximate four-fold increase shown a decrease–from 2 percent in 2013 to from an average (mean) revenue of IDR 293 only about 1 percent in 2015. This appears to million in 2013 to IDR 1.056 billion in 2015 be encouraging, however, in absolute monetary (Table 5.6). The increases have primarily been due terms, OOP has varied from about IDR 6 million to increasing capitation payments from BPJS, which per puskesmas in 2013, to IDR 13 million in 2014, to provided close to two-thirds of the revenue of the just over IDR 10 million in 2015. The contribution puskesmas in 2015. Non-capitation claims, at 3 from the budget of regional governments94 to percent, form only a small portion of the revenue. puskesmas revenue has reduced from 20 percent Jamkesda now contributes a far reduced proportion of in 2013 to 14 percent in 2015. BOK’s contribution95 to total revenues (2 percent) and Jampersal, Jamkesmas puskesmas revenue has reduced by one-half, from and Askes contributed no revenue to puskesmas in 35 percent in 2013 to 16 percent in 2015. This indicates 2015, in line with the objective of JKN replacing these the importance of JKN in puskesmas revenue, schemes. which is, therefore, a very important lever to drive performance of puskesmas. Table 5.6 Source of Revenue for Puskesmas Year 2013 2014 2015 Total (Million IDR) 293 659 1,056 Jamkesda 6% 5% 2% Jampersal 20% 0% 0% Jamkesmas 16% 0% 0% Askes 1% 0% 0% Jamsostek 0% 0% 0% OOP 2% 2% 1% BPJS (Total) 0% 55% 65% BPJS-Capitation 0% 52% 62% BPJS-Non Capitation 0% 2% 3% BPJS-Others 0% 1% 0% APBD 20% 18% 14% Donor 0% 0% 0% TP-BOK 35% 19% 16% Other 0% 0% 0% Unclassified 0% 0% 1% Source: Indonesia QSDS 2016. 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). 72 Puskesmas Expenditure Monetary incentives to puskesmas staff diagnostics, when supply from the warehouse is accounted for more than two-thirds (66 delayed, puskesmas are entitled to make local percent) of puskesmas expenditures in 2015 purchases from their own funds. The relatively low (Table 5.7). It is important that this is studied further level of spending on these items could, however, be to see that these increased incentives are resulting in one of the contributory reasons for frequent stock- productivity increases and quality improvements. outs of the same. A detailed study of this head may The next largest share is for monitoring and also provide interesting insights into the spending supervision activities, which form close to one- pattern of puskesmas. fifth (18 percent) of expenditures. Expenditures on equipment, consumables, and medicines form a No clear link between increased operational small part of operational expenses. Unless these are expenditures with supply-side readiness was being made available from other sources such as observed. There was no significant difference the APBD, it is a matter of concern as expenditures observed between puskesmas that retained all on medicines is also a large driver of OOP expenses. revenue versus those that did not and supply-side In cases of stock-outs of drugs, consumables and readiness for general services. Table 5.7 Puskesmas Heads of Expenditure as a Proportion of Total Expenditure 2013 2014 2015 Percentage allocation and expenditure 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% Source: Indonesia QSDS 2016. Is Indonesia ready to serve? 73 Management of Health Facilities 74 Governance for the underutilization of data.96 MoH’s Center of Data and Information (Pusdatin) has developed a Health Sector 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 Decentralization has been accompanied puskesmas use other electronic systems, with the by increased complexity of fiscal transfers, remainder using paper-based systems.97 BPJS collects diffuse governance and accountability and data through two systems that are distinct from strained subnational capacity to improve MoH (p-Care and e-Klaim), which are much widely health service delivery. In 2001, responsibility used (more than 90 percent coverage, by both public for the delivery of most health services was shifted and private providers and facilities) but only for JKN to the district level, with fund transfers being made patients. directly to the district level, bypassing the provincial level. In principle, decentralized health sector Between the various systems, there is a decision making, coupled with large fiscal transfers lack of consistency in data fields, such as from the center to subnational levels, was intended facility and patient identifiers and treatment, to empower LGs to efficiently and effectively design which does not allow the various systems to and implement health programs, especially by communicate with each other and share data. adapting to local contexts (Rokx et al. 2009). In The fragmentation of systems is driven by low levels practice, however, health financing flows are much of coordination among different MoH Directorates- more complex and difficult to manage, marked General, between MoH and BPJS, and between line by seven vertical intergovernmental financing ministries and MoF, along with competing demands channels, each with different rules and procedures. from development partners. The fragmentation is The introduction of demand-side financing through also driven by innovation from LGs seeking to fill the JKN in 2015 has further fragmented the fund gaps left by the central level and meet local needs. flows. This splintered model strains LGs capacity to Fragmentation increases the reporting burden on plan, manage, and allocate funds efficiently in order facilities (reducing time for service delivery), reduces to maximize results, and hinders governance and compliance, heightens the chances of error and accountability systems (World Bank 2008). confusion (that is, the same information shows up differently in different systems) and reduces the Central government has underutilized levers availability of comparable data for policy making to direct service-delivery improvement at the and programming. local level. The majority of intergovernmental transfers are unconditional, and those transfers that Very little is done to verify the quality are conditional have weak performance orientation. (including completeness) of data, which There are multifaceted and competing mixtures will become even more problematic as of central and subnational regulations governing performance elements are introduced into authority over key decisions which complicates financing, and thus incentives for gaming health service delivery, and is one reason behind the system increase. Despite the many online, the disparity of HRH distribution in the country offline and paper-based information systems used (Rokx et al. 2010). Finally, another challenge of by MoH, local governments and BPJS Health, there decentralization in the health sector has been the is no system for comprehensively benchmarking disruption to, and varying quality of, monitoring, performance of districts and facilities. The lack of reporting, and data systems (Rokx et al. 2009). complete, timely and credible data makes it difficult to properly assess the performance of facilities Health information management in Indonesia and LGs, or truly understand the kinds of capacity, is characterized by high fragmentation, resourcing and incentives needed to improve service poor compliance, little data verification and 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. Is Indonesia ready to serve? 75 Availability of Operational Guidelines 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. Table 6.1 Availability of Operational Guidelines at Puskesmas (%) Proportion of Puskesmas Where Name of Guideline 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 72.4 81.3 65.9 Services Model for Puskesmas Minimum Service Standards (MSS) 90.3 98.3 84.5 JKN/BPJS Guidelines 94.6 94.9 94.3 Source: Indonesia QSDS 2016. 76 Monitoring and Evaluation Monitoring of health facilities is important Posyandu visits by the puskesmas staff were to ensure quality of services. These visits by the conducted regularly. Puskesmas supervise the “authorities” also serve as mentoring opportunities village-level centers like posyandu and are required to to improve areas of work that were found lacking. pay monitoring visits to each posyandu under them As the puskesmas are primary health care facilities, once a month. Only about 9 percent of the sampled they are monitored by the DHO members. puskesmas did not monitor all the active posyandu in their area on a monthly basis. This was slightly more Monitoring visits to the puskesmas from the common for the rural puskesmas (12 percent) than the DHO were more common for RMNCH-related urban ones (6 percent). Among those who could not issues compared to those for infectious diseases monitor each posyandu every month, the commonest (Figure 6.1). More than 90 percent of the puskesmas had reason given was the distance of the posyandu from received such visits for maternal health, child health, the puskesmas, which resulted in increased travel immunization and nutrition. The proportion of facilities time. Others stated shortage of resources, both in terms that received monitoring visits for HIV and AIDS and of human resources and funds to carry out this activity. 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. Figure 6.1 Monitoring Visits From the DHO to the Puskesmas in the 12 Months Preceding QSDS 92% Maternal Health 96% 94% 91% Child health 96% 93% 92% Immunization 98% 94% 89% Tuberculosis 90% 90% 60% HIV/AIDS 82% 69% 74% Malaria 52% 65% 91% Nutrition 93% 92% 54% Others 52% 53% Rural Urban All Source: Indonesia QSDS 2016. Is Indonesia ready to serve? 77 While visiting the posyandu is an important Collection and analysis of data from the first step for monitoring, the visit is posyandu was a regular activity done by the meaningful only if the staff reviews the puskesmas; however, provision of feedback on activities, discusses problems, and offers the data collected has scope for improvement. solutions and technical updates to the Another means of monitoring the puskesmas posyandu staff (kader). Reviewing records activities is the collection and assessment of the and reporting formats was the most common coverage (of outreach services) data from the kaders. activity carried out by the puskesmas staff during All but three of the sampled puskesmas had a posyandu monitoring visits, and was mentioned dedicated staff member who was responsible for spontaneously by 26 percent of the puskesmas staff collecting coverage data from the posyandu. Over and another 72 percent when prompted (Figure 95 percent also had a staff member to analyze this 6.2). The staff also said that they shared regular data. They lagged in terms of providing feedback technical updates with the kader during their to the posyandu with respect to this coverage data, visits. One area that requires improvement was however, with only 88 percent of the puskesmas the provision of written feedback to the posyandu doing it. Even among those that provided the staff which was offered spontaneously by only 4 feedback, only 70 percent provided it on a monthly percent of respondents. Written feedback maintains or more frequent basis. 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. Figure 6.2 Activities Carried Out by Puskesmas Staff During Posyandu Monitoring Visit Percentage Check Supplies 18 63 19 Check Record Keeping and Reporting 26 72 2 Observe Cader Posyandu Interaction with Mothers 17 76 7 Provide Written Feedback 4 68 28 Provide Encouragement 20 78 2 Provide Updates on Administrative or Technical Issues 26 70 5 Discuss Problems Identified by Puskesmas Staffs 13 83 3 Plan Follow Up Actions on The Identified Problem 10 85 6 Review Work Plans and Results 16 79 5 Conduct Household Visits with Kader Posyandu 15 82 3 Provide Clinical Treatment 74 23 3 Do Nothing 33 13 54 Spontaneous Prompted No/Dknow Source: Indonesia QSDS 2016. 78 In many countries, including through pilot There is no correlation between receipt projects in Indonesia, the problem of not of monitoring visits from the DHO to the providing regular feedback has been addressed puskesmas and the service readiness index using mHealth technology. This involves of the latter (Table 6.2). These findings need to be digitizing the family-level data onto a platform that interpreted with caution, however, because most can be accessed and updated using mobile phones of the facilities had received at least one visit from and/or computers. This enables health workers to the authorities on a particular theme in the 12 access real-time information of clients and patients, months preceding the survey; thus, the sample size get worksheets related to services that need to be for the ones which did not receive these visits is provided (for example, names of children that need small. That could also be the reason why, contrary to be immunized), and update records in real time. to expectations, the average service-readiness scores This enables better supervision of staff, including for TB is higher, for the facilities that did not receive providing feedback as well as substantially reducing the monitoring visits, although the difference is not time taken by staff on administrative tasks. 