2. MARCO TEÓRICO CONCEPTUAL
2.1 BASES TEÓRICAS
2.1.1 LA POSESIÓN Y SUS DERIVACIONES
2.1.1.6 EFECTOS JURÍDICOS DE LA POSESIÓN
McGarry, K. 2004. “Health and Retirement: Do Changes in Health Affect Retirement Expectations?” Journal of Human Resources 39 (3): 624–48. Parliamentary Commission X. 2008. Unpublished report by Medical Education
Working Group, Jakarta.
Roberts, M. J., W. Hsiao, P. Berman, and M. R. Reich. 2004. Getting Health Reform
Right: A Guide to Improving Performance and Equity. New York: Oxford
University Press.
Statistics Indonesia, BKKBN, Indonesia Ministry of Health, and Macro International. 2008. “Indonesia Demographic and Health Survey 2007: Preliminary Report.” Jakarta: Statistics Indonesia, and Calverton, MD: Macro International.
Thabrany, H. 2006. “Human Resources in Decentralized Health Systems in Indonesia, Challenges for Equity.” Regional Health Forum 10 (1): 75–88. USAID (DRSP). 2006. “Decentralization 2006: Stock Taking on Indonesia’s
Recent Decentralization Reforms. Summary of Findings.” Donor Working Group on Decentralization, Jakarta.
World Health Organization, United Nations Children’s Fund, United Nations Population Fund, and World Bank. 2007. Maternal Mortality in 2005. Geneva: World Health Organization.
World Bank. 2004. “Decentralization in Indonesia’s Health Sector: The Central Government’s Role.” Working paper 7, World Bank, Jakarta.
———. 2006. Making Services Work for the Poor: Nine Case Studies from Indonesia. Jakarta: World Bank.
133 A
adult curative care, 5, 6–7 education and quality of health
workforce training, 84, 85t, 128t IFLS vignettes on quality of service, 75t,
76, 78–79t, 80, 81–82t, 106f quality convergence by region, 107–9,
108f
alert village (Desa Siaga) program, 46, 55n6
Alma Ata “Health for All” paradigm, 41, 54n1
anemia, 73–74b, 80
Askeskin/Jamkesma (health insurance for the poor), 2, 8, 11, 21, 58, 59, 62–63, 67n2 auxiliary health centers. See pustu B
background and context, 1–2, 22, 25–39 decentralization, 32–33
deployment policies, 33–34 dual practice and provider payment
methods, 35
health education system, quality of, 36 private sector growth, 36
provider payment methods, 35 public expenditures, 35–36 underlying transitions, 11, 36–37 Bali. See Java and Bali
Bappenas (Indonesian National Development Agency), 1, 16 Barber, S. L., 76
Bidan Di Desa (BDD; village midwife) program, 4, 50, 54, 102 budgeting. See public expenditures
C
child curative care, 5–6
education and quality of health workforce training, 84, 85t, 125t, 127t
IFLS quality of service vignettes, 75t, 76, 78, 78–79t, 80, 82t, 83, 106f quality convergence by region, 107–9,
108f
child malnutrition, 26, 29f
child mortality, 26, 31f. See also infant mortality rate
choice of providers, 60–65, 61t, 64t, 113–21
chronic disease, increase in, 1, 15, 37, 38n7
Index
civil service
midwives, employment of, 46 physicians, employment of, 48 reform, 4, 10, 33
contract employee program. See PTT program
D Das, J., 19
data and methodology, 17–19, 99–100 decentralization, 3, 4, 15, 21, 32–33 definitions of health facilities and
providers, 101–4 Demographic and Health Survey
(2008), 72
demographics of Indonesia, 25, 26 poverty reduction, 67n1 underlying transitions, 11, 36–37 deployment policies, 3–4, 33–34
policy recommendations for, 8–9 Desa Siaga (alert village) program, 46,
55n6
diagnostic and treatment ability, 77–83 measuring from Indonesia Family Life
Survey vignettes, 5, 18–19, 23n6, 76–77, 78t, 83t, 84, 85t, 87nn4–5, 105–10, 106f quality of, 5, 77–83, 78t disease prevalence, 1, 15, 37 Donabedian’s definition of quality, 18, 23n5 dual practice, 4, 6, 8
effect of legalization of, 35, 41, 42 policy recommendations for, 10 puskesmas physicians, 42, 49, 49t quality of health services and, 79–80 quality of services and, 86–87
E
education and quality of health workforce training, 7, 21, 36, 84–85, 123–28 accreditation and certification standards,
7, 12, 36, 71
adult curative care, 84, 85t, 128t applications to medical schools, 3 child curative care, 84, 85t, 125t, 127t diagnostic ability improvements and, 79 internships, shortage of, 7, 84
law enacting standards for, 2 maternal health, 5
midwives, 54
prenatal care, 84, 85t, 124–28, 124t, 126t
education level associated with utilization of health services, 60
F
family practice physicians, 5
financial protection for the poor, 2, 21–22. See also Askeskin/Jamkesma (health insurance for the poor)
focus of study, 20–22
formasi (civil service posts), 35, 37n3 G
