The Contribution of the Private and Non – Governmental Sectors to the National Health Goals of Indonesia : Current Evidences and Alternatives of Policy/Strategy

The continued monetary crisis in Indonesia has affected public funding for health care and there is a need for new strategies and approaches to meet the health care needs of the Indonesian people. Government resources have not been sufficient to maintain the existing health systems, to meet increased demand due to population growth and rising public expectations, to increase access to services for those not covered by the current systems nor to improve the quality and level of care provided. Evidence has shown that much of the health care of many countries is being provided by the private sector, even among poor and rural populations. As efficiency concerns come to the fore, there is the greater willingness to see how the private sector can play a role in the provision of health care that was formerly provided by the government. For that reason, the GOI Ministry of Health (MoH) officially views the private sector as a partner in the provision of health services, and private health care providers are a significant part of the health care delivery system in Indonesia. In terms of health care provision, GOI actively encourages the private sector to become more involved in the direct provision of services. To achieve that goal, policymakers should know about what private providers could contribute to public health goals. The decision to collaborate with the private sector depends on whether working with the private sector offers a more cost effective way to achieve health objectives than other intervention involving public providers. It is usually believed that private providers are expensive and motivated by profit rather than the welfare of their consumers, are usually concentrated in urban areas, and provide only curative services and ignore prevention in primary health care.

The rapid escalation of cost of health caused by the economic crisis is likely to continue and virtually no one will be able to afford the full cost of health care. Thus it makes sense for the government to become proactive in managing resources and containing costs. The process of decentralization has been underway in Indonesia for a number of years but began in earnest in January 2001. The implication in decentralization was that functions, process and resources were devolved from the MoH to local authorities. Regional autonomy will allow district and provincial governments to raise local revenue to fund their recurrent and development costs. A good degree of regulatory control including licensing, accreditation and implementation of the health care system will now devolve to local governments. The central government ceased its role and instead began to concentrate on policy formulation, setting technical standards, monitoring, evaluation, and offering management advice and training. The increase in local regulatory authority and the efforts to raise local public revenues in the decentralization era have direct ramifications for the health sector in general and the private health sector in particular (Marzolf, 2002). This dual government role of regulator and competitor may discourage private health sector investment and development. Decentralization seems to hold both a threat and a promise for the private sector providers.

Private sector providers in Indonesia have been under researched and therefore there are no available studies to compare the quality of care in the public and private sectors. However, Swan and Zwi (1997) cit Smith (2001) stated that the available evidence revealed serious technical weaknesses in the services supplied by many for profit providers in developing countries. Lack of information and an ability to make sound judgments about the technical quality of available types of health care as well as information asymmetry are the major constraints when people purchase care. Poor prescribing, dispensing and self-medication practices waste scarce resources, harm individuals and contribute to the spread of infectious diseases.

The continued monetary crisis in Indonesia has affected public funding for health care and there is a need for new strategies and approaches to meet the health care needs of the Indonesian people. Government resources have not been sufficient to maintain the existing health systems, to meet increased demand due to population growth and rising public expectations, to increase access to services for those not covered by the current systems nor to improve the quality and level of care provided. Evidence has shown that much of the health care of many countries is being provided by the private sector, even among poor and rural populations. As efficiency concerns come to the fore, there is the greater willingness to see how the private sector can play a role in the provision of health care that was formerly provided by the government. For that reason, the GOI Ministry of Health (MoH) officially views the private sector as a partner in the provision of health services, and private health care providers are a significant part of the health care delivery system in Indonesia. In terms of health care provision, GOI actively encourages the private sector to become more involved in the direct provision of services. To achieve that goal, policymakers should know about what private providers could contribute to public health goals. The decision to collaborate with the private sector depends on whether working with the private sector offers a more cost effective way to achieve health objectives than other intervention involving public providers. It is usually believed that private providers are expensive and motivated by profit rather than the welfare of their consumers, are usually concentrated in urban areas, and provide only curative services and ignore prevention in primary health care.

The rapid escalation of cost of health caused by the economic crisis is likely to continue and virtually no one will be able to afford the full cost of health care. Thus it makes sense for the government to become proactive in managing resources and containing costs. The process of decentralization has been underway in Indonesia for a number of years but began in earnest in January 2001. The implication in decentralization was that functions, process and resources were devolved from the MoH to local authorities. Regional autonomy will allow district and provincial governments to raise local revenue to fund their recurrent and development costs. A good degree of regulatory control including licensing, accreditation and implementation of the health care system will now devolve to local governments. The central government ceased its role and instead began to concentrate on policy formulation, setting technical standards, monitoring, evaluation, and offering management advice and training. The increase in local regulatory authority and the efforts to raise local public revenues in the decentralization era have direct ramifications for the health sector in general and the private health sector in particular (Marzolf, 2002). This dual government role of regulator and competitor may discourage private health sector investment and development. Decentralization seems to hold both a threat and a promise for the private sector providers.

Private sector providers in Indonesia have been under researched and therefore there are no available studies to compare the quality of care in the public and private sectors. However, Swan and Zwi (1997) cit Smith (2001) stated that the available evidence revealed serious technical weaknesses in the services supplied by many for profit providers in developing countries. Lack of information and an ability to make sound judgments about the technical quality of available types of health care as well as information asymmetry are the major constraints when people purchase care. Poor prescribing, dispensing and self-medication practices waste scarce resources, harm individuals and contribute to the spread of infectious diseases.

The Role of The Private Sector in the Provision of Obstetric Services in the Autonomy Era in Yogyakarta Province

Private sector health services form a very important part of the entire health system. As the private sector has provided the community with ease of access to health services, efforts to maintain quality in the private sector and attention to its potential for development are very important. Synergy between the public and private sectors should be directed towards efforts to provide quality health services and to guarantee equity for all.

This research aims to describe the role of the private sector in the provision of obstetric services, policy related to the role of the private sector in health services, as well as making policy recommendations to support the growth of the private sector. A sample of 75 health facilities was made. This consisted of 10 private hospitals, 9 maternity clinics/birthing centres, 19 specialist obstetricians in private practice, and 37 privately practicing midwives. The patient sample included 137 people, consisting of 41 patients of private hospitals, 32 patients of maternity clinics/birthing centres, 30 patients of specialist doctors and 34 patients of privately practicing midwives.

There is a great variation in the private midwifery/obstetric services in Yogyakarta province. The particularity of each form of service represents a great capacity for the community to choose the type service they feel most comfortable with.