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 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Received Monitoring for Maternal Health No 12 25.25 1.40 4.86 22.16 28.34 -0.77 -0.55 0.58 Yes 169 26.02 0.36 4.62 25.32 26.72 All 181 25.97 0.34 4.63 25.29 26.65 Supply-side Readiness for Child Health 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Received Monitoring for Child Health Program No 16 16.31 0.73 2.94 14.75 17.88 -0.66 -0.90 0.37 Yes 252 16.97 0.18 2.85 16.62 17.33 All 268 16.93 0.17 2.85 16.59 17.28 Supply-side Readiness for Immunization 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Received Monitoring for Childhood Immunization Program No 13 9.85 0.44 1.57 8.90 10.80 -0.43 -0.72 0.47 Yes 252 10.27 0.13 2.10 10.01 10.53 All 265 10.25 0.13 2.07 10.00 10.50 Supply-side Readiness for TB 95% CI N Mean SE Sd Diff t-test p-val Lower Upper Received Monitoring for TB Program No 19 6.84 0.19 0.83 6.44 7.24 0.46 1.38 0.17 Yes 193 6.38 0.10 1.42 6.18 6.59 All 212 6.42 0.10 1.39 6.24 6.61 Source: Indonesia QSDS 2016. Note: Only for Independent & Referral Puskesmas Is Indonesia ready to serve? 79 Health Information System 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. 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. Source: Indonesia QSDS 2016. 98 SP2TP: Sistem Pencatatan Pelaporan Terpadu Puskesmas (Puskesmas Integrated Reporting and Recording System). 80 Is Indonesia ready to serve? 81 Summary of Findings and Key Issues to be Addressed 82 Findings The key findings are summarized in Table have improved (green color) during the period, some 7.1 which also compares differences in key indicators (such as the availability of electricity service-readiness indicators for puskesmas supply) have shown no change (yellow color), based on national estimates from Rifaskes simply because they were already at high levels and 2011 and QSDS 2016. It must be reiterated here there was no room for change. Despite improvement that the Rifaskes was a facility census of public- over Rifaskes levels, many other indicators–such as sector health facilities–unlike the QSDS. In addition, the management of infectious waste– leave room Rifaskes did not include private-sector facilities in for considerable improvement even now. Although its sample, hence there are no comparisons available very few indicators have shown a dip compared to for the same. Overall, both service availability and Rifaskes (red color), these are still a cause of concern. service readiness for general and specific services Table 7.1 Key Findings From QSDS 2016 and Comparison With Rifaskes 2011 THEME AND PUSKESMAS GENERAL PRACTITIONERS SUBTHEME (Public Sector) (Private Sector) (if any) SERVICE AVAILABILITY • On average, each puskesmas served about Data not captured in QSDS. 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 Access to Facilities 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. • 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. • All the sampled puskesmas offered outpatient • All the sampled private GPs offered outpatient care. care. General Health Services • About one-half of the puskesmas offered • Only 13 percent of the sampled clinics provided inpatient care. inpatient services. • There was an almost universal availability of Data not captured in QSDS. 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. Specific Health Services • The availability of various methods matches – Family Planning 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. Is Indonesia ready to serve? 83 THEME AND PUSKESMAS GENERAL PRACTITIONERS SUBTHEME (Public Sector) (Private Sector) (if any) • There was universal availability of ANC. Data not captured in QSDS. 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 Specific Health Services and blood grouping were not available in in – ANC 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. • Availability of obstetric care has also shown an Data not captured in QSDS. 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 Specific Health Services partographs, were being performed by almost – Obstetric Care 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. • While 86 percent of the public-sector facilities • Only 15 percent of private GP clinics provided provided immunization services in 2011 immunization services. according to the Rifaskes data, almost all • Only 15 percent of the private clinics that (98 percent) of the puskesmas provided provided immunization also did so through immunization services according to QSDS. outreach sessions. • Almost all the puskesmas that provided • Almost all the private clinics that offered Specific Health immunization also provided the same through immunization services also offered the newer Services – Childhood outreach sessions. vaccines like the ones against pneumococcus, Immunization • Newer vaccines like IPV, pneumococcal rotavirus and Japanese Encephalitis. vaccines and those against rotavirus and Japanese Encephalitis were conspicuous by their absence from the list of vaccines provided by puskesmas. • 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. • 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. Specific Health Services • Availability of services to diagnose and manage malaria in children is a cause of concern, as it was – Childhood Health available in only 63 percent of the puskesmas and 28 percent of the private clinics. • Nutrition services for children were almost • Nutrition services for children were available universally available in the puskesmas. 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. 84 THEME AND PUSKESMAS GENERAL PRACTITIONERS SUBTHEME (Public Sector) (Private Sector) (if any) • Some 88 percent of the puskesmas offered • Only 28 percent of the private facilities offered services for malaria. any malaria services. • Health staff at the puskesmas relied on both • The private clinics depended almost Specific Health Services clinical symptoms and laboratory tests to exclusively on clinical symptoms to diagnose – Malaria diagnose malaria. malaria. • There was low availability of preventive treatment for malaria in both puskesmas (46 percent) and private-sector facilities (20 percent). • Almost all the puskesmas offer TB services. • Only one-half of the private-sector clinics offer • Active case detection for TB is almost any services for TB. exclusively carried out by the public-sector • Only 21 percent of the facilities that offer any facilities, using the services of the TB kaders for TB services also offer active case detection. this purpose. • Most of the private clinics rely on clinical Specific Health Services • Puskesmas rely primarily on sputum symptoms to diagnose TB, with only two- – Tuberculosis microscopy for diagnosis of TB. thirds opting for sputum microscopy; only 38 • Almost all puskesmas use FDCs for treatment percent offer FDCs for treatment and less than of TB. one-half of the clinics offer DOTS for TB. The quality of care for TB offered in the private sector is, therefore, questionable. • 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). Specific Health Services • Within the PMTCT bandwidth of services, availability of ART for the HIV-positive pregnant – PMTCT 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. • 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 Specific Health Services in the puskesmas, care and support services and services meant for special target groups are – HIV Services 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. • 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. Specific Health Services • Only about one-half of the puskesmas and a smaller proportion of the private clinics had – STIs diagnostic services for STIs, indicating that treatment for STIs was probably based on the syndromic management approach. • Diagnostic services for hypertension and diabetes were almost universally available in Specific Health Services puskesmas and private clinics. – NCDs • 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 • There was a lack of communication means at • Private clinics were more likely to have at least the puskesmas. some means of communication. • There was a wide interdistrict as well as • The availability of cell phones was higher in urban-rural variation in the availability of the private clinics compared to puskesmas. General Services – communication means. • Only two-thirds of private clinics had Communication • Almost all the puskesmas had a computer computers; those that are part of the BPJS available at the facility. network were more likely to have one. • Urban puskesmas were more likely to have Internet access. • Some 96 percent of the puskesmas had their • Only 33 percent of the private clinics had their own means for referral transportation and it own functional referral transportation. General Services – was functional on the day of the survey. This Referral Transport was an increase from 82 percent of the facilities under Rifaskes. Is Indonesia ready to serve? 85 THEME AND PUSKESMAS GENERAL PRACTITIONERS SUBTHEME (Public Sector) (Private Sector) (if any) • As with Rifaskes, the QSDS too found that almost all the facilities had electricity supply. General Services – • The primary source of power for most facilities was the central grid supply. Electricity • Puskesmas were more likely to have a secondary/back-up source of power. • Generators were the most common source of back-up power supply. • The proportion of facilities that received water supply from an “improved water source” increased General Services – from 72 percent in 2011 to over 90 percent in 2016. Water, Hygiene and • Piped water into the facility was the commonest source of water supply. Sanitation • Almost all the facilities had functioning toilets for patients’ use. • Only one-quarter of the puskesmas had at • More than one-half of the private clinics had least one room that allowed both auditory and chambers that offered both auditory and visual privacy. visual privacy. General Services – • One-half (48 percent) of the puskesmas did not Privacy offer any privacy. • Rural puskesmas were more likely to offer no privacy compared to urban ones. • 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. General Services – • More than one-half of facilities in both the public and private sector did not store infectious waste Infection Prevention appropriately. and Waste disposal • 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 • Only 64 percent of private clinics had a medical one piece of medical sterilizing equipment. equipment sterilizer. • While only 28 percent of the facilities had • Equipment was less available in the private all the basic equipment available in 2011, clinics. it increased marginally to 39 percent in General Services – 2016–still leaving considerable scope for Equipment improvement. • 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). • The availability of the drugs at the puskesmas QSDS tool inquired about the availability of only was variable depending on the type of drug. a limited number of drugs in the private clinics. General Services – For example, basic oral antibiotics were readily • Lifesaving medicines were available in a Medicines available, whereas injectable and high-end smaller proportion of the private clinics antibiotics were less likely to be found in stock. compared to the puskesmas. • More than 90 percent of the puskesmas had a • Less than 40 percent of the private clinics had General Services – laboratory within their premises. laboratory facilities; the availability of all Diagnostics diagnostic tests was, therefore, significantly lower in the private clinics. • Puskesmas were more likely than private The QSDS tool did not inquire about the facilities to have the various technical availability of maternal health and family guidelines available in their facilities. planning-related guidelines in the private • The availability of RMNCH-related clinics. guidelines was higher compared to those for • The availability of guidelines and staff communicable diseases and NCDs. trained for NCDs almost matched that in the • Puskesmas staff were more likely to be trained puskesmas. Specific Services – Staff in provision of RMNCH and communicable Training and Guidelines 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. 