Gadjah Mada University, 9 Center of Health Service
Management, 16
gender differences in utilization. See utilization of health services general practitioners. See also physicians
distribution of, xi
emergency obstetric training for, 5 Gertler, P. J., 76
global comparisons of physician, health worker, and hospital bed supply to income, 26, 27f Global Fund, 72 Gorontalo province, 26 H Hammer, J., 19 Harimurti, P., 76
health education system. See education and quality of health workforce training “Health for All” (Alma Ata Conference),
41, 54n1
health insurance. See Askeskin/Jamkesma (health insurance for the poor) health outcomes, 2, 25–31
equitable access to health services and, 22, 22f, 30
global comparisons, 26, 27–29f, 30t quality of health services and, 73–74b Health Professional Education Quality
project, 12–13n3, 88n6 health spending. See public expenditures “Healthy Indonesia 2010,” 3
hemoglobin levels, 73–74b hospitals
distribution of, 50, 52f
global comparisons of hospital bed supply to income, 26, 27f management of district hospitals, 55n11 utilization patterns, 61t, 64t
I
IFLS. See Indonesia Family Life Survey illegal sales of prescription drugs, 58 IMMPACT. See Initiative for Maternal
Mortality Programme Assessment immunizations. See vaccines and
immunizations importance of Indonesian health
workforce, 2–3 incentives, 9, 20, 44, 49, 129–30 Indonesia Family Life Survey (IFLS), xi,
5, 17, 18, 23nn3–4, 99 data shortcomings, 19, 63 diagnostic vignettes, 5, 18–19, 23n6, 76–77, 78–83t, 84, 85t, 87nn4–5, 105–10, 106f dual practice, 495 puskesmas staffing, 47
quality of care providers and, 30 quality of training and, 84 utilization rates, 57–58, 58t
Indonesian Medical Association (IDI), 5 Indonesian Medical Council (KKI), 2,
54–55n3
Indonesia’s Health Work Force (World Bank 1994), 16
Indonesia’s Physicians, Midwives, and Nurses (World Bank 2009), 16 infant mortality rate, 26, 28f, 31f, 37 Initiative for Maternal Mortality
Programme Assessment (IMMPACT), 17, 23n2, 54 inpatient vs. outpatient utilization, 30,
59, 59t, 61t
in-service training, 84–85. See also education and quality of health workforce training
iron deficiency anemia, 73–74b, 80
J
Jamkesma (Community Health Insurance Scheme). See Askeskin/Jamkesma (health insurance for the poor) Java and Bali
choice of provider, 61t
coverage of region, 55n5
inpatient vs. outpatient utilization, 59t midwife distribution, 45, 45t physician distribution, 43, 43t, 47 private physician utilization, 63 puskesmas and hospital distribution, 52f puskesmas staffing, 47, 48t
quality convergence, 107–9, 108f utilization rates, 58, 58t Jiminez, Emmanuel Y., xii
K
KKI. See Indonesian Medical Council Kruse, I., 63
L
Law No. 32/2004, to correct problems in decentralization law (Law No. 22/1999), 32
Law No. 40/2004, Universal Health Insurance Coverage, 15 Leonard, K., 19
licensing practices, 9–10, 12, 71 life expectancy, 26, 28f local government autonomy. See
decentralization
M
management of personnel. See recruitment and management of health workforce
mandatory service period, 33. See also PTT (contract employee) program shortening of, 16–17, 34, 49 maternal health, 5, 74 maternal mortality, 26, 29f, 37 measles immunizations, 7, 72, 74 Medical Practice Act (2004), 2 midwives
adult curative care, 80, 81–82t, 83 change in supply (1996–2006), 3
private practice, 51, 53–54, 53t rural vs. urban, 45–46, 45t child curative care, 80, 82t, 83 civil service employment of, 46 definition of, 103, 104 distribution of, xi, 4, 45–46 in dual practice. See dual practice prenatal care, 79t, 80, 81t, 83 as provider of choice, 60, 61t, 64t
PTT program. See PTT (contract employee) program puskesmas and pustu employment
of, 47t, 49–50
quality of services, 75t, 86t, 87, 88n9 in remote and underserved areas, 11, 17 training of, 5, 6
utilization rates of private midwives, 60, 61t, 64t, 65
effect of increasing number of private midwives, 67
vaccines availability, 7
village midwife program (Bidan di Desa, BDD), 4, 46, 50
Millennium Development Goal on infant mortality, 26 Ministry of Health (MoH)
December 2005 platform, 17 Health Profiles administrative
database, 18 hospitals operated by, 50 Indonesia Health Profiles, 46 planning for health workforce
needs, 34–35, 41 post-decentralization role of, 32
N
National Development Plan 2010–14, 1, 16
nurses
adult curative care, 80, 81–82t
change in supply (1996–2006), 3, 46–47 child curative care, 80, 82t
definition of, 103
