Academic journal article Bulletin of the World Health Organization

The Costs of Public Primary Health Care Services in Rural Indonesia

Academic journal article Bulletin of the World Health Organization

The Costs of Public Primary Health Care Services in Rural Indonesia

Article excerpt

The costs of public primary health care services in rural Indonesia


Although in most developing countries there is little information available about the costs of public health services, such data are useful, especially in times of increasing concern about health care financing [1].

Cost data are needed for health planning and budgeting purposes, where information on the total and unit cost of services can be used to assess the financial requirements of programme maintenance or expansion. Also, several important policy questions require cost data for proper analysis. For example, fees for services should be set with dome reference to costs, both average and marginal [2, 3]. Usually, the actual allocation of health resources geographically, socially, and programmatically is difficult to obtain from published budgets and expenditures. Direct costing of services can, however, provide detailed estimates of allocations for comparison with programme and planning priorities. Cost data can also be used to measure service efficiency or productivity and hence to support efforts to improve the management of health services [4].

In view of the above-mentioned applications, the lack of adequate data on service costs is notable. Information on the costs of health services in less developed countries has been extensively reviewed by Robertson [5], and only one large-scale study has appeared [6]. Comparisons within specific countries suggest that costs vary for similar facilities. Small studies of a few facilities are likely to give misleading or unrepresentative results, and larger samples are therefore required to provide representative data on cost levels and variations for policy-making and planning purposes.

Here, we describe the results obtained in the Indonesia Rural Health Services Cost Study. It was designed to provide a large enough sample of cost data on Indonesia's rural health services to obtain national and regional estimates of the total, per capita, and unit costs of the major public health programmes.

Information on the costs of health services in five provinces in different parts of Indonesia are reported here in two ways. First, weighted means and ranges of total, per capita, and unit (per output) costs of public health care for subdistricts are presented for the whole study sample; costs are also shown for major service programmes. Second, province-specific average costs are shown for the five provinces studied, and these provide some insight into regional variability.

Materials and methods

In the cost analysis study of health centres, data were collected on expenditures and revenue from a total of 173 facilities in 42 health centre work areas. (a) These areas make up 42 subdistricts in the following provinces: East Java, West Java, Nusu Tenggara Barat (NTB), South Sulawesi, and West Sumatra. Data from one subdistrict were not included in the sample because they were of poor quality, and thus the study sample comprised 41 subdistricts and 168 health facilities. The data were collected between November 1986 and March 1987.

The sample included provinces from the three development regions identified by the government of Indonesia. Within each province, regencies (b) were selected from mountainous, hilly, and coastal plain areas to reflect a range of physical environments and distances from major population centres. The location of the study sites and the number of areas in each are shown in Table 1. The data were collected by a team drawn from the Faculty of Public Health, University of Indonesia, the Department of Health, Jakarta, local faculties of public health, and The John Hopkins University.

Costs were taken to be the estimated expenditure by government on rural (subdistrict) health services for 1 month. The time and travel costs of the users were not estimated. Data limitations precluded inclusion of the prorated cost of the education of health personnel, while the costs associated with government administration at the regency, provincial, and national levels were also omitted. …

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