86 THEME AND PUSKESMAS GENERAL PRACTITIONERS SUBTHEME (Public Sector) (Private Sector) (if any) • 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. Specific Services – • Among all the NCDs, the availability of equipment for CRDs needs attention. Equipment • 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. • The availability of diagnostics was low, Specific Services – especially in single-provider managed clinics. Diagnostics • Stock-outs of RDTs for various diseases was common. • Stock-outs of drugs and diagnostics was common in both the public and private sector. • The puskesmas had a functioning LMIS. • Private clinics did not appear to have a formal • The quality of the LMIS was questionable given system for logistics management. Logistics Management the frequent stock-outs. • The common reason for a stock-out was the of Drugs and • In most cases, the facility stated that the failure of the clinic to place an order for the Consumables inability of the warehouse to supply the product on time. needed drug/diagnostic was the reason for the • In case of stock-outs, patients were often asked stock-out. to purchase the product from the open market/ pharmacy. HUMAN RESOURCES FOR HEALTH • When compared to the norms set by GoI, • While there are no norms for staff availability puskesmas were found to be short on the in the private clinics, the availability of availability of nonmedical staff such as the paramedical and nursing staff in these clinics nutritionist and pharmacists. was far less than that of the puskesmas. Staff Availability • The availability of staff was poorer in the rural • The overall staffing pattern in the clinics facilities compared to the urban ones. reflects a reliance on doctors to provide patient • The nonlegitimate absenteeism rate among the care as well as to manage the facility. puskesmas staff was almost nonexistent. • The puskesmas regularly conduct mini- • The private-sector staff were less likely to be workshops in their premises, most commonly trained on various themes compared to the on topics related to program management. puskesmas. • Reasons for missing out on other training • Most of the clinics stated lack of awareness organized by GoI or the local governments and information about the existence of such Staff Training was the nonselection of a staff member for the training as the reason for not attending the training or the distance of the training venue same. from the puskesmas. • 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. Is Indonesia ready to serve? 87 THEME AND PUSKESMAS GENERAL PRACTITIONERS SUBTHEME (Public Sector) (Private Sector) (if any) FINANCING OF PUSKESMAS • 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 JKN Empanelment were not empaneled. • Urban clinics were more likely to be empaneled. • 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. Capitation Fee • The lack of an adequate number and type of staff as mandated by BPJS was the key reason for receipt of less capitation fees. • Over 85 percent of the puskesmas were unable Data not available. Utilization of Funds to utilize all the funds received through the payment of capitation fees. • Between 2013 and 2015, puskesmas have seen Data not captured in QSDS. a four-fold increase in revenue–from IDR 293 million to IDR 1,056 million. • The primary reason for this increase is the Revenue increase in capitation fees from BPJS. • Revenues from OOP have reduced as a proportion although there is no reduction in terms of absolute amounts. • Monetary incentives and bonuses to staff Data not captured in QSDS. account for more than one-half of puskesmas ’ Expenditure expenses. • Spending on equipment and consumables is a very small part of puskesmas ’ expenses. MANAGEMENT OF HEALTH FACILITIES • The DHO was more likely to visit the Data not captured in QSDS. 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 Monitoring and reviewed the records and reports regularly, Evaluation 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. • Both the puskesmas and the private clinics were using the HMIS designed by GoI, that is, the SP2TP. Health Information system • Some 87 percent of the puskesmas were using • Only 60 percent of the private clinics were computers for data entry into SP2TP, both with using computers for data entry. and without a back-up paper trail. 88 Issues of Concern QSDS 2016 shows an overall improvement the gold standard, that is, sputum microscopy, in service availability and readiness at to confirm their diagnosis. These facilities cited puskesmas. This survey has also yielded important the absence of a laboratory in the facility as the information related to the service availability, reason for not offering these diagnostic services. readiness and functioning of the private-sector In addition, less than one-half of the private primary-care clinics, which was not available clinics that prescribed ATT (43 percent) offered through any of the previous studies. FDCs and/or DOTS. Owing to the long duration of the antitubercular drugs’ course, nonDOTS Despite the overall progress, there are many treatment is known to increase treatment areas of concern which will need focus and default. Additionally, only one-quarter (26 corrective action, including: percent) offered follow-up services of patients, which means that cases of default are neither a. The service availability and readiness of captured not brought back into the system for the private-sector clinics lagged that of treatment continuation. Both these can lead to the puskesmas. The mean readiness index for a rise in MDR-TB rates. general services for the private clinics was 61 • In contrast to the puskesmas that used both percent compared to 78 percent for the puskesmas clinical presentation and laboratory tests like (Appendix 5). Similar differences in readiness microscopic examination of peripheral smear index were visible across the specific-services and RDTs to diagnose malaria, practitioners spectrum (Appendix 6). in private clinics relied almost exclusively on clinical symptoms. b. Within the private sector, the clinics that were not empaneled with BPJS fared worse than d. While the average population served by a the empaneled ones. As this is a cross-sectional puskesmas has remained constant over the survey, it cannot be said whether empanelment years (at around 30,000), ensuring equitable with BPJS is the cause or the effect of improved distribution of the puskesmas deserves readiness. On one hand, there were many facilities greater attention. While this confirms that the that did not get empaneled as they did not meet increase in the number of these primary-care the human resource and service-delivery criteria facilities has kept pace with the rising population set by the agency. On the other hand, the receipt in Indonesia, QSDS 2016 has revealed a wide of maximum capitation fees from BPJS did have variation in access to the puskesmas in terms of a positive correlation with improved service both distance and time to reach care, indicating readiness in the BPJS-empaneled private clinics. At that factors beyond the population size served a minimum BPJS, therefore, appears to be a platform need to be borne in mind when improving access that can be used to improve service readiness of to primary health care services. private facilities, whether it is through setting stringent standards for empanelment and/or by e. The restricted availability of the following encouraging facilities to improve their position specific services deserves attention: further through appropriate use of capitation fees. • While 75 percent of the puskesmas provided delivery services, only one-half had BEmONC c. Besides being less “ready” than the public services. Even in these limited facilities, sector to provide services, the quality of however, key signal functions of BEmONC services provided by the private clinics was (such as manual removal of placenta) was also questionable in many cases: provided by very few facilities. This lack of • Some 90 percent of the private clinics that services to manage obstetric complications offered TB services based their diagnosis on could be a direct cause of the slow progress in clinical symptoms and only two-thirds used MMR reduction in the country. Is Indonesia ready to serve? 89 • Availability of malaria-related services– f. QSDS has revealed frequent stock-outs especially for childhood malaria–were limited. of diagnostics, medicines and other Less than two-thirds (63 percent) of puskesmas commodities in both the puskesmas and and less than one-third (28 percent) of private- private-sector clinics. sector facilities offered these services for children. • The biggest reason for the stock-outs cited by While a higher proportion of puskesmas (88 the puskesmas was the inability of the local/ percent) stated that they provide these services regional warehouse to provide supplies in a for the general population, the proportion timely manner, which points towards an issue remained similarly low (28 percent) for the of SCM between the districts and the suppliers private sector. Within the spectrum of malaria under the e-catalogue system. In some other services, preventive treatment for malaria was cases, the flaw lay with the estimation made available in only 46 percent of the puskesmas by the facility of its requirements. While the and 20 percent of the private facilities. While it puskesmas can, and should, expend part of their is recognized that malaria services are linked to facility budget on local purchase of items in case endemicity of the disease, no province or district of impending stock-outs, the very low level of can be presumed to be completely free of the expenditure under this head indicates that this disease and, therefore, not having any facility in is not being done by the puskesmas. Most of that area provide services requires attention. the puskesmas did, in fact, have a functioning • Very few facilities, especially in the private LMIS, which included a system and designated sector, offer HIV-related services. Even among personnel to calculate requirements, ordering those that do, the focus is on HIV-related for commodities and its supply to the facility. counseling, whereas testing facilities and the • Unlike the puskesmas, the private clinics are provision of ART (both for the people living with not mandated to keep stocks of many of the HIV and AIDS and under the PMTCT program) is items that the QSDS enquired about. The QSDS provided by very few. For example, while only revealed that these clinics do not have a system about one-half of the puskesmas provide PMTCT to ensure adequate stocks of even the essential services, the availability of ART for HIV-positive commodities such as emergency drugs. women and/or the newborns was restricted to only 18 percent of these facilities, which Solutions specific to the type of facility translates to less than 10 percent of the sampled would need to be explored to ensure regular puskesmas. The figure is similar for provision of and constant availability of essential drugs, ART for the “general” (nonpregnant) population. diagnostics and other commodities. For Such a low availability at primary-care facilities example, public-private partnerships could be drastically reduces access to these services and used to expand diagnostic availability to both increases the risk of treatment noncompliance, puskesmas and BPJS-empaneled private-sector which, in the case of HIV and AIDS, also results clinics. Similarly, an improved LMIS that enables in an increased risk of transmission. Other than both puskesmas and BPJS-empaneled private-sector provision of ART, other HIV-related services clinics to do better demand forecasting for medicines directed towards special target groups, such and supplies, along with provision of quality as methadone maintenance therapy and a generic medications could be rolled out–with these needle syringe program, are offered by very few supplies being reimbursed under the JKN. puskesmas and none of the private clinics. • While the health sector appears to be geared a. Staff of both the puskesmas and the private up to handle some NCDs, like diabetes and clinic were found to be missing out on CVDs, there appears to be a lack of focus on the training being offered by MoH and