A. The Role of Private Hospitals in Obstetric Services

There is quite a large variation in the capacity of hospitals. Almost all hospitals are semi profit-oriented. Most have accreditation status and are general hospitals with maternity beds. In terms of facilities, equipment, quality of staff and capacity of infrastructure, hospitals are capable of providing emergency obstetric services. Compared to other health facilities, hospitals are also superior in terms of medical technology, facilities and quality of staff. Nevertheless, in most hospitals the need for specialist medical staff and midwives is not fulfilled and this also varies widely.

All hospitals cater for patients from all social backgrounds. Beds allocated for those of the lowest socio-economic group, made compulsory by the government, are provided with a wide variation of percentages. In general, patient fees depend on class, type of service, medicine, as well as the diagnostic tools or medical action taken. Almost all health facilities apply various pricing levels (classes) and different fee patterns. In determining tarifs for service most hospitals apply cross subsidies for the lowest strata. Compared to the fees at Regional General Hospitals, the fees at private hospitals for birthing services and caesarian surgery are several times more expensive. Private hospitals have efficiently taken up opportunities through cooperation with various third parties funders such as Health Insurance, Workers Health Insurance and Work Cover.

Given their resources, especially facilities/equipment and capacity, it is appropriate for hospitals to handle referred obstetric cases. Yet we have only a limited picture of the role hospitals play in the referral system because of a lack of appropriate recording in most hospitals. Approximately half of the hospitals accept maternity inpatient referrals in varying percentages, being referred from specialist doctors and midwives. The high figures for caesarian surgery prominent in several medium type hospitals are not supported by the pathological child-birth data, and this is an indicator of supplier induced demand or hospital over-service toward their patients.

There is a trend for the maintenance of service quality to be done by the individual health facility through the existence of a medical committee. Nevertheless there are at least three factors that hinder the medical committee’s efforts to guard the quality of service in private hospitals. Those are, difficulty in gathering doctors together for committee meetings, a low level of understanding about their role in efforts to guard quality, and a low level of concern about some mechanisms to guard quality. All large hospitals claim to undertake regular efforts to safeguard service quality regardless of the way they choose to do this. Only two-thirds of medium hospitals claim to do this regularly, another third occasionally and a remaining few not at all. This means that these facilities rich in capital and technology may not put enough emphasis on technical quality.

Private-public coordination is still very limited. A strong link has only just commenced surrounding licencing and reporting. It is understandable that private hospitals don't consider recording as a priority issue except when it is connected with information for the market and marketing. They are also not particularly interested in health promotion for patients. Yet these hospitals are quite interested in education for health workers.

B. The Role of Private Maternity Clinics/Birthing Centres in Obstetric Services.

It seems that accreditation for maternity clinics/birthing centres is not common. Only one birthing centre was accredited, and this was spurred more by the initiative of the clinic owner. The variation in the number of beds and rates of occupancy is not too wide, and the average occupancy rate is lower than the hospitals. Maternity clinics/birthing centres tend to focus more on midwifery services especially services for normal births and basic family planning. Nevertheless there are also some that have opened special services in accordance with market demand. Most clinics are semi profit-oriented.

The capacity to handle obstetric emergencies varied and was limited to handling level-one midwifery emergencies. Only five maternity clinics/birthing centres accepted referrals and the number of referrals differed. In terms of staffing, only some of the small clinics had a full time specialist obstetrician, and none of the clinics had a full time pediatrician. Most of the midwives that worked in the maternity clinics/ birthing centres were full time midwives, with quite a wide difference in composition between each health facility. As in the case of the private hospitals there was a great variation in the facilities and equipment.

None of the maternity clinics/birthing centres discriminated based on the background of the patient. Although social aspects were not forgotten, it was acknowledged that private clinics certainly consider commercial aspects or profit orientation when providing services. Although they do provide services to the lowest socio-economic strata, it is difficult to determine with certainty the number of beds actually allocated, and the proportion varies widely between facilities.

Each maternity clinic/birthing centre has its own policy for patients who are unable to pay, from debt systems to being free from costs based on government regulations. Clinic managers see a need for the government and private health facilities to work together in providing services for the poor. Almost all maternity clinics/birthing centres apply the same outpatient fee system, while in terms of fees for other services some apply cross subsidies for the lowest strata patients. Meanwhile, the cost of services and also the total for childbirth varies widely and is several times higher compared with the community health centres (Puskesmas). The method of accepted payment is usually cash, and none of them accept payment through a health fund or health card.

All the directors of the maternity clinics/birthing centres considered it necessary to develop information systems, especially for mother and child health services in order to expand the network into the community and foster a beneficial communication between sectors and the government. The recording system in private clinics was also insufficient, and as was also the case with other private health facilities, this made quality observation or surveillance of community health difficult.

C. The Role of Privately Practicing Specialist Doctors in Obstetric Services.

One prominent characteristic of privately practicing specialist obstetricians is that a large proportion of them work at more than one health facility. For example they may be affiliated with a maternity clinic/birthing centre, a private hospital and also a group practice. It seems that the role of the professional organization (POGI) is limited only to providing recommendation as a base for the registration of a practice. The official role in giving permission is more administrative, that is issuing the licence, which must be renewed every five years. From the services provided, it seems that privately practicing specialist doctors are not particularly interested in immunisation services. Yet all doctors provide antenatal and family planning services that are more based on the demand of the patients. A small proportion of the family planning and immunisation services provided by privately practicing doctors receive subsidies for equipment and vaccines from the government. A two-sided debate always arises surrounding the issue of patient fees. That is from the side of consumer rights, where the patients have a right to know prior to treatment how much they will be charged, and from the side of the medical profession where it is not always appropriate to apply a certain fee. At this time it is almost not possible that a privately practicing doctor will give written information about the service fee. Most doctors apply the same fee, and some apply varying fees depending on the situation of the patient, where the fees for different services can vary greatly.

D. The Role of Privately Practicing Midwives in Obstetric Services

Most midwives work for more than one private and/or public health facility, and may be affiliated with private hospitals, public hospitals and maternity clinic/birthing centres. The role of the Indonesian Midwives Association (IBI) in professional guidance is to provide recommendations based on 5-yearly tests in terms of issuing licences to practice. All midwives provide antenatal and family planning services, and most midwives provide immunisation services. A small amount of the family planning and immunisation services provided by privately practicing midwives receive subsidies of equipment and vaccines from the government. Their service fees do not vary greatly and are quite reasonable (not much different to public health facilities).

E. Private Childbirth Services from the Viewpoint of the Consumers.

Private health facilities contribute to various socio-economic levels of society. Based on their education and employment, the social strata of patients of specialist obstetricians and hospitals is relatively higher than that of the patients of maternity clinics/birthing centres.