lack of data on distribution and number of, 4, 42, 46 prenatal services, 6, 80, 81t as provider of choice, 60, 61t, 64t puskesmas and pustu employment
of, 47t, 49
quality of services, 75t, 76
in remote and underserved areas, 11 utilization rates of private nurses, 60,
61t, 64t, 65
O
objectives of study, 16–19 Other Provinces
coverage of regions, 55n5
inpatient vs. outpatient utilization, 59t midwife distribution, 45, 45t, 48t, 53, 53t
physician distribution, 43–44, 43t, 47, 48t, 53t
private physician utilization, 63 puskesmas and hospital distribution, 52f puskesmas staffing, 47–48, 48t quality convergence, 107–9, 108f utilization rates, 58, 58t outcomes. See health outcomes outpatient services. See inpatient vs.
outpatient utilization over-the-counter (OTC) drugs,
use of, 58, 58t
P
payment systems, 20, 35. See also incentives
physicians
change in supply (1996–2006), 3 accurate data on, 54–55n3 private practice, 51, 53t
rural vs. urban distribution, 42–44, 43t child curative care, 79t, 80, 82t, 83 definition of, 103
in dual practice. See dual practice global comparisons of physician supply
to income, 26, 27f prenatal care, 79t, 80, 81t private, 51 as provider of choice, 60–63, 61t, 64t quality of services, 75t, 76 PTT program. See PTT (contract
employee) program
pilot programs, recommendation of, 11 planning for health workforce needs, 9–10,
11, 34–35
PODES. See Survey of Village Potential policy recommendations, 8–12, 23
on quality of health services, 11–12 on supply and distribution, 8–11 the poor
Askeskin/Jamkesma (health insurance), 2, 8, 11, 21, 58, 59, 62–63, 67n2 poverty reduction since 1997–98, 67n1 utilization practices of, 4, 8, 60, 62 posyandu outreach program, 55n9 PP No. 38/2008 (government regulation
to divide responsibility between administrative levels), 32–33 Pradhan, M., 63
education and quality of health workforce training, 84, 85t, 124–28, 124t, 126t
IFLS quality of service vignettes, 75t, 76, 78–79t, 80, 81t, 106f preservice training, 84–85. See also
education and quality of health workforce training
private health services adult curative care, 6–7
changes in supply of, 2, 5, 9, 26, 36, 51–54, 53t, 65–67
child curative care, 6, 79t, 80, 82t, 83 dual practice, effect on, 42. See also
dual practice effect of, 111–21 lack of oversight, 5, 11, 36 midwives, 51, 53–54, 53t physicians, 51, 53t
policy recommendations for, 10 quality of, 6, 74–75, 75t
diagnostic and treatment ability, 77–83, 78–83t
growth in number of private sector providers, 85–87, 86t
rural vs. urban, 4
types of, 41, 60–65, 61t, 64t utilization patterns, 8, 60–65,
61t, 64t, 111–21
effect of increasing number of private physicians, 65–67, 66t
vaccines availability, 7
provider payment methods, 35, 37n6. See also incentives
provinces. See Other Provinces; specific provinces by name
PTT (contract employee) program, 17, 23n1, 33–34, 35, 37nn4–5 midwives, 46
physicians, 44, 44t, 48–49, 51 public expenditures, 9, 10, 35–36 public health centers. See puskesmas puskesmas (public health centers)
adult curative care, 6–7, 80, 81–82t, 83 child curative care, 6, 79t, 80, 82t, 83 definition of, 102
distribution trends of, 17–18, 34, 50–51, 52f
dual practice, effect on, 10, 42. See also dual practice
increase in number of, 3, 25, 50 mandatory service in, 33
prenatal care, 79t, 80, 81t, 83 as provider of choice, 60, 61t, 64t quality improvements, 72, 75, 75t
diagnostic and treatment practice, 78, 78–79t, 80
as referral point, 50 staffing at, 41
change in (1997–2007), 4, 47–50, 47t, 48t
tuberculosis treatment services, 7 utilization patterns, 4, 61t,
62–63, 64t, 65
effect of increasing number of private physicians, 66–67
pustu (auxiliary health centers) definition of, 102
distribution trends of, 17–18 increase in number of, 3, 25, 50 prenatal care, 79t, 80, 81t as provider of choice, 64t quality improvements, 72, 75, 75t staffing at, change in (1997–2007),
47–50, 47t
tuberculosis treatment services, 7 utilization patterns, 61t, 64t
Q
quality of health facilities and health practitioners, 5–7, 23, 71–89 challenges for, 2, 71
convergence in quality, 105–10 diagnostic and treatment ability,
77–83, 78t
measuring with Indonesia Family Life Survey vignettes, 18–19, 23n6, 76–77, 78t, 83t, 84, 85t, 87nn4–5, 105–10, 106f
dual practice and, 86–87
education and training. See education and quality of health workforce training
future policy research needs, 72, 73–74b
law enacting standards for physician competencies and medical education, 2
policy recommendations for, 11–12 private sector growth and, 85–87, 86t.