CRDs. Compared to other NCDs like diabetes, employing alternate means for professional not only do fewer facilities offer services for development of staff. this component, but are less ready in terms of • The reasons cited by the public-sector facilities availability of trained staff and equipment (for (such as staff not being selected for the same, example, peak flow meters were available in or the training not being available in their only 13 percent and 43 percent of the public district) point towards certain flaws in the and private-sector facilities that were offering selection system and planning of this training. NCD coverage respectively). In comparison, the private clinics were not 90 aware of much of the training, indicating the vehicle, only one-third (33 percent) of the need for MoH to improve communication with private clinics had such facilities–with single- the private sector and regularly inform them provider run clinics being far less likely to have about the training on offer. There is, therefore, a such a referral transport system ready. As these need to strengthen the training system such that are primary-care facilities that are more likely all puskesmas are given a chance to get their to refer complicated cases than manage them at staff trained on various issues. Training needw the facility, there is a need for a more systematic to be held close to the facility to avoid travel ambulance system to be introduced for timely and other logistical issues that may hinder referrals, especially by the private sector. participation in the training. Providing training • About one-half of the sampled facilities in both sessions closer to the facility will also reduce the the public and private sector were found to be time that the staff are absent from facility, thus not adhering to waste segregation guidelines for reducing the disruptive impact staff training infectious medical waste. Storage of sharp waste sometimes has on staff attendance at the facility. material was also an issue with the private sector. • In the absence of government-led training, • Lack of privacy in the clinics for provider-patient the facilities rely on alternate means such as interaction, was a cause for concern, especially in holding internal discussions and/or relying the puskesmas. This was of greater concern in the on the staff to take the initiative to update facilities offering HCT services, where less than themselves depending on the technical topic one-half of these facilities had these amenities. concerned. The latter is not a reliable way to ensure technical updates and wherever d. Lack of availability of skilled human government training is not available, the facility resources was concerning. When compared management needs to take charge to update its to the norms set by GoI, there was an overall staff on evidence-based technical standards. lack of nonmedical staff such as the pharmacist and nutritionist at the puskesmas. In contrast, b. While QSDS 2016 found an overall increase the private-sector clinics, especially the single- in service readiness at the puskesmas when provider ones, were overly dependent on the compared to Rifaskes 2011, the following doctors and had significantly fewer nursing, areas of concern were noted: administrative and other support staff. Lack of • There was not much change in the availability staff was also the main reason for the facilities of general medicines and basic equipment receiving less than the mandated maximum required for general service readiness in the capitation fee per member as their staff strength facility. did not meet the norms set by BPJS. • Availability of medicines and commodities for a number of specific services such as ANC, e. The maximum capitation fee per registered immunization and diabetes management member provided to a puskesmas was IDR showed a decline compared to Rifaskes. 6,000, whereas it was IDR 10,000 for the • In both the surveys, lack of availability of basic private facilities as puskesmas also receive diagnostics was a cause of concern. other government budgetary financing. Some • The availability of guidelines for various 43 percent of the puskesmas and 46 percent of the specific services generally improved. The private clinics received less than the maximum exceptions were guidelines for TB and malaria, capitation fee–the primary reason for being lack of which showed a steep decline of over 10 staff as mandated by BPJS. There was no significant percentage points (from 75 percent to 49 difference observed between puskesmas that percent for TB and from 59 percent to 49 percent received maximum capitation versus those for malaria) compared to Rifaskes. that did not in terms of supply-side readiness. • None of the facilities met all the indicators for In contrast, the difference in service readiness general service readiness in both the surveys. between empaneled private-sector facilities that received the maximum capitation fee versus those c. Other issues related to service readiness that received less than the full fee was statistically include: significant. This indicates that JKN is a key • In contrast to the puskesmas all of which had instrument that can be used to influence supply- at least one functioning emergency transport side readiness for the private sector. Is Indonesia ready to serve? 91 f. About one-half of puskesmas revenue was This report brings out the key findings in primary spent on providing monetary incentives to health care supply-side readiness across public their staff, with relatively little being spent and private facilities, rural and urban facilities, on drugs and consumables. Further analysis private facilities empaneled by BPJS Health reveals that the facilities that utilize the funds versus those who have not, amongst others. completely are, contrary to expectations, less The primary aim of the report is to present findings service ready than those that do not expend the from the survey that can inform policy choices. It is complete allocated amount. These differences important that these findings are addressed through were not, however, found to be statistically key policy and implementation actions related to significant except for child-health preparedness. It health financing, service delivery and governance. points to the need to direct and monitor spending While this report itself does not cover these of BPJS funds by the puskesmas and ensure that recommendations, many of these have been covered JKN serves as a driver to improve supply-side by other publications and will also be covered in readiness. other forthcoming work. g. The public sector had a functional As mentioned earlier, supply-side readiness monitoring system with a few lacunae: improvement is necessary, but not sufficient, • While regular monitoring visits from the DHO to improve service-delivery access and to the puskesmas and by the puskesmas staff outcomes. There needs to be a package of policy to the posyandu were being performed, the interventions to improve performance and system of providing written feedback needs quality of primary health care quality, including improvement. strengthening performance monitoring and • The fact that there was no significant difference accountability, ensuring supply-side readiness in terms of supply-side readiness between verification and improving managerial capacity puskesmas that received regular monitoring as well as strengthening adherence to clinical and supervision versus those that did not processes through accreditation, incentivizing local reflects the need to improve the system so that governments and providers to achieve results by it has the desired effect of improving supply- linking supply-side (DAK) and demand-side (JKN) side readiness and quality of services being financial transfers to performance, strengthening provided by the facility. human resource skills and competencies, enabling better distribution of human resources as well as h. Both the public and private-sector facilities introducing innovations for better service delivery were using the SP2TP (health management by frontline providers. 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. 92 Appendixes Is Indonesia ready to serve? 93 Appendix 1 A Brief Description of GoI’s Health Program Introduced in 2015, the GoI’s fl agship health three priority outcomes. Promoting a Healthy program is the Healthy Indonesia Program Paradigm, is implemented through strengthening (HIP). The program aims to improve the health and of preventive and promotive efforts such as the nutritional status of the community through health Healthy Indonesia through the Family Approach and community empowerment efforts, backed by Program or Program Indonesia Sehat Melalui financial protection and the equitable distribution Pendekatan Keluarga (PIS-PK) and a community of health services. HIP is an umbrella program that campaign for healthy living (Gerakan Masyarakat encompasses the entire public health expenditure, Hidup Sehat or GERMAS). The aim of Strengthening through central and local governments, and was Health Care Services is to improve access to quality IDR 178 trillion (US$13.2 billion) in 2016. primary health care and hospital services, and to strengthen the referral system, including through HIP is organized around three pillars: accreditation and human resources. The third Promoting a Healthy Paradigm (Pillar 1); pillar, which is the National Health Insurance Strengthening Health Care Services (Pillar 2); Scheme (JKN) is focused on beneficiary enrolment and The National Health Insurance Scheme and expansion of benefits, as well as a focus on (JKN) (Pillar 3). HIP has 12 subprograms, the first achieving quality and cost control. The cross-cutting three are related to priority outcomes, the remaining strategies support all three pillars. nine subprograms are designed to achieve these GoI Healthy Indonesia Flagship Program: Twelve Subprograms Under Three Pillars and Cross-cutting Areas 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 3: PILLAR 1: PILLAR 2: The National Health Insurance Promoting a Healthy Paradigm Strengthening Health Care Services Scheme OBJECTIVE Strengthening preventive and Improve access to quality primary Improve beneficiary enrolment and promotive efforts “Healthy care, hospital care and referral expansion of benefits at the same Indonesia” through the Family through accreditation and HRH. time as achieving better quality and Approach Program (PIS-PK) and controlling costs. Community Campaign for Healthy Living (GERMAS). SUBPROGRAMS Health prevention, promotion and • Quality primary care National Health Insurance (JKN) community empowerment • Quality referral care • Pharmaceutical & Equipment • Food and Drug Regulation • HRH CROSS-CUTTING PROGRAMS -Management, research and development, health information systems; and -Health financing 94 Appendix 2 Indicators for Measuring General Service Readiness of Health Facilities 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 • Electric dry heat sterilizer, electric boiler or steamer (no pressure), nonelectric pot with Precautions cover for boiling/steam, heat source for nonelectric equipment for Infection • Safe final disposal of sharps includes incineration, open burning in protected area, dump Prevention 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) Is Indonesia ready to serve? 95 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] 96 Appendix 3 Indicators for Measuring Specific Service Readiness of Health Facilities HEALTH MEDICINES AND GUIDELINES TRAINING EQUIPMENT DIAGNOSTICS SERVICES COMMODITIES Basic Obstetric • Pocket book of • Training on basic • Emergency • Eye ointment antibiotic Care essential neonatal emergency obstetric transportation • Injectable oxytocin care (Buku Saku and neonatal • Electric autoclave • Injectable beta- Pelayanan lifesaving skills (pressure & wet heat), lactam antibiotic: (for Neonatal Esensial) • Training on nonelectric autoclave, example, Ampicillin • Pocket book of management electric dry heat injection, Benzathine maternal health of asphyxia for sterilizer, Electric benzylpenicillin care in primary neonates boiler or steamer (no injection, Procaine and referral health • Training on assisted pressure), nonelectric Benzylpenicillin facility vaginal delivery pot with cover for injection) • Any guideline • Any training boiling/steam, heat • Injectable aminoglycoside related to obstetric on obstetric and source for nonelectric antibiotic: Gentamycin and neonatal care: neonatal care, equipment injection specify: • Examination light • Injectable anticonvulsant (flashlight) drugs for preeclampsia • Delivery pack and eclampsia: • Electric suction Magnesium sulphate pump (for suction injection apparatus) and • Skin disinfectant (for suction catheter example, Povidone Iodine • Suction bulb solution) • Manual vacuum • Ringer’s lactate IV extractor solution • Vacuum aspirator or • Normal saline IV solution Dilation & Curettage (NaCl 0.9%) kit • 5% dextrose IV solution • Neonatal bag and • Injectable oxytocic mask for term drugs for prevention babies (for neonatal and treatment of PPH: resuscitation) Methylergometrine • Delivery table maleate • Blank partograph • Oral oxytocic drugs for • Disposable latex prevention and treatment gloves of PPH: Capsule/tablet • Infant scale Methylergometrine • Blood pressure maleate apparatus • Antiamoebic and • Soap and running antigiardial drugs: water 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) Is Indonesia ready to serve? 