The motivation of patients to come to the various private health facilities is because of close proximity to their homes, and faith in the quality of service. The reason they prefer to choose private health facilities is particularly because of their belief in and perception of quality and because they are close to home.

In general, more than 90% of patients felt satisfied with the treatment they had received. This level of satisfaction is high compared to the level of patient satisfaction at public health facilities, according to several studies. There was also a high level of satisfaction in terms of the various aspects such as cleanliness and neatness of the waiting room, cleanliness and neatness of the examination rooms, waiting time, medical equipment, friendliness of the service providers and competence of the service providers. Patients’ high level of trust in private health facilities was also shown by their high level of interest in returning for treatment, their desire to recommend the service to friends and relatives and the possibility of returning to be treated at the same health facility.

In terms of service fees, some patients of hospitals, doctors and maternity clinics/birthing centres considered that the fees they had to pay were expensive. Nevertheless, almost all patients stated that they were able to pay for the services. Almost all health costs the patients had to pay private health facilities were cash (out of pocket).

F. The Distribution of Private Health Facilities Providing

Maternity Services.

The distribution of health services was viewed based on the population ratio of the 5 Districts per total number of beds or public and private health facilities. It was revealed that the distribution of beds in hospitals, maternity clinics/birthing centres and privately practicing specialist doctors was biased in Yogyakarta city. This was different to the distribution of practicing midwives, which was in fact higher in the districts of Bantul, Kulonprogo and Gunung Kidul compared to Yogyakarta city and Sleman districts. This highlights the importance of the role of midwives in guaranteeing equity of service in village regions.

Policy related to the development of the private sector.

Before decentralisation, all regulations for establishing private health service facilities were handled by the Regional Office of the Health Department. While during and after decentralisation, regulations for establishment were handed over to the regions (districts), except in cases of Special Hospitals. Based on the decree by the Director General of Medical Services of the Health Department of the Republic of Indonesia number: HK.00.06.3.5.5797 of the 17th of April 1998, the former decree of the Director General of Medical Services of the Health Department of the Republic of Indonesia number: 098/Yanmed/RSKS/1986 was no longer valid, even though this latter decree is still the main reference for the district governments.

As yet there has not been any government policy to guarantee the quality of private health facilities, either before or after decentralisation. Evaluation of the quality of private health facilities tends to depend on the accreditation mechanism that is only directed toward hospitals and implemented by the Central Health Department. Meanwhile the existing accreditation is considered not fully effective.

It has been acknowledged that the reporting system from private health facilities up til now has been not effective and is still done especially at the provincial level as attachments to the health department. After decentralisation this reporting mechanism has become increasingly chaotic because of the change in roles of the different levels of the central, provincial and district governments. Reporting and recording for health facilities is regulated by the decree of the Director General for Community Health No. 664/BINKESMAS/DJ/V/1987 chapter VII section 12.

The role of the government in regulating the growth of the private sector.

Managers of maternity clinics and hospitals consider that the scope of government policy for private health facilities is currently very narrow, as it is limited only to regulation. There are at least three important things the government must address to influence the growth of the private sector. Those are connected to scope, quality, and cost. In terms of scope, the existing policy that is the reference for the regional government is the regulation on permission to establish a private health facility. Rather than encouraging the growth of private health facilities, the way this regulation is implemented is considered more to limit or cause difficulties for private health facilities. When a clinic develops and wants to increase its capacity to become a hospital for example, there are still many obstacles they must face stemming from the government itself. In terms of quality of service, people no longer doubt that private health facilities care about the quality of service to patients, especially the physical appearance of the facilities, the speed of service, friendliness and patient relations. This is due to the efforts made by the health facility itself to provide as much satisfaction as possible to their patients and to the community. On the other hand, attention to technical quality that is not a consideration to patients is still low. The government has not really made many efforts to guarantee the quality of the private health facilities that are already trusted by the community, and the community itself doesn't have sufficient knowledge to be able to choose a quality health facility in terms of its technical side. There are also no available regulations concerning medical staff, equipment and facilities at the levels below hospital. Following the efficiency principle, private health facilities will be motivated to utilise the minimal number of staff and equipment. Likewise, facilities/equipment that are a source of profit will be seen as an investment from which maximum advantage should be gained.

In terms of costs, patient preference for private health facilities and the basic principle of the private sector: orientation toward profit, may trigger better service or even supplier-induced demand. Especially as there is no rational regulation concerning the service fees for private health facilities following the changes that occurred after Indonesia experienced financial crisis and decentralisation.

In the autonomy era, government policy must create an atmosphere that supports the growth of the private sector. It must be understood that the private sector, both the profit-oriented and non-profit will be based on economic principles, although what's more important is how the centrally functioning government will manage the health system that is continually developing. Good stewardship includes various strategies to influence the behaviour of the different stakeholders in the health system and to build coalitions from various different groups, with various incentives. (WHO 2000, Smith et al, 2001)

The potential of the private sector in providing obstetric services and the potential negative effects of private sector growth that can be prevented.

The potential of the private sector in obstetric services stems from the high level of consumer confidence in it. Because of this, the private sector has a relatively stable market. Patients have accepted private health facilities even though they admit that their fees are more expensive. In obstetric services, the role of private providers has proved to be important, and not only for the richer segment of society. The private sector also has an important role for the poorer segments of society through the maternity clinics and the distribution of midwives in village regions whose fees are within the range of the general public.

The interaction between the government and private sector and its problems.

Co-operation between private health service institutions and the government in various ways are generally considered to be operational although minimal with a tendency not to be well planned or organised. In terms of childbirth services, there is existing co-operation in terms of immunisation and family planning. Most of the private sector services are not connected with a public service role, and programs or government incentives that could influence the service mission of the private sector are few. Real communication between the government and private sector is still limited to licensing. However, private health facilities are in fact implementing and are always interested in taking part in providing service to poor and marginalised groups like occurs under the Social Safety Net for Health program.

From this cross sectional study it was difficult to measure the contribution of the private sector including their payment schedule and system to lowering the maternal and infant mortality rate.

POLICY RECOMMENDATIONS

The role of the private sector in the health system as a whole, and in obstetric services in particular is most significant. With decentralisation and given the various limitations the government has in financing and providing services for society, the potential of the private sector in obstetric services could be increased, particularly in order to reduce the maternal and infant mortality rates and to provide services to the poor.

