e-ISSN 2598-3849       print ISSN 2527-8878

Vol 7, No 1 (2022)


Firdaus Hafidz, Anedya Niedar, Krishna Hort


Policy has focused on the unequal distribution of health workers, while the potential for improvements in efficiency to address this problem has been neglected. This study aims to measure and compare the level of efficiency in the use of the available health workforce for the delivery of selected primary healthcare services among districts/cities in Indonesia, and to identify factors influencing that efficiency. The Data Envelopment Analysis method with output orientation to measure efficiency and Tobit regression analysis was performed to determine the effect of contextual factors. The average score for the technical efficiency of primary health care service delivery throughout Indonesia was 1.29, indicating the potential to achieve on average 29% higher coverage of the selected primary health services if all were as efficient as the most efficient. The average efficiency score in the Eastern Indonesia region was 1.62 and the average in the Java-Bali region was 1.05, indicating higher potential efficiency gains in the Eastern Indonesia region. Access to health care facilities was a consistently significant factor influencing the efficiency of primary health care in almost all regions. This study has demonstrated the potential for significant gains in coverage of key primary care services through improvements in the efficiency of use of the existing health workforce.


Health Workers; Primary Health Care; Efficiency; Data Envelopment Analysis


Abimbola, Seye, Leonard Baatiema, and Maryam Bigdeli. 2019. “The Impacts of Decentralization on Health System Equity, Efficiency and Resilience: A Realist Synthesis of the Evidence.” Health Policy and Planning 34 (8): 605–17.

Akpan, Nkereuwem. 2021. “The Role of Incentives on the Performance of