97 HEALTH MEDICINES AND GUIDELINES TRAINING EQUIPMENT DIAGNOSTICS SERVICES COMMODITIES Family Planning Practical guidelines • Training on • Blood pressure • Contraceptive pills (for Services on contraceptive contraceptive apparatus (may be example, combined services technique update digital or manual Levonorgestrel and • Training on sphygmomanometer Ethinylestradiol) counseling on with stethoscope) • Injectable contraceptive family planning • Implant kit (for example, using “Alat Bantu • IUD kit Medroxyprogesterone Pengambilan acetate) Keputusan Ber-KB” • Male condoms • IUD • Implant (for example, Levonorgestrel) ANC Services • KIA book • Any ANC training • Blood pressure • Hemoglobin • IFA • National guidelines • Any guideline apparatus meter (HemoCue) • Tetanus toxoid vaccine on integrated ANC related to ANC • Stethoscope • Urine protein • National guidelines • Training on • Adult weighing scale dipstick testing on PMTCT pregnant women • Doppler • Delivery class preparedness • Any intermittent and complication preventive readiness program treatment (IPT) • Manual and/or of malaria in training package pregnancy training on pregnant • Training on women class Delivery Planning (including package Program and and/or facility Complication guidelines and/or Prevention pregnant women • Training on PMTCT class operation guidelines) Routine Child • Guideline on • Training on • Vaccine carrier(s)/cold • Measles vaccine Immunization Immunization microplanning box/thermos • DPT-Hib+HepB vaccine Delivery • Training on • Refrigerator • Oral polio vaccine • Guideline on immunization • Sharps container/ • BCG vaccine Monitoring and service delivery safety box Management of • Training on • AD syringes Adverse Effects injection safety • Temperature Following • Training on vaccine monitoring device in Immunization management/ refrigerator (AEFI) handling and cold • Adequate refrigerator chain temperature • Training on data reporting and data monitoring of service delivery • Training on AEFI Child Preventive • Guidelines for IMCI Staff trained in IMCI • Infant weighing scale • Hemoglobin • ORS and Curative • Guidelines for • Child weighing scale testing • Oral antibiotic drugs: Care growth monitoring • Height measurement • General Amoxycillin dispersible tape/Microtoise microscopy/ tablet or syrup/suspension • Length measurement wetmounts • Oral antibiotic drugs: board • Rapid malaria Co-trimoxazole syrup/ • MUAC measuring testing/malaria suspension tape smear test • Oral antipyretic or • Thermometer analgesic: (for example, • Stethoscope pediatric Paracetamol syrup/ or any stethoscope suspension • Growth charts • Retinol capsule (Vitamin • Blood pressure strap A) for children • Oral anthelmintic drugs: • ARI timer/ stopwatch (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 98 HEALTH MEDICINES AND GUIDELINES TRAINING EQUIPMENT DIAGNOSTICS SERVICES COMMODITIES Malaria National Guideline • Training on malaria • Rapid Malaria • Artemisinin Combination for Malaria Diagnosis diagnosis and Testing Therapy: Artesunate and Treatment treatment • Malaria Smear + Amodiaquine + • Any IPT of malaria Test Primaquine in pregnancy • Light microscope • Paracetamol 500 mg training or Diagnostic • LLINS and LLIN vouchers Microscopy Tuberculosis • National Guideline • Training on • Light microscope Isoniazid, Pyrazinamide, for TB Diagnosis and diagnosis and • Rapid test HIV Rifampicin, and Treatment treatment of TB • Screening or Ethambutol, or • National Guideline • Training on testing for TB combinations to meet first- for Management management of HIV among People line TB treatment of HIV and TB and TB coinfection Living with HIV coinfection • Training on • Mantoux Test management • Provision of drugs and treatment of to TB patients MDR-TB • Sputum smear and microscopy examination HCT National guidelines Training on HCT (VCT Counseling room has Rapid test HIV Condoms on HCT, others and/or PITC), others to be comfortable, private, separate from waiting room and blood sampling room, and has separate entry and exit HIV – CST • National guidelines • Training on HIV CST Screening or testing • Normal saline IV for ARV therapy for • Training on HIV for TB among People solution, Ringer’s lactate adults and TB coinfection Living with HIV IV solution, 5% dextrose • National guidelines • Any training on IV solution on HIV treatment HIV CST • Oral antifungal drugs: for children (for example, Fluconazole • Any guidelines capsule/tablet, on CST Ketoconazole capsule/ tablet, Griseofulvin capsule/tablet, Nystatin capsule/tablet) • Oral sulfa-trimethoprim antibiotic: Co-trimoxazole • First-line TB treatment medications HIV – National guidelines Training on HIV CST • Hemoglobin • Zidovudine cap/tab (ZDV, Antiretroviral for ARV therapy for testing, white AZT) Prescription adults blood cell testing, • Zidovudine syrup/ and Client thrombocyte suspension (ZDV, AZT) Management testing • Abacavir cap/tab (ABC) • CD4 count • Lamivudine cap/tab (3TC) • Specific assay • Tenofovir Disoproxil kit, centrifuge, Fumarate cap/tab(TDF) biochemistry • Emtricitabine cap/tab analyzer (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) Is Indonesia ready to serve? 99 HEALTH MEDICINES AND GUIDELINES TRAINING EQUIPMENT DIAGNOSTICS SERVICES COMMODITIES HIV - PMTCT • PMTCT guidelines Training on Visual and auditory Rapid test HIV • Oral NNRTI antiretroviral (for example, counseling on IYCF privacy drugs: Nevirapine syrup/ guidance book, Training on PMTCT suspension (NVP) poster on the wall) • Option A: • Guidelines on • AZT, NVP, and 3TC infant and young • Option B: child feeding • AZT + 3TC + LPV or practices (IYCF) • AZT + 3TC + ABC or • AZT + 3TC + EFV or • TDF + 3TC (or FTC) + EFV Diabetes Guidelines for Staff trained in • Blood pressure Blood glucose • Metformin cap/tab diabetes diagnosis diabetes diagnosis apparatus Urine dipstick- • Glibenclamide cap/tab and treatment and treatment • Adult scale protein • Glucose injectable • Measuring tape Urine dipstick- solution (height board ketones • Glipizide stadiometer) CVDs Guidelines for Staff trained in • Stethoscope • ACE inhibitors (for diagnosis and diagnosis and • Blood pressure example, enalapril) treatment of chronic management apparatus • Beta blockers (for cardiovascular of chronic • Adult scale example, atenolol) conditions cardiovascular • Oxygen • Calcium channel blockers conditions (for example, amlodipine) • Aspirin cap/taps • Metformin cap/taps • Hydrochlorothiazide CRDs Guidelines for Staff trained in • Stethoscope • Antiasthmatic agent for diagnosis and diagnosis and • Peak flow meter acute attack management of CRD management of CRD • Spaces for inhalers • Oral corticosteroid • Electrocardiogram • Injectable corticosteroid • Oxygen • Epinephrine injectable 100 Appendix 4 QSDS Sampling and Analytical Methodology Background and Objectives Indonesia comprises 34 provinces (propinsi) report, however, only puskesmas and private clinic and special administrative areas, such as DKI instruments were used in the analysis. Jakarta, and 98 urban districts (kota) and 413 rural districts (kabupaten). It consists of a vast Where possible, baseline quantitative data– archipelago of 250 million people in 18,000 islands for example on financing and health-related ranging from densely populated areas (including indicators–were collected for the period one of the largest conurbations in the world– 2013–15. This time period was selected so that the Jabodetabek)99 to remote and isolated islands and government could assess changes in the financing of jungle communities. frontline service delivery because of the transition to JKN in 2014 and to serve as a baseline for the Due to reforms in decentralization, districts implementation of JKN. have greater autonomy and, therefore, are an important of unit of analysis. Furthermore, As the government indicated its concern for within the health sector, a major reform initiative remote and rural areas, for sampling of districts (JKN) was introduced, effective from January 2014. and facilities, methodologies that would Given this background context, Indonesia QSDS 2016 oversample large and heavily populated was envisioned as a primary health care facility and districts or facilities (for example, sampling services survey in Indonesia, with a specific ‘disease- methodologies that were proportionate to focus’ on nutrition, maternal and child health, district population) were judged to be less communicable diseases (particularly, HIV and appropriate for the intended objectives of this AIDS, TB, and malaria), and NCDs). Thematically, survey, especially given the large variations the survey captured information based on WHO’s in the population and sizes of districts in SARA conceptual framework, adjusted according Indonesia. Sampling was not designed to be to national guidelines, but also included modules regionally representative (for example, regions like on governance, health indicators, health financing Java, NTT, and Sumatra). Resource constraints were (but not costing information), provider ability, and a further important consideration and, therefore, an patient satisfaction. efficient survey methodology was desired. Instruments were developed to survey The primary objectives of, and tradeoffs considered dinkes, various primary health care facilities in, the sampling methodology were to provide, (puskesmas, polindes/poskesdes, private MH especially as a baseline for JKN: providers, and private clinics), health workers, and conduct patient exit interviews in DKI 1. National estimates of facility-level indicators for: Jakarta. As one of the key objectives of this survey (i) public primary care (puskesmas); (ii) private is to provide baseline indicators for JKN, facilities primary care; and (iii) posyandu, stratified by established in 2014 or later were excluded from the urban (kota) and rural (kabupaten) districts; survey. In addition, a small number of hospitals 2. DKI Jakarta estimates of facility-level indicators: were also sampled while at the community level (i) public primary care (puskesmas); (ii) private the posyandu were also sampled–especially for primary care; and (iii) posyandu, not further nutrition-related indicators. For the purposes of this stratified by urban or rural districts; 96 Jabodetabek: Jakarta, Bogor, Depok, Tangerang, and Bekasi. Is Indonesia ready to serve? 