Through stewardship, the government must create a conducive atmosphere for the growth of private health facilities, and on the other hand be able to direct the behaviour of the private sector to provide high quality and efficient services and to contribute to the achievement of national goals, without efforts to obstruct. Regulations concerning quality, scope and pricing must be directed to this end. For example, there needs to be a simplification of the regulations for establishing private health facilities and for practicing licences for health workers by the regional government. The central government could encourage private health facility associations and professional organisations to take a bigger role in standardization and certification, and furthermore the provincial government could assist in consistency of quality.

Support for the private sector to take on a larger role may be provided through various incentives such as tax breaks for private health facilities oriented to social goals; technical quality financed (contracted out) by the government; incentives of investment support (such as the provision of land) to establish private health facilities in areas that are not attractive for full private investment; and real facilities from the government in areas like staffing such as training of health workers, provision of KIE materials and provision of vaccines.

Private sector health services form a very important part of the entire health system. As the private sector has provided the community with ease of access to health services, efforts to maintain quality in the private sector and attention to its potential for development are very important. Synergy between the public and private sectors should be directed towards efforts to provide quality health services and to guarantee equity for all.

This research aims to describe the role of the private sector in the provision of obstetric services, policy related to the role of the private sector in health services, as well as making policy recommendations to support the growth of the private sector. A sample of 75 health facilities was made. This consisted of 10 private hospitals, 9 maternity clinics/birthing centres, 19 specialist obstetricians in private practice, and 37 privately practicing midwives. The patient sample included 137 people, consisting of 41 patients of private hospitals, 32 patients of maternity clinics/birthing centres, 30 patients of specialist doctors and 34 patients of privately practicing midwives.

There is a great variation in the private midwifery/obstetric services in Yogyakarta province. The particularity of each form of service represents a great capacity for the community to choose the type service they feel most comfortable with.

A. The Role of Private Hospitals in Obstetric Services

There is quite a large variation in the capacity of hospitals. Almost all hospitals are semi profit-oriented. Most have accreditation status and are general hospitals with maternity beds. In terms of facilities, equipment, quality of staff and capacity of infrastructure, hospitals are capable of providing emergency obstetric services. Compared to other health facilities, hospitals are also superior in terms of medical technology, facilities and quality of staff. Nevertheless, in most hospitals the need for specialist medical staff and midwives is not fulfilled and this also varies widely.

All hospitals cater for patients from all social backgrounds. Beds allocated for those of the lowest socio-economic group, made compulsory by the government, are provided with a wide variation of percentages. In general, patient fees depend on class, type of service, medicine, as well as the diagnostic tools or medical action taken. Almost all health facilities apply various pricing levels (classes) and different fee patterns. In determining tarifs for service most hospitals apply cross subsidies for the lowest strata. Compared to the fees at Regional General Hospitals, the fees at private hospitals for birthing services and caesarian surgery are several times more expensive. Private hospitals have efficiently taken up opportunities through cooperation with various third parties funders such as Health Insurance, Workers Health Insurance and Work Cover.

Given their resources, especially facilities/equipment and capacity, it is appropriate for hospitals to handle referred obstetric cases. Yet we have only a limited picture of the role hospitals play in the referral system because of a lack of appropriate recording in most hospitals. Approximately half of the hospitals accept maternity inpatient referrals in varying percentages, being referred from specialist doctors and midwives. The high figures for caesarian surgery prominent in several medium type hospitals are not supported by the pathological child-birth data, and this is an indicator of supplier induced demand or hospital over-service toward their patients.

There is a trend for the maintenance of service quality to be done by the individual health facility through the existence of a medical committee. Nevertheless there are at least three factors that hinder the medical committee’s efforts to guard the quality of service in private hospitals. Those are, difficulty in gathering doctors together for committee meetings, a low level of understanding about their role in efforts to guard quality, and a low level of concern about some mechanisms to guard quality. All large hospitals claim to undertake regular efforts to safeguard service quality regardless of the way they choose to do this. Only two-thirds of medium hospitals claim to do this regularly, another third occasionally and a remaining few not at all. This means that these facilities rich in capital and technology may not put enough emphasis on technical quality.

Private-public coordination is still very limited. A strong link has only just commenced surrounding licencing and reporting. It is understandable that private hospitals don't consider recording as a priority issue except when it is connected with information for the market and marketing. They are also not particularly interested in health promotion for patients. Yet these hospitals are quite interested in education for health workers.

B. The Role of Private Maternity Clinics/Birthing Centres in Obstetric Services.

It seems that accreditation for maternity clinics/birthing centres is not common. Only one birthing centre was accredited, and this was spurred more by the initiative of the clinic owner. The variation in the number of beds and rates of occupancy is not too wide, and the average occupancy rate is lower than the hospitals. Maternity clinics/birthing centres tend to focus more on midwifery services especially services for normal births and basic family planning. Nevertheless there are also some that have opened special services in accordance with market demand. Most clinics are semi profit-oriented.

The capacity to handle obstetric emergencies varied and was limited to handling level-one midwifery emergencies. Only five maternity clinics/birthing centres accepted referrals and the number of referrals differed. In terms of staffing, only some of the small clinics had a full time specialist obstetrician, and none of the clinics had a full time pediatrician. Most of the midwives that worked in the maternity clinics/ birthing centres were full time midwives, with quite a wide difference in composition between each health facility. As in the case of the private hospitals there was a great variation in the facilities and equipment.

None of the maternity clinics/birthing centres discriminated based on the background of the patient. Although social aspects were not forgotten, it was acknowledged that private clinics certainly consider commercial aspects or profit orientation when providing services. Although they do provide services to the lowest socio-economic strata, it is difficult to determine with certainty the number of beds actually allocated, and the proportion varies widely between facilities.

Each maternity clinic/birthing centre has its own policy for patients who are unable to pay, from debt systems to being free from costs based on government regulations. Clinic managers see a need for the government and private health facilities to work together in providing services for the poor. Almost all maternity clinics/birthing centres apply the same outpatient fee system, while in terms of fees for other services some apply cross subsidies for the lowest strata patients. Meanwhile, the cost of services and also the total for childbirth varies widely and is several times higher compared with the community health centres (Puskesmas). The method of accepted payment is usually cash, and none of them accept payment through a health fund or health card.

All the directors of the maternity clinics/birthing centres considered it necessary to develop information systems, especially for mother and child health services in order to expand the network into the community and foster a beneficial communication between sectors and the government. The recording system in private clinics was also insufficient, and as was also the case with other private health facilities, this made quality observation or surveillance of community health difficult.