See also private health services puskesmas and pustu improvements, 72,
75, 75t
R
rationale of study, 16–19 recommendations. See policy
recommendations
recruitment and management of health workforce, 4, 15, 21
remote and underserved areas, 4. See also deployment policies
family practice physicians providing emergency obstetric care in, 5 mandatory service in. See mandatory
service period
nurses and midwives as health providers in, 11, 17
policy recommendations for, 10–11 rural vs. urban distribution, xi, 4
creation of “rural pipeline” of providers, 9
dual practice favoring urban settings, 42
expansion of rural primary care as focus of health care delivery, 41 midwives, 45–46, 45t, 51, 53–54, 53t physicians, 42–44, 43t, 51, 53t quality convergence, 109, 110f utilization patterns, effect of increasing
number of private physicians, 66–67, 66t
S
Sardjunani, Nina, xii self-medication rates, 58, 58t socioeconomic status
quality convergence and, 109–10 utilization of health services and, 8,
59t, 60, 61t, 62, 112, 113–21t sorting of patients, 10, 66 Sparrow, R., 63, 68n8 structure of study, 22–23 Sumatra choice of provider, 61t coverage of region, 55n5 hospital distribution, 52f
inpatient vs. outpatient utilization, 59t midwife distribution, 45, 45t, 53, 53t physician distribution, 43–44,
43t, 47, 51, 53t
private physician utilization, 63 puskesmas distribution, 47, 48t, 52f quality convergence, 107–9, 108f utilization rates, 58, 58t
supply of health facilities and health practitioners, 3–5, 22, 41–56 challenges for, 2 change in (1996–2006), 42–47 midwives, 45–46 nurses, 46–47 physicians, 42–44, 43t deployment policies, 33–34 global comparisons of supply to
income, 26, 27f planning for needs, 34–35 policy recommendations for, 8–11 private health services. See private
health services
public health facilities, change in (1996–2007), 51
puskesmas and pustu, change in staffing (1997–2007), 47–50, 47t Survey of Village Potential (PODES), 17,
18, 19, 55n3, 99 midwives, 45 nurses, 46 physicians, 42
Susenas (national household survey) 2000 data, 63, 67n2, 68n8, 99–100 Suyahadi, A., 63, 68n8
T
tetanus immunizations, 7, 72, 74 traditional healers, 61t, 65
training. See education and quality of health workforce training tuberculosis treatment services, 7, 74, 75
U
underserved areas. See remote and underserved areas
Universal Health Insurance Coverage (Law No. 40/2004), 15
urban areas. See rural vs. urban distribution utilization of health services, 7–8,
23, 57–69
education level associated with, 60 inpatient vs. outpatient, 30, 59, 59t private health services, 4, 8, 60–65,
61t, 64t, 111–21, 114t changes in supply, 65–67
provider choice, 60–65, 61t, 64t, 113–21 patterns and changes (1997–2007),
57–60
socioeconomic status associated with, 8, 59t, 60, 61t, 62, 112, 113–21t women vs. men, 8, 66t, 113, 114–15t,
117–18t, 120–21t
V
vaccines and immunizations, 7, 72, 74 village midwife program. See Bidan Di
Desa (BDD) program W
wages of health workforce, 35–36. See also incentives
West Java IMMPACT, 54 West Nusa Tenggara province, 26 Widjanti, W., 63, 68n8
women
anemia and, 73–74b, 80
utilization of health services and, 8, 66t, 113, 114–15t, 117–18t, 120–21t World Health Organization,
72, 74b
Z
zero-growth policy, 37n4