101 3. Estimates of facility-level indicators for the 64 Sampling Methodology high-priority districts: (i) public primary care (puskesmas); (ii) public maternity care (such Summary as polindes, poskesdes, and bidan di desa); (iii) private maternity care (both single and multiprovider facilities); and (iv) posyandu, SAMPLING OF DISTRICTS stratified by kota and kabupaten; Due to resource constraints and the desire to 4. Estimates for a sample of matched counterfactual produce district-level estimates for the sampled districts to the 64 high-priority maternity districts, there were relatively few districts (Level 1) districts, for the same facilities as for the priority sampled and a relatively larger number of facilities MH districts, stratified by kota and kabupaten; per district (Level 2) sampled in this two-level 5. Estimates for the 75 priority HIV and AIDS and clustered random sampling. TB districts for: (i) public hospitals; (ii) private hospitals; (iii) puskesmas; and (iv) private To reduce the likelihood of randomly selecting primary care; districts that were less typical of sample frame 6. Estimates for a sample of matched counterfactual of districts, cube sampling (Grafström 2014) was, districts to the 75 priority HIV and AIDS and therefore, used. This balances the sampled districts TB districts for the same facilities as for the 75 with the sample frame of districts, based on observable priority HIV and AIDS and TB districts; characteristics: (i) district population in 2013; (ii) GDP 7. Estimates for the 132 priority malaria districts per capita; (iii) Human Development Index (HDI); for: (i) puskesmas; and (ii) private primary, not and (iv) district land area. This does not, however, further stratified by urban or rural districts; specifically address intraclass correlation issues 8. For each of the sampled districts, an estimate between the two levels and the variation of facility- at the level of that district for facility-level level indicators between districts was, therefore, traded indicators. This was intended to allow off to strengthen estimates within a district. comparisons between district-level indicators and district characteristics; For each sample frame of districts–that is, DKI 9. Estimates for health care worker (HCW)-level Jakarta districts, nonDKI Jakarta national indicators, including provider ability, for health districts, MH priority districts, HIV and workers at puskesmas, private primary care, AIDS and TB priority districts, and malaria public maternity care, and private maternity districts–sampling of districts was conducted care; and independently of each other. There was further In DKI Jakarta, where the supply readiness 10. stratification between urban districts (kota) and rural was not anticipated to be a critical constraint, districts (kabupaten) for nonDKI Jakarta national estimates of patient user-level indicators through districts, MH priority districts, and HIV and AIDS and TB patient exit surveys. priority districts, and counterfactuals for the latter three. Field work for this survey was conducted from May There is, however, overlap in the sampling 30 to October 31, 2016. 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. 102 SAMPLING OF COUNTERFACTUAL DISTRICTS These counterfactual districts were For the populations of two districts–MH matched (Hansen and Klopfer 2006) from a priority districts and HIV and AIDS and counterfactual sample frame comprising TB priority districts, and for their urban districts sampled for other purposes if they districts (kota) and rural districts (kabupaten) were not ‘intervention’ districts–that is, in the independently–‘counterfactual’ districts were case of MH priority counterfactual districts, matched to districts from the overall sample the counterfactual sample frame excluded of districts already sampled (for example, DKI all MH priority districts. Matching was based Jakarta and nonDKI Jakarta). As these districts on the same four observable characteristics: (i) had already been sampled, albeit for other purposes, district population in 2013; (ii) GDP per capita; (iii) there were fewer additional resources required to HDI; and (iv) district land area. Health outcomes include these, apart from ensuring the relevant or health outputs were not considered appropriate counterfactual survey instruments and facilities parameters for balancing the sample due to were included. 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 Private Public Private Private Public Frame Puskesmas Primary Maternity Maternity Posyandu Hospitals Hospitals Care Care Care A. DKI Jakarta Yes Yes No No Yes No No B. National Yes Yes No No Yes No No nonDKI Jakarta C. Priority MH and Yes No Yes Yes Yes No No Counterfactual D. Priority HIV/ Yes, see Yes, see AIDS/TB and Yes Yes No No No note note Counterfactual 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 Frame Private Public Private Puskesmas Primary Care Maternity Care 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 HCW HCW HCW HCW counterfactual Priority Malaria HCW HCW HCW HCW How many and which HCW type? Two of: doctors, One doctor One midwife One midwife midwives, and/ (generalist or or nurses specialist) Is Indonesia ready to serve? 103 Matching of counterfactual districts for malaria SAMPLING OF HCWS priority districts was attempted but, due to Depending on the specific facility, doctors, the systematic differences in the observable midwives, or nurses were sampled from among characteristics of malaria priority districts, this health workers who were present at the time attempt was discarded. 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 GENERATING THE HEALTH FACILITY SAMPLING type present at the facility was used. FRAMES AND SAMPLING HEALTH FACILITIES District sample frames, health facility types For puskesmas, the sampling design intent included, and other instruments used are was to sample two HCWs (doctors, midwives, summarized in Table A4-1 and Table A4-2. or nurses), with a slight bias to doctors in the sample. In addition, to allow multilevel analysis, a Within each district, health facilities were sampled mechanism was established to ensure the possibility of by simple random sampling, with equal probability sampling two doctors, to create a third level, to analyze of sampling, regardless of catchment population, within and between facility variation in HCW-level utilization, or the ‘size’ of the health facility (in terms indicators. This simple random sampling mechanism, of staff or financing). with an equal probability of selection from among the desired health worker type present at the facility. 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 SAMPLING FOR PATIENT EXIT INTERVIEWS purposes of sampling and analysis. The sample Patient exit interviews were only conducted frame for polindes/poskesdes was obtained from in the five DKI Jakarta districts (excluding sampled puskesmas as these facilities form part of a Kepulauan Seribu) and in three facilities types: ‘network’ under the puskesmas. (i) puskesmas; (ii) private primary care clinic; and (iii) private maternity clinic. Each facility has Generating the sample frame for private a specific target number of respondents: for puskesmas facilities (private MH and private primary- four respondents were targeted for interview (two care facilities, independently of each other) adult general outpatients, one ANC patient, and one was challenging, as up-to-date, accurate, and [parent of a] child patient). For private primary care complete information on private facilities clinics, two respondents were targeted (any adult was not consistently available at the district or [parent of a] child patient). For private maternity level. Although attempts were made to use methods clinics, two ANC patients were targeted. described in an earlier study (Heywood and Harahap 2009), these were insufficient to generate a reliable There were two types of patient exit district-wide sample frame of private facilities. interviewees: (i) a ‘linked’ patient seen by a sampled HCW (interviewed with the HCW For this reason, and for field work expediency, instrument as part of the overall survey); the sample frame of private facilities was and (ii) an ‘unlinked’ patient not seen by a generated from within the catchment of sampled HCW. All patient exit interviewees in sampled puskesmas, as puskesmas are private general clinic and maternity facility should responsible for the supervision of private be linked. In puskesmas, two selected patients facilities and, therefore, more reliable would be linked and two would be unlinked. Linked information on the existence of providers was patient interviewees were randomly selected from obtainable at this level. There were, however, the list of patients seen by the linked HCW; unlinked inadequate samples, including due to rejection, and patient interviewees were randomly selected from private facilities were, therefore, sampled from a the remaining list of patients not seen by the linked nearby unsampled puskesmas catchment area. HCW. The interviews were conducted after the clinical encounter, at the patient’s house or in the facility/place preferred by the patient. 104 SAMPLE SIZE CALCULATIONS AND SERVICE-READINESS INDICATORS ASSUMPTIONS WHO’s SARA framework consists of multiple The target number of facilities to be sampled within binary indicators (for example, the availability a sampled district was based on standard sample size of specific drugs or equipment). These binary calculations and assumptions used by WHO SARA (2013). 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, Analytical Methods Summary diagnostics, and medicines and commodities. These indicators were contextualized with national guidelines as described in Appendix 2. It should SUPPLY-SIDE AND DEMAND-SIDE WEIGHTS be noted that these indicators are generally As the survey design is a two-level cluster not comparable to the licensing and BPJS self- survey, weights are needed to correct for assessment list. the differential probability of a district and facility to be included in the sample from the To collapse these multiple binary indicators, overall sample frame. Depending on the choice a simple unweighted mean is used. This of perspective, different weights may be applied. methodology, suggested by WHO (2013), is also Supply-side weights provide an estimate of facility- used in earlier SARA-related reports on Indonesia level indicators from the perspective of the supply. (World Bank 2014), and more broadly in the If Indonesia has, for example, 100 health facilities in published literature for similar surveys such as the total, a supply-side weight would allow the estimate Demographic and Health Survey–Service Provision of the mean value for a specific indicator for facilities Assessments (Kruk et al. 2016). A mean of 100 percent in Indonesia. Some facilities may, however, be or 1 would imply that all the binary indicators are remote and serve a limited population and hardly met. This simple unweighted mean can apply to a be utilized and yet would be weighted in the same single facility and a simple mean of facility means way as a large and busy facility that serves a much can be used to compare groups of facilities (for larger population and is heavily utilized. example, private vs public, across time, and across geographical locations). A mean of 100 percent or To construct such weights, the number of 1 would imply that all facilities have met all the facilities in each district forms the basis of this binary indicators. 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, HCW ABILITY the perspective of the potential (that is, proxied by In addition to modules that included the target population in the catchment area) or actual health worker demographics, workload, user (that is, proxied by utilization of the relevant compensation, and training, the health worker health service) may be more important to provide survey instrument included seven different a picture of what would be the mean value for a clinical vignettes. These were: (i) preventive child specific facility-level indicator, as experienced or health (growth monitoring and immunization); (ii) potentially experienced from the demand side. This curative child health; (iii) ANC; (iv) obstetrics (PPH); would answer the question of what would be the (iv) HIV and AIDS; (v) malaria; (vi) TB; and (vii) an typical expected experience of a health facility by NCD (hypertension). Not all cases were presented to a user of the health facility. For the purposes of this all health workers. survey, information was collected to allow the use of either weight although, for the purposes of the Given the limitation of the survey whereby analysis, supply-side weights were generally used. 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 Is Indonesia ready to serve? 105 the form, for example, of growth charts and blood not include analysis of the vignettes and will be test results). To standardize the clinical context, the covered in a forthcoming report on human resources cases included an initial description of the facility for health. and referral context including, where relevant, the expected equipment, medicines, and referral times. To validate the responses provided by health SAMPLE SIZE & REPRESENTATIVENESS FOR THIS workers, a panel of Indonesian clinical REPORT specialists in the relevant field will be This report analyzed data to generate national- convened and the same case and responses level estimates. Hence, sample size calculation posed to them. Using a modified Delphi technique was 10 out of 413 districts and 12 out of 98 cities. to gain consensus, appropriate responses expected of Table A-4-3 shows the sample sizes for each type of a health worker in a local Indonesian setting were primary health care facility per district. elicited and used for the analysis. This report does Table 4A-3 Summary of Selected Facilities (by Type and District) for the National QSDS Estimates Number of Sample District Private Primary Health Care Puskesmas Posyandu Health Carea Workerb Simeulue District 9 5 15 23 Aceh Jaya District 9 9 16 27 Lhokseumawe City 6 17 15 29 Tapanuli Selatan District 14 12 16 40 Pesisir Selatan District 15 15 16 126 Padang City 17 22 17 109 Indragiri Hilir District 20 18 16 121 Sungai Penuh City 7 14 14 28 Cilacap District 25 22 17 72 Semarang District 19 21 17 59 Tegal City 8 19 16 35 Pasuruan City 8 18 16 34 Tangerang City 23 23 17 137 Cilegon City 8 18 16 34 Mataram City 9 21 16 39 Bima City 5 12 15 22 Banjar City 18 15 16 51 Banjarmasin City 19 21 16 116 Banjar Baru City 7 17 15 67 Tomohon City 7 12 13 26 Merauke District 13 14 16 40 Yalimo District 4 2 8 13 Total number of sample in 270 347 339 1,248 22 District/City Notes: a= private primary health care facilities include: private clinics, private general practitioners. b= health care worker includes: doctor, midwife, nurse. 