C. The Role of Privately Practicing Specialist Doctors in Obstetric Services.

One prominent characteristic of privately practicing specialist obstetricians is that a large proportion of them work at more than one health facility. For example they may be affiliated with a maternity clinic/birthing centre, a private hospital and also a group practice. It seems that the role of the professional organization (POGI) is limited only to providing recommendation as a base for the registration of a practice. The official role in giving permission is more administrative, that is issuing the licence, which must be renewed every five years. From the services provided, it seems that privately practicing specialist doctors are not particularly interested in immunisation services. Yet all doctors provide antenatal and family planning services that are more based on the demand of the patients. A small proportion of the family planning and immunisation services provided by privately practicing doctors receive subsidies for equipment and vaccines from the government. A two-sided debate always arises surrounding the issue of patient fees. That is from the side of consumer rights, where the patients have a right to know prior to treatment how much they will be charged, and from the side of the medical profession where it is not always appropriate to apply a certain fee. At this time it is almost not possible that a privately practicing doctor will give written information about the service fee. Most doctors apply the same fee, and some apply varying fees depending on the situation of the patient, where the fees for different services can vary greatly.

D. The Role of Privately Practicing Midwives in Obstetric Services

Most midwives work for more than one private and/or public health facility, and may be affiliated with private hospitals, public hospitals and maternity clinic/birthing centres. The role of the Indonesian Midwives Association (IBI) in professional guidance is to provide recommendations based on 5-yearly tests in terms of issuing licences to practice. All midwives provide antenatal and family planning services, and most midwives provide immunisation services. A small amount of the family planning and immunisation services provided by privately practicing midwives receive subsidies of equipment and vaccines from the government. Their service fees do not vary greatly and are quite reasonable (not much different to public health facilities).

E. Private Childbirth Services from the Viewpoint of the Consumers.

Private health facilities contribute to various socio-economic levels of society. Based on their education and employment, the social strata of patients of specialist obstetricians and hospitals is relatively higher than that of the patients of maternity clinics/birthing centres.

The motivation of patients to come to the various private health facilities is because of close proximity to their homes, and faith in the quality of service. The reason they prefer to choose private health facilities is particularly because of their belief in and perception of quality and because they are close to home.

In general, more than 90% of patients felt satisfied with the treatment they had received. This level of satisfaction is high compared to the level of patient satisfaction at public health facilities, according to several studies. There was also a high level of satisfaction in terms of the various aspects such as cleanliness and neatness of the waiting room, cleanliness and neatness of the examination rooms, waiting time, medical equipment, friendliness of the service providers and competence of the service providers. Patients’ high level of trust in private health facilities was also shown by their high level of interest in returning for treatment, their desire to recommend the service to friends and relatives and the possibility of returning to be treated at the same health facility.

In terms of service fees, some patients of hospitals, doctors and maternity clinics/birthing centres considered that the fees they had to pay were expensive. Nevertheless, almost all patients stated that they were able to pay for the services. Almost all health costs the patients had to pay private health facilities were cash (out of pocket).

F. The Distribution of Private Health Facilities Providing

Maternity Services.

The distribution of health services was viewed based on the population ratio of the 5 Districts per total number of beds or public and private health facilities. It was revealed that the distribution of beds in hospitals, maternity clinics/birthing centres and privately practicing specialist doctors was biased in Yogyakarta city. This was different to the distribution of practicing midwives, which was in fact higher in the districts of Bantul, Kulonprogo and Gunung Kidul compared to Yogyakarta city and Sleman districts. This highlights the importance of the role of midwives in guaranteeing equity of service in village regions.

Policy related to the development of the private sector.

Before decentralisation, all regulations for establishing private health service facilities were handled by the Regional Office of the Health Department. While during and after decentralisation, regulations for establishment were handed over to the regions (districts), except in cases of Special Hospitals. Based on the decree by the Director General of Medical Services of the Health Department of the Republic of Indonesia number: HK.00.06.3.5.5797 of the 17th of April 1998, the former decree of the Director General of Medical Services of the Health Department of the Republic of Indonesia number: 098/Yanmed/RSKS/1986 was no longer valid, even though this latter decree is still the main reference for the district governments.

As yet there has not been any government policy to guarantee the quality of private health facilities, either before or after decentralisation. Evaluation of the quality of private health facilities tends to depend on the accreditation mechanism that is only directed toward hospitals and implemented by the Central Health Department. Meanwhile the existing accreditation is considered not fully effective.

It has been acknowledged that the reporting system from private health facilities up til now has been not effective and is still done especially at the provincial level as attachments to the health department. After decentralisation this reporting mechanism has become increasingly chaotic because of the change in roles of the different levels of the central, provincial and district governments. Reporting and recording for health facilities is regulated by the decree of the Director General for Community Health No. 664/BINKESMAS/DJ/V/1987 chapter VII section 12.

The role of the government in regulating the growth of the private sector.

Managers of maternity clinics and hospitals consider that the scope of government policy for private health facilities is currently very narrow, as it is limited only to regulation. There are at least three important things the government must address to influence the growth of the private sector. Those are connected to scope, quality, and cost. In terms of scope, the existing policy that is the reference for the regional government is the regulation on permission to establish a private health facility. Rather than encouraging the growth of private health facilities, the way this regulation is implemented is considered more to limit or cause difficulties for private health facilities. When a clinic develops and wants to increase its capacity to become a hospital for example, there are still many obstacles they must face stemming from the government itself. In terms of quality of service, people no longer doubt that private health facilities care about the quality of service to patients, especially the physical appearance of the facilities, the speed of service, friendliness and patient relations. This is due to the efforts made by the health facility itself to provide as much satisfaction as possible to their patients and to the community. On the other hand, attention to technical quality that is not a consideration to patients is still low. The government has not really made many efforts to guarantee the quality of the private health facilities that are already trusted by the community, and the community itself doesn't have sufficient knowledge to be able to choose a quality health facility in terms of its technical side. There are also no available regulations concerning medical staff, equipment and facilities at the levels below hospital. Following the efficiency principle, private health facilities will be motivated to utilise the minimal number of staff and equipment. Likewise, facilities/equipment that are a source of profit will be seen as an investment from which maximum advantage should be gained.

In terms of costs, patient preference for private health facilities and the basic principle of the private sector: orientation toward profit, may trigger better service or even supplier-induced demand. Especially as there is no rational regulation concerning the service fees for private health facilities following the changes that occurred after Indonesia experienced financial crisis and decentralisation.

In the autonomy era, government policy must create an atmosphere that supports the growth of the private sector. It must be understood that the private sector, both the profit-oriented and non-profit will be based on economic principles, although what's more important is how the centrally functioning government will manage the health system that is continually developing. Good stewardship includes various strategies to influence the behaviour of the different stakeholders in the health system and to build coalitions from various different groups, with various incentives. (WHO 2000, Smith et al, 2001)

The potential of the private sector in providing obstetric services and the potential negative effects of private sector growth that can be prevented.