106 Appendix 5 Factsheets for General Service Readiness A. BASIC AMENITIES Basic Amenities Improved Room auditory Access to computer Emergency readiness Number of District/Type of facility sanitation Communication Power (%) water source privacy only with internet transportation index (met facility (%) (%) (%) (%) access (%) (%) 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 Is Indonesia ready to serve? 107 General Service Readiness-Basic Amenities General Service Readiness-Basic Amenities by Type of Facility at Private GP/Clinic by BPJS Empanelment 40 50 40 30 Percentage Percentage 30 20 20 10 10 0 0 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 7 Number of component = 7 General Service Readiness-Basic Amenities General Service Readiness-Basic Amenities at Puskesmas by Urban/Rural at Private GP/Clinic by Urban/Rural 60 40 30 40 Percentage Percentage 20 20 10 0 0 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 7 Number of component = 7 108 B. BASIC EQUIPMENT Basic Amenities District/Type of Number of facility Adult Child Infant Thermometer Stethoscope Blood pressure Light readiness index facility Scale (%) scale (%) scale (%) (%) (%) apparatus (%) source (%) (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 Is Indonesia ready to serve? 109 General Service Readiness-Basic Equipment General Service Readiness-Basic Equipment by Type of Facility at Private GP/Clinic by BPJS Empanelment 80 60 60 40 Percentage Percentage 40 20 20 0 0 0 1 2 3 4 5 0 1 2 3 4 5 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Only compared 5 components measured in both facility type Number of component = 5 General Service Readiness-Basic Equipment General Service Readiness-Basic Equipment at Puskesmas by Urban/Rural at Private GP/Clinic by Urban/Rural 40 40 30 30 Percentage Percentage 20 20 10 10 0 0 0 1 2 3 4 5 6 7 0 1 2 3 4 5 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 7 Number of component = 5 110 C. ITEMS FOR STANDARD PRECAUTIONS Standard Precaution Soap and Distric/type of Safe Final Appropriate Appropriate Single use “Readiness Number of Safe Final running Latex facility Sterillizer disposal for storage of storage of Disenfectant of standard Index facilities disposal for water or al- gloves (%) infectious sharps waste infectious (%) disposable (meet All)” sharps (%) cohol based (%) waste (%) (%) waste (%) syringe (%) (%) handrub (%) 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 Is Indonesia ready to serve? 111 General Service Readiness-Standard Precaution General Service Readiness-Standard Precaution by Type of Facility at Private GP/Clinic by BPJS Empanelment 40 30 30 Percentage Percentage 20 20 10 10 0 0 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 9 Number of component = 9 General Service Readiness-Standard Precaution General Service Readiness-Standard Precaution at Puskesmas by Urban/Rural at Private GP/Clinic by Urban/Rural 50 30 40 20 Percentage Percentage 20 30 10 10 0 0 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 9 Number of component = 9 112 D. DIAGNOSTIC CAPACITY ITEMS Diagnostic Capacity Distric/type of “HIV Number of Blood “Malaria Urine Urine Syphilis Urine test for “Readiness facility Hemoglobin Diagnostic facilities Glucose Diagnostic disptick disptick Rapid test pregnancy Index (%) Capacity (%) Capacity” (%) capacity (%) glucose (%) (%) (%) (meet All)” (%) (RDT Kit)” (%) 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 Is Indonesia ready to serve? 113 General Service Readiness-Diagnostic Capacity General Service Readiness-Diagnostic Capacity by Type of Facility at Private GP/Clinic by BPJS Empanelment 50 40 40 30 Percentage Percentage 30 20 20 10 10 0 0 0 1 2 3 4 5 Number of Component 0 1 2 3 4 5 Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Comparing 5 components measured in both type of facility Note : vertical solid line=mean; vertical dash line=median General Service Readiness-Diagnostic Capacity General Service Readiness-Diagnostic Capacity at Puskesmas by Urban/Rural at Private GP/Clinic by Urban/Rural 30 40 30 20 Percentage Percentage 20 10 10 0 0 0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median 114 E. ESSENTIAL MEDICINES Essential Medicine Ampicillin powder for Magnesium sulphate Ceftriaxone injection Zinc sulphate tablets Diazepam injection Amoxicillin tablet Simvastatin tablet Amlodipine tablet Amoxicillin syrup Enalapril tablet or Metformin tablet “Readiness index alternative ACE Aspirin cap/tab Beta blocker (met all)” inhibitor injection injection District/type of Number of facility facility 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 Is Indonesia ready to serve? 115 General Service Readiness-Essential Medicines General Service Readiness-Essential Medicines by Type of Facility at Private GP/Clinic by BPJS Empanelment 40 50 40 30 Percentage Percentage 30 20 20 10 10 0 0 0 1 2 3 4 5 0 1 2 3 4 5 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Comparing 5 components measured in both type of facility Number of component = 5 General Service Readiness-Essential Medicines General Service Readiness-Essential Medicines at Puskesmas by Urban/Rural at Private GP/Clinic by Urban/Rural 40 25 20 30 Percentage Percentage 15 20 10 10 5 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 0 1 2 3 4 5 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 13 Number of component = 5 116 F. GENERAL SERVICE READINESS Standard Essential General service Basic Amenities Basic Equipment Basic Diagnostic Number of District/type of facility Precaution Medicine readiness facility met 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 Is Indonesia ready to serve? 117 General Service Readiness-All Domain General Service Readiness-All Domain by Type of Facility at Private GP/Clinic by BPJS Empanelment 15 15 10 Percentage Percentage 10 5 5 0 0 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Comparing 34 component measured in both type of facility Number of component = 34 General Service Readiness-All Domain General Service Readiness-All Domain at Puskesmas by Urban/Rural at Private GP/Clinic by Urban/Rural 20 15 15 10 Percentage Percentage 10 5 5 0 0 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 44 Number of component = 34 118 Appendix 6 Specific Services’ Readiness Index A. FAMILY PLANNING Family Staff & Training Equipment Medicines & Commodities Planning Supply Side Guideline book (%) “Readiness Index “Readiness Index “Readiness Index “Readiness Index contraceptive (%) BP apparatus (%) Combine pill (%) District/type of Number of (all met)” (%) (all met)” (%) (all met)” (%) (all met)” (%) Training (%) Condom (%) Implant (%) Implant (%) IUD Kit (%) Injectable facility facility IUD (%) 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 Family Planning Readiness at Puskesmas 40 30 Percentage 10 20 0 0 1 2 3 4 5 6 7 8 9 10 Number of Component National Urban Rural Note : vertical solid line=mean; vertical dash line=median Number of component = 10 Is Indonesia ready to serve? 119 B. ANTENATAL CARE “Antenatal Guidelines & Medicines & Equipment Diagnostic Care Trainings Commodities Supply Side” Urine dipstick-protein Training in the last 2 Hemoglobin Test (%) Doppler Ultrasound Weighing scale (%) Iron-Folic acid (%) Blood Pressure (%) “Diagnostic Index “Readiness index “Readiness index “Readiness index “Readiness index Stethoscope (%) Tetanus Toxoid (all items)” (%) Guideline (%) (met all)” (%) (met all)” (%) (met all)” (%) (met all)” (%) District/type of Number of Vaccine (%) years (%) facility Facilities (%) (%) 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 Antenatal Care Readiness at Puskesmas 50 40 Percentage 20 3010 0 4 5 6 7 8 9 10 Number of Component National Urban Rural Note : vertical solid line=mean; vertical dash line=median Number of component = 10 120 C. OBSTETRIC CARE Guidelines & Equipments Trainings Emergency transportation (%) Manual vacuum extractor (%) Blood pressure apparatus (%) Soap and running water OR Disposable latex gloves (%) Neonatal bag and mask (%) alcohol based hand rub (%) Infant weighting scale (%) Suction apparatus (mucus Vacuum aspirator or D&C Doppler ultrasound (%) Resuscitation table (%) Examination light (%) Guideline book (%) “Readiness Index “Readiness Index Delivery pack (%) Delivery bed (%) Partograph (%) Incubator (%) extractor) (%) (met all)” (%) Sterilizer (%) (met all)” (%) Training (%) District/type of Number of kit (%) facility facility 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 Basic Obstetric Care Readiness 20 15 Percentage 10 5 0 10 12 14 16 18 20 22 24 26 28 30 32 34 36 Number of Component National Urban Rural Note : vertical solid line=mean; vertical dash line=median Number of component = 36 Is Indonesia ready to serve? 121 OBSTETRIC CARE (CONTINUED) Basic Obstetric Care Medicines & Commodities Supply Side Dexamethasone (Injectables) Antibiotics Eye ointment (%) Oral antihypertensive drugs Ergometrine (Injectable) (%) Metronidazole infusion (%) Diazepam (Inejectable) (%) Injectables antibiotics (%) Adrenalin (Injectable) (%) Vitamin K (Injectable) (%) Oxytocin (injectable) (%) Number of facility Intravenous solution Magnesium sulphate Oral Ergometrine (%) Skin disinfectant (%) Oral antibiotics (%) Calcium gluconate (normal) saline (%) Oral analgesics (%) "Readiness Index "Readiness Index (Injectable) (%) Injectables (%) (met all)" (%) (met all)" (%) District/type of facility (%) (%) 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 Guidelines & “Immunization Equipment Medicines & Commodities Trainings Supply Side” medicine: BCG vaccine Adequate refrigerator Auto-disable syringes Hib+Hepb Vac ine (%) monitoring device in medicine: Oral Polio carrier with ice pack medicine: Measles Sharps container/ Staff Trainned (%) “Readiness Index “Readiness Index “Readiness Index “Readiness Index Cold box/vaccine temperature (%) Refrigerator (%) medicine: DPT- refrigerator (%) Guidelines (%) Termperature safety box (%) (met all)” (%) (met all)” (%) (met all)” (%) (met all)” (%) Vaccine (%) vaccine (%) District/type of Number of facility Facilities (%) (%) (%) 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 Is Indonesia ready to serve? 123 Immunization Service Readiness Immunization Service Readiness by Type of Facility at Private GP/Clinic by BPJS Empanelment 25 30 20 20 Percentage Percentage 10 15 10 5 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 12 Number of component = 12 Immunization Service Readiness Immunization Service Readiness at Puskesmas by Urban/Rural at Private GP/Clinic by Urban/Rural 40 30 30 20 Percentage Percentage 20 10 10 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 12 Number of component = 12 124 E. CHILD HEALTH “Child Health Guidelines & Equipment Diagnostic Medicines & Commodities Services Trainings Supply Side” Height measurement tape/Microtoise Amoxicillin(dispersible tablet 250 or Oral rehydration solution packet (%) Blood pressure strap for children (%) Malaria diagnostic capacity (%) Length measurement board (%) “Readiness Index (met all)” (%) “Readiness Index (met all)” (%) “Readiness Index (met all)” (%) “Readiness Index (met all)” (%) “Readiness Index (met all)” (%) MUAC measuring tape (%) Infant weighing scale (%) Co-trimoxazole syrup (%) ARI timer/stopwatch (%) Child weighing scale (%) Staff trained in IMCI (%) Test parasite in stool (%) Guidelines for IMCI (%) Vitamin A capsules (%) Paracetamol syrup (%) Number Growth charts (%) District/type of Thermometer (%) Hemoglobin (%) Stethoscope (%) of Zinc tablets (%) facility 500 mg (%) Facilities (%) 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 Is Indonesia ready to serve? 