The potential of the private sector in obstetric services stems from the high level of consumer confidence in it. Because of this, the private sector has a relatively stable market. Patients have accepted private health facilities even though they admit that their fees are more expensive. In obstetric services, the role of private providers has proved to be important, and not only for the richer segment of society. The private sector also has an important role for the poorer segments of society through the maternity clinics and the distribution of midwives in village regions whose fees are within the range of the general public.

The interaction between the government and private sector and its problems.

Co-operation between private health service institutions and the government in various ways are generally considered to be operational although minimal with a tendency not to be well planned or organised. In terms of childbirth services, there is existing co-operation in terms of immunisation and family planning. Most of the private sector services are not connected with a public service role, and programs or government incentives that could influence the service mission of the private sector are few. Real communication between the government and private sector is still limited to licensing. However, private health facilities are in fact implementing and are always interested in taking part in providing service to poor and marginalised groups like occurs under the Social Safety Net for Health program.

From this cross sectional study it was difficult to measure the contribution of the private sector including their payment schedule and system to lowering the maternal and infant mortality rate.

POLICY RECOMMENDATIONS

The role of the private sector in the health system as a whole, and in obstetric services in particular is most significant. With decentralisation and given the various limitations the government has in financing and providing services for society, the potential of the private sector in obstetric services could be increased, particularly in order to reduce the maternal and infant mortality rates and to provide services to the poor.

Through stewardship, the government must create a conducive atmosphere for the growth of private health facilities, and on the other hand be able to direct the behaviour of the private sector to provide high quality and efficient services and to contribute to the achievement of national goals, without efforts to obstruct. Regulations concerning quality, scope and pricing must be directed to this end. For example, there needs to be a simplification of the regulations for establishing private health facilities and for practicing licences for health workers by the regional government. The central government could encourage private health facility associations and professional organisations to take a bigger role in standardization and certification, and furthermore the provincial government could assist in consistency of quality.

Support for the private sector to take on a larger role may be provided through various incentives such as tax breaks for private health facilities oriented to social goals; technical quality financed (contracted out) by the government; incentives of investment support (such as the provision of land) to establish private health facilities in areas that are not attractive for full private investment; and real facilities from the government in areas like staffing such as training of health workers, provision of KIE materials and provision of vaccines.

Studi dan Pengembangan Konsep Pertanggung Gugatan Publik dalam Sektor Kesehatan di Propinsi Daerah Istimewa Yogyakarta

Dalam proses desentralisasi yang secara nyata baru digulirkan pada tahun tahun terakhir ini, kata akuntabilitas atau pertanggung gugatan seakan marak dibicarakan sebagai implikasi yang harus diwujudkan oleh pemerintah daerah dalam proses desentralisasi. Namun disisi lain masih banyak yang belum memahami arti pertanggung gugatan atau menafsirkannya dalam arti yang sempit (pertanggung gugatan keuangan saja) atau dengan cara yang berbeda. Pertanggung gugatan masih belum menjadi kebutuhan, karena berbagai agenda reformasi dalam desentralisasi yang digulirkan masih merupakan wacana atau konsep. Dalam sistem pelayanan kesehatan, pasien belum mempunyai kekuatan tawar (bargaining power) yang memadai. Sistem informasi yang merupakan prakondisi utama bagi berlangsungnya mekanisme pertanggung gugatan publik bisa dikatakan ‘belum ada’, jadi bisa diramalkan bagaimana mekanisme pertanggung gugatan bisa berjalan. Pertanggung gugatan bahkan masih dianggap sebagai ‘pengetahuan baru’ bagi sebagian besar aktor reformasi kesehatan beserta stakeholder yang lain dan dengan demikian masih akan terjadi mekanisme pembelajaran yang akan didapat dari proses reformasi sendiri yang sedang bergulir dengan adanya PHP I. Studi dan pengembangan ini juga merupakan satu proses partisipasi dimana diharapkan akan tumbuh pengetahuan dan wawasan tentang pertanggung gugatan. Selain itu diharapkan dorongan untuk mulai melaksanakan mekanisme ini akan makin kuat. Hambatan lainnya adalah: “Bagaimana akan dapat mempertanggung gugatkan kinerja, sedangkan indikator itu sendiri belum sepenuhnya disepakati?”

Studi dan pengembangan mekanisme pertanggung gugatan ini berusaha memulai mengambil inisiatif untuk membangun mekanisme pertanggung gugatan sistem pelayanan kesehatan melalui:

a. Studi deskripsi dan eksploratif untuk melihat fakta fakta di lapangan yang akan mempengaruhi pengembangan mekanisme pertanggung gugatan publik dan partisipasi masyarakat,

b. Mengusulkan rekomendasi dan konsep pertanggung gugatan dalam sistem pelayanan kesehatan,

c. Implementasi.

Studi deskripsi dan eksplorasi meliputi penilaian pertanggung gugatan manajemen pelayanan kesehatan menggunakan analisis stakeholder, pertanggung gugatan pelayanan kesehatan melalui kelompok diskusi terarah (focus group discussion) dan menilai potensi wadah partisipasi yang telah ada melalui kelompok diskusi terarah (focus group discussion). Berbasis pada data dilapangan yaitu di 5 kabupaten/kota di propinsi DI Yogyakarta dan pembelajaran dari negara negara berkembang lain yang juga sedang melaksanakan reformasi sistem kesehatannnya, rekomendasi untuk membangun prakondisi mekanisme pertanggung gugatan serta model model partisipasi yang mungkin dilakukan kemudian disusun. Struktur struktur yang memungkinkan untuk mendukung mekanisme juga sedapat mungkin diusulkan dari struktur yang telah ada seperti Unit Pengaduan Masyarakat (UPM) program Jaring Pengaman Sosial Bidang Kesehatan (JPSBK). Dalam model pertanggung gugatan yang diusulkan, terdapat 2 komponen penting untuk terjadinya mekanisme pertanggung gugatan dalam sistem pelayanan kesehatan yaitu pemerintah dan masyarakat. Dalam sistem kesehatan era reformasi, komponen pemerintah yang memegang peranan paling luas adalah Dinas Kesehatan Kabupaten/kota. Unit Pertanggung gugatan dalam Pelayanan Kesehatan (UPPK) perlu dibentuk sebagai unit dalam Dinas Kesehatan pada tingkat propinsi dan kabupaten/kota yang paling bertanggung jawab untuk mendorong mekanisme pertanggung gugatan dari sisi pemerintah. Di sisi lain, Forum Komunikasi Masyarakat yang merupakan representasi masyarakat dapat mendorong agar pemerintah melaksanakan mekanisme pertanggung gugatannya dengan partisipasi dari masyarakat langsung. Dengan partisipasi ini, segala permasalahan dalam kebijakan dan intervensi kesehatan adalah permasalahan masyarakat juga, bukan hanya milik pemerintah. Dalam implementasi dilakukan hal hal seperti

a. Memperkenalkan konsep pertanggung gugatan kepada pemerintah dan pemberi jasa pelayanan kesehatan,

b. Mengajak stakeholder untuk menyadari bahwa pertanggung gugatan publik adalah suatu hal yang harus dilakukan dari sekarang dari kesadaran sendiri sebagai bagian dari sistem melalui proses diskusi dan dialog,

c. Memperkuat dan mengajak berbagai potensi struktur pertanggung gugatan yang ada yaitu Lembaga Swadaya Masyarakat sebagai representasi dari masyarakat,

d. Mencoba memulai partisipasi publik dengan mempertemukan para pelaku yang relevan dan memahami berbagai hambatan proses partisipasi.

Dalam proses desentralisasi yang secara nyata baru digulirkan pada tahun tahun terakhir ini, kata akuntabilitas atau pertanggung gugatan seakan marak dibicarakan sebagai implikasi yang harus diwujudkan oleh pemerintah daerah dalam proses desentralisasi. Namun disisi lain masih banyak yang belum memahami arti pertanggung gugatan atau menafsirkannya dalam arti yang sempit (pertanggung gugatan keuangan saja) atau dengan cara yang berbeda. Pertanggung gugatan masih belum menjadi kebutuhan, karena berbagai agenda reformasi dalam desentralisasi yang digulirkan masih merupakan wacana atau konsep. Dalam sistem pelayanan kesehatan, pasien belum mempunyai kekuatan tawar (bargaining power) yang memadai. Sistem informasi yang merupakan prakondisi utama bagi berlangsungnya mekanisme pertanggung gugatan publik bisa dikatakan ‘belum ada’, jadi bisa diramalkan bagaimana mekanisme pertanggung gugatan bisa berjalan. Pertanggung gugatan bahkan masih dianggap sebagai ‘pengetahuan baru’ bagi sebagian besar aktor reformasi kesehatan beserta stakeholder yang lain dan dengan demikian masih akan terjadi mekanisme pembelajaran yang akan didapat dari proses reformasi sendiri yang sedang bergulir dengan adanya PHP I. Studi dan pengembangan ini juga merupakan satu proses partisipasi dimana diharapkan akan tumbuh pengetahuan dan wawasan tentang pertanggung gugatan. Selain itu diharapkan dorongan untuk mulai melaksanakan mekanisme ini akan makin kuat. Hambatan lainnya adalah: “Bagaimana akan dapat mempertanggung gugatkan kinerja, sedangkan indikator itu sendiri belum sepenuhnya disepakati?”

Studi dan pengembangan mekanisme pertanggung gugatan ini berusaha memulai mengambil inisiatif untuk membangun mekanisme pertanggung gugatan sistem pelayanan kesehatan melalui:

a. Studi deskripsi dan eksploratif untuk melihat fakta fakta di lapangan yang akan mempengaruhi pengembangan mekanisme pertanggung gugatan publik dan partisipasi masyarakat,

b. Mengusulkan rekomendasi dan konsep pertanggung gugatan dalam sistem pelayanan kesehatan,

c. Implementasi.

Studi deskripsi dan eksplorasi meliputi penilaian pertanggung gugatan manajemen pelayanan kesehatan menggunakan analisis stakeholder, pertanggung gugatan pelayanan kesehatan melalui kelompok diskusi terarah (focus group discussion) dan menilai potensi wadah partisipasi yang telah ada melalui kelompok diskusi terarah (focus group discussion). Berbasis pada data dilapangan yaitu di 5 kabupaten/kota di propinsi DI Yogyakarta dan pembelajaran dari negara negara berkembang lain yang juga sedang melaksanakan reformasi sistem kesehatannnya, rekomendasi untuk membangun prakondisi mekanisme pertanggung gugatan serta model model partisipasi yang mungkin dilakukan kemudian disusun. Struktur struktur yang memungkinkan untuk mendukung mekanisme juga sedapat mungkin diusulkan dari struktur yang telah ada seperti Unit Pengaduan Masyarakat (UPM) program Jaring Pengaman Sosial Bidang Kesehatan (JPSBK). Dalam model pertanggung gugatan yang diusulkan, terdapat 2 komponen penting untuk terjadinya mekanisme pertanggung gugatan dalam sistem pelayanan kesehatan yaitu pemerintah dan masyarakat. Dalam sistem kesehatan era reformasi, komponen pemerintah yang memegang peranan paling luas adalah Dinas Kesehatan Kabupaten/kota. Unit Pertanggung gugatan dalam Pelayanan Kesehatan (UPPK) perlu dibentuk sebagai unit dalam Dinas Kesehatan pada tingkat propinsi dan kabupaten/kota yang paling bertanggung jawab untuk mendorong mekanisme pertanggung gugatan dari sisi pemerintah. Di sisi lain, Forum Komunikasi Masyarakat yang merupakan representasi masyarakat dapat mendorong agar pemerintah melaksanakan mekanisme pertanggung gugatannya dengan partisipasi dari masyarakat langsung. Dengan partisipasi ini, segala permasalahan dalam kebijakan dan intervensi kesehatan adalah permasalahan masyarakat juga, bukan hanya milik pemerintah. Dalam implementasi dilakukan hal hal seperti

a. Memperkenalkan konsep pertanggung gugatan kepada pemerintah dan pemberi jasa pelayanan kesehatan,

b. Mengajak stakeholder untuk menyadari bahwa pertanggung gugatan publik adalah suatu hal yang harus dilakukan dari sekarang dari kesadaran sendiri sebagai bagian dari sistem melalui proses diskusi dan dialog,

c. Memperkuat dan mengajak berbagai potensi struktur pertanggung gugatan yang ada yaitu Lembaga Swadaya Masyarakat sebagai representasi dari masyarakat,

d. Mencoba memulai partisipasi publik dengan mempertemukan para pelaku yang relevan dan memahami berbagai hambatan proses partisipasi.