125 Child Health Service Readiness Child Health Service Readiness by Type of Facility at Private GP/Clinic by BPJS Empanelment 20 15 15 Percentage Percentage 10 10 5 5 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 21 Number of component = 21 Child Health Service Readiness Child Health Service Readiness at Puskesmas by Urban/Rural at Private GP/Clinic by Urban/Rural 20 20 15 15 Percentage Percentage 10 10 5 5 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 21 Number of component = 21 126 F. MALARIA Guidelines & Trainings Diagnostic Medicines & Commodities First-line antimalarial Rapid malaria testing Paracetamol cap/tab malaria microscopy Capacity to conduct Staff trained in IPT Malaria smear test “Readiness Index “Readiness Index “Readiness Index “Readiness Index ITNs or vouchers Staff trained Guidelines (met all)” (met all)” (met all)” (met all)” District/type of Number of in stock facility Facilities 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 Is Indonesia ready to serve? 127 Malaria Service Readiness Malaria Service Readiness at Private GP/Clinic by Type of Facility by BPJS-Empanelment 50 60 40 40 Percentage Percentage 20 30 20 10 0 0 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 7 Number of component = 7 Malaria Service Readiness at Puskesmas Malaria Service Readiness at Private GP/Clinic by Urban/Rural by Urban/Rural 40 50 40 30 Percentage Percentage 30 20 20 10 10 0 0 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 7 Number of component = 7 128 G. TUBERCULOSIS Guidelines & Trainings Diagnostic Items Medicine Items Training on diagnosis treatment of MDR-TB Provision of drugs to for TB Diagnosis and and treatment of TB National Guideline clinical symptoms management and “Readiness Index “Readiness Index “Readiness Index “Readiness Index and microscopy TB diagnosis by HIV diagnostic TB Microscopy Sputum smear examination medications First-line TB Training on TB patients Treatment (met all)” (met all)” (met all)” (met all)” capacity Number of District/type of facility Facilities 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 Is Indonesia ready to serve? 129 Tuberculosis Service Readiness Tuberculosis Service Readiness At Independent/Referral Puskesmas At Satellite Puskesmas 40 30 30 20 Percentage Percentage 20 10 10 0 0 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 Number of Component Number of Component National Urban Rural National Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 9 Number of component = 6 Tuberculosis Service Readiness Tuberculosis Service Readiness At Private GP/Clinic At Private GP/Clinic by BPJS-Empanelment 40 40 30 30 Percentage Percentage 20 20 10 10 0 0 0 1 2 3 4 5 6 0 1 2 3 4 5 6 Number of Component Number of Component National Urban Rural National Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 6 Number of component = 6 130 H. HCT “HIV Counseling Guidelines & Training Equipment Diagnostic Commodities & Testing Supply Side” National Training District/type of guidelines on HIV Visual Number of facility “Readiness “Readiness HIV “Readiness “Readiness Facilities on HIV counseling and Index Index diagnostic Index Comdoms Index “Readiness Index Counseling and testing auditory (met all)” (met all)” capacity (met all)” (%) (met all)” (met all)” (%) and Testing (VCT and/or privacy (%) (%) (%) (%) (%) (HCT),Others PICT),Othres (%) (%) (%) 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 Is Indonesia ready to serve? 131 HIV-HCT Service Readiness HIV-HCT Service Readiness at Private GP/Clinic by Type of Facility by BPJS-Empanelment 40 60 30 40 Percentage Percentage 20 20 10 0 0 0 1 2 3 4 5 0 1 2 3 4 5 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 5 Number of component = 5 HIV-HCT Service Readiness at Puskesmas HIV-HCT Service Readiness at Private GP/Clinic by Urban/Rural by Urban/Rural 50 40 40 30 Percentage Percentage 30 20 20 10 10 0 0 0 1 2 3 4 5 0 1 2 3 4 5 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 5 Number of component = 5 132 I. HIV – CST HIV Care Support and Guidelines & Trainings Diagnostic Medicines & Commodities Treatment Supply Side Guidelines for clinical management of HIV & First-line TB reatment Intravenous solution clinical management with infusion set (%) System for diagnosis IV treatment fungal Co-trimoxazole cap/ Palliative care pain of TB among HIV + of HIV & AIDS (%) “Readiness Index “Readiness Index “Readiness Index “Readiness Index management (%) District/type of Number of medications (%) Staff trained in infections (%) Comdoms (%) (met all)” (%) (met all)” (%) (met all)” (%) (met all)” (%) facility Facilities clients (%) AIDS (%) tab (%) 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 HIV-Care, Support & Treatment Readiness 40 30 Percentage 20 10 0 0 1 2 3 4 5 6 7 8 9 Number of Component National Urban Rural Note : vertical solid line=mean; vertical dash line=median Number of component = 9 Is Indonesia ready to serve? 133 J. HIV – ANTIRETROVIRAL THERAPY “HIV - ARV Prescrip- Guidelines & Medicines & Commodities tion Training Supply Side” Zidovudine syrup/suspension (ZDV, AZT) Lopinavir + Ritonavir Cap/tab (LPV/r) (%) Guidelines for antiretroviral therapy (%) Zidovudine + Lamivudine cap/tab(AZT + Zidovudine + Lamivudine + Nevirapine Nevirapine syrup/suspension (NVP) (%) Stavudine + Lamivudine + Nevirapine Renal function test(serum creatinine Staff trained in ART prescription and Liver function test (ALT or other) (%) Tenofovir Disoproxil Fumarate cap/ Zidovudine Cap/tab (ZDV, AZT) (%) Diagnostics Index (all items) (%) Emtricitabine cap/tab (FTC) (%) “Readiness Index (met all)” (%) “Readiness Index (met all)” (%) “Readiness Index (met all)” (%) Diagnostics Index (mean) (%) Lamivudine Cap/tab (3TC) (%) Nevirapine cap/tab (NVP) (%) Cap/tab (AZT + 3TC + NVP) (%) Cap/tab (D4T + 3TC + NVP) (%) Didanosine cap/tab (DDI) (%) Efavirenz Cap/tab (EFV) (%) Abacavir Cap/tab (ABC) (%) CD4 or Viral load (%) Full blood count (%) testing or other) (%) District/type of Number of management (%) facility Facilities tab(TDF) (%) 3TC) (%) (%) 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 HIV-Antiretroviral Readiness 40 30 Percentage 20 10 0 0 2 4 6 8 10 12 14 16 18 20 Number of Component National Urban Rural Note : vertical solid line=mean; vertical dash line=median Number of component = 20 134 K. HIV – PMTCT Medicines & “PMTCT Service Guidelines & Training Equipment Diagnostic Commodities Supply Side” Staff trained in PMTCT capacity for adults (%) Guidelines for PMTCT (AZT + 3TC + NVP) (%) Guidelines on infant Visual and auditory Nevirapine Cap/tab “Readiness Index “Readiness Index “Readiness Index “Readiness Index “Readiness Index feeding practices (IYCF/PMBA) (%) and young child HIV diagnostic Lamivudine + Zidovudine + (met all)” (%) (met all)” (%) (met all)” (%) (met all)” (%) (met all)” (%) privacy (%) District/type of Number of facility Facilities (%) (%) 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 Is Indonesia ready to serve? 135 HIV-PMTCT Service Readiness HIV-PMTCT Service Readiness at Private GP/Clinic by Type of Facility by BPJS-Empanelment 80 60 60 40 Percentage Percentage 40 20 20 0 0 0 1 2 3 4 5 6 0 1 2 3 4 5 6 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 6 Number of component = 6 HIV-PMTCT Service Readiness at Puskesmas HIV-PMTCT Service Readiness at Private GP/Clinic by Urban/Rural by Urban/Rural 60 30 40 20 Percentage Percentage 20 10 0 0 0 1 2 3 4 5 6 0 1 2 3 4 5 6 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 6 Number of component = 6 136 L. SEXUALLY TRANSMITTED INFECTIONS (STIS) “STI Service Guidelines & Training Diagnostic Medicines & Commodities Supply Side” diagnosis & treatment diagnosis & treatment Syphilis rapid test (%) Ceftriaxone injection Metronidazole cap/ Sfaff trained in STI Ciprofloxacin cap/ “Readiness Index “Readiness Index “Readiness Index “Readiness Index District/type of Number of Guidelines for Condoms (%) (met all)” (%) (met all)” (%) (met all)” (%) (met all)” (%) facility Facilities tab (%) tab (%) (%) (%) (%) 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 Is Indonesia ready to serve? 137 STI Service Readiness STI-PMTCT Service Readiness at Private GP/Clinic by Type of Facility by BPJS-Empanelment 40 40 30 30 Percentage Percentage 20 20 10 10 0 0 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 7 Number of component = 7 STI Service Readiness at Puskesmas STI Service Readiness at Private GP/Clinic by Urban/Rural by Urban/Rural 40 40 30 30 Percentage Percentage 20 20 10 10 0 0 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 7 Number of component = 7 138 M. NCDS – DIABETES “Diabetes Guidelines & Service Equipment Diagnostic Medicines & Commodities Training Supply Side” Metformin cap/tab (%) Height measurement Glibenclamide cap/ tape/Microtoise (%) Glipizide tablet (%) Glucose injectable “Readiness Index “Readiness Index “Readiness Index “Readiness Index “Readiness Index Blood glucose (%) Staff Trained (%) District/type of Number of Urine dipstick- Urine dipstick- Blood pressure Adult scale (%) apparatus (%) Guideline (%) (met all)” (%) (met all)” (%) (met all)” (%) (met all)” (%) (met all)” (%) solution (%) ketones (%) protein (%) tabalet (%) facility Facilities 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 Is Indonesia ready to serve? 139 Diabetes Service Readiness Diabetes Service Readiness at Private GP/Clinic by Type of Facility by BPJS-Empanelment 25 20 20 15 Percentage Percentage 15 10 10 5 5 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 12 Number of component = 12 Diabetes Service Readiness at Puskesmas Diabetes Service Readiness at Private GP/Clinic by Urban/Rural by Urban/Rural 30 25 20 20 Percentage Percentage 10 15 10 5 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 12 Number of component = 12 140 N. NCDS – CARDIOVASCULAR DISEASES (CVDS) “Cardiovascular Guidelines & Equipment Medicines & Commodities Service Training Supply Side” Hydrochlorothiazide Aspirin cap/tabs (%) Metformin cap/tabs “Readiness Index “Readiness Index “Readiness Index “Readiness Index ACE Inhibitor (%) Calcium Channel Staff Trained (%) Beta Blocker (%) Stethoscope (%) Blood Pressure Adult Scale (%) Apparatus (%) Guideline (%) District/type of Number of (met all)” (%) (met all)” (%) (met all)” (%) (met all)” (%) Blockers (%) Oxygen (%) facility Facilities (%) (%) 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 Is Indonesia ready to serve? 141 Cardiovascular Service Readiness by Type of Facility by BPJS-Empanelment 25 30 20 20 Percentage Percentage 10 15 10 5 0 0 0 1 2 3 4 5 6 7 8 9 10 11 0 1 2 3 4 5 6 7 8 9 10 11 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Compared 11 components measured in both facility type Number of component = 11 Cardiovascular Service Readiness at Puskesmas Cardiovascular Service Readiness at Private GP/Clinic by Urban/Rural by Urban/Rural 40 30 30 20 Percentage Percentage 20 10 10 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 12 Number of component = 11 142 O. NCDS – CHRONIC RESPIRATORY DISEASES (CRD) “Chronic Respiratory Guidelines & Training Equipment Medicines & Commodities Service Supply Side” Electrocardiogram (%) Oral corticosteroid (%) Spacer for inhaler (%) Antiasthmatic agent Peak flow meters (%) for acute attack (%) “Readiness Index “Readiness Index “Readiness Index “Readiness Index corticosteroid (%) District/type of Number of Staff Trained (%) Stethoscope (%) injectable (%) Guideline (%) Epinephrine (met all)” (%) (met all)” (%) (met all)” (%) (met all)” (%) Oxygen (%) facility Facilities Injectable 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 Is Indonesia ready to serve? 143 CRD Service Readiness CRD Service Readiness at Private GP/Clinic by Type of Facility by BPJS-Empanelment 20 20 15 15 Percentage Percentage 10 10 5 5 0 0 0 1 2 3 4 5 6 7 8 9 10 11 0 1 2 3 4 5 6 7 8 9 10 11 Number of Component Number of Component Puskesmas Private GP/Clinic Empaneled Not empaneled Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 11 Number of component = 11 CRD Service Readiness at Puskesmas CRD Service Readiness at Private GP/Clinic by Urban/Rural by Urban/Rural 25 20 20 15 Percentage Percentage 15 10 10 5 5 0 0 0 1 2 3 4 5 6 7 8 9 10 11 0 1 2 3 4 5 6 7 8 9 10 11 Number of Component Number of Component Urban Rural Urban Rural Note : vertical solid line=mean; vertical dash line=median Note : vertical solid line=mean; vertical dash line=median Number of component = 11 Number of component = 11 144 References Asia Pacific Observatory and WHO. 2015. “Health ———. 2014. “Indonesia Health Profile 2013.” System in Transition, Country Report: Indonesia.” Jakarta: MoH. http://www.depkes.go.id/resources/ Final draft, unpublished. 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