Public Accountability for Health System in Lampung Province

All Stakeholders agreed that health facilities in Lampung Province still need to improve their health service quality. With decentralization, services must be brought closer to the community, and the district/city government is required to provide a better quality health services. A model of accountability for health system would be developed to improve health service quality that is more customer-oriented.

In connection with quality, the role of stakeholders, i.e., the Provincial Health office is to be responsible for handling cross-regional problems, or problems that are beyond the regional government’s capability to solve. The District Health Office is responsible for the planning, advocacy, monitoring, and evaluation on all health facilites in their own region. Health facilites themself should is responsible for the monitoring and improvement of health service quality given to the community/patients. Professional Organization plays its role in building its members’ capacity, for example through sustainable membership and capacity building, technical assistance and advocacy. Meanwhile, Non Government Organization acts as mediator, partner, or actor.

An observational study based on a qualitative method was conducted to find facts in the field, and then from these facts the study proposed a recommendation for a public-accountability model having been adjusted to the real condition in the field. In addition to taking the Provincial dan District Health Office as its samples, the study also took other samples, namely hospitals, Primary Health Care Centres, Association of Indonesian Doctors (IDI), and Non Government Organizations. For the analysis in hospital unit, the study conducted interviews with respondents from medical service and medical record sections, customer relation unit or other units of similar function as well as the patients. For primary health care centre analysis, the respondents consisted of medical record responsible person (in-patient primary health care centre), the head, and patients. For Provincial and District Health Offices, the respondents were represented by sub-sections of health service.

The system for taking and solving complaints in health service system should be based on the principles of easy access and procedure, speedy and transparent process, fairness for all -patients and medical staffs as well-, and beneficial to health service quality improvement. By adopting these principles, health facility is expected to deal with complaints directly in the front line. However, if this ideal is difficult to achieve, the role of a Patient Support Manager (PSM) is needed to help deal with complaints as promptly as possible and in a transparent, non-defensive, and mediating manner. A PSM must have personal access to the top leader of health facility and to medical record, in addition to having high motivation to do his tasks of mediation to offer win-win solution to both conflicting parties. Whenever it fulfils the requirement and gets approval from the two parties, an unresolved complaint in health facility level can be handled by the Health Office, which acts as mediator by doing an independent review. The system of taking and solving complaints must be integrated into service quality improvement measures.

In connection with service quality improvement and malpractice prevention, everyone in the health system of Lampung Province must build a quality framework, and taking into account non-medical indicator. The current indicator together with the one to be developed must be extended periodically, and must include dimensions of health status, clinical effectiveness, medical error/safety, efficiency and incentive, as well as fairness. Meanwhile, the steps to be taken for quality improvement in order to prevent malpractice are as follows: first, to decide an effort to maintain retrospective quality for example through technical standardization, periodical licensing, and certification and prospective quality for example through record review to diagnosis and medication and satisfaction survey to be conducted by health facility, and also to decide who to carry them out; and second, to give feed back to health facility and the Office of heath Offices in city/district level as for periodical and continuous advocacy. These steps can be implemented first in health facilities with autonomous management, under an assumption that they can make a decision more quickly.

In the implementation of health service performance evaluation, the Provincial and District Health Office and health facilities need to include responsiveness with its all dimensions as one of the important performances in the health service system, which relates to non medical aspects and patient’s rights. The mechanism can be introduced through survey on responsiveness at the household and health facility levels.

All Stakeholders agreed that health facilities in Lampung Province still need to improve their health service quality. With decentralization, services must be brought closer to the community, and the district/city government is required to provide a better quality health services. A model of accountability for health system would be developed to improve health service quality that is more customer-oriented.

In connection with quality, the role of stakeholders, i.e., the Provincial Health office is to be responsible for handling cross-regional problems, or problems that are beyond the regional government’s capability to solve. The District Health Office is responsible for the planning, advocacy, monitoring, and evaluation on all health facilites in their own region. Health facilites themself should is responsible for the monitoring and improvement of health service quality given to the community/patients. Professional Organization plays its role in building its members’ capacity, for example through sustainable membership and capacity building, technical assistance and advocacy. Meanwhile, Non Government Organization acts as mediator, partner, or actor.

An observational study based on a qualitative method was conducted to find facts in the field, and then from these facts the study proposed a recommendation for a public-accountability model having been adjusted to the real condition in the field. In addition to taking the Provincial dan District Health Office as its samples, the study also took other samples, namely hospitals, Primary Health Care Centres, Association of Indonesian Doctors (IDI), and Non Government Organizations. For the analysis in hospital unit, the study conducted interviews with respondents from medical service and medical record sections, customer relation unit or other units of similar function as well as the patients. For primary health care centre analysis, the respondents consisted of medical record responsible person (in-patient primary health care centre), the head, and patients. For Provincial and District Health Offices, the respondents were represented by sub-sections of health service.

The system for taking and solving complaints in health service system should be based on the principles of easy access and procedure, speedy and transparent process, fairness for all -patients and medical staffs as well-, and beneficial to health service quality improvement. By adopting these principles, health facility is expected to deal with complaints directly in the front line. However, if this ideal is difficult to achieve, the role of a Patient Support Manager (PSM) is needed to help deal with complaints as promptly as possible and in a transparent, non-defensive, and mediating manner. A PSM must have personal access to the top leader of health facility and to medical record, in addition to having high motivation to do his tasks of mediation to offer win-win solution to both conflicting parties. Whenever it fulfils the requirement and gets approval from the two parties, an unresolved complaint in health facility level can be handled by the Health Office, which acts as mediator by doing an independent review. The system of taking and solving complaints must be integrated into service quality improvement measures.

In connection with service quality improvement and malpractice prevention, everyone in the health system of Lampung Province must build a quality framework, and taking into account non-medical indicator. The current indicator together with the one to be developed must be extended periodically, and must include dimensions of health status, clinical effectiveness, medical error/safety, efficiency and incentive, as well as fairness. Meanwhile, the steps to be taken for quality improvement in order to prevent malpractice are as follows: first, to decide an effort to maintain retrospective quality for example through technical standardization, periodical licensing, and certification and prospective quality for example through record review to diagnosis and medication and satisfaction survey to be conducted by health facility, and also to decide who to carry them out; and second, to give feed back to health facility and the Office of heath Offices in city/district level as for periodical and continuous advocacy. These steps can be implemented first in health facilities with autonomous management, under an assumption that they can make a decision more quickly.

In the implementation of health service performance evaluation, the Provincial and District Health Office and health facilities need to include responsiveness with its all dimensions as one of the important performances in the health service system, which relates to non medical aspects and patient’s rights. The mechanism can be introduced through survey on responsiveness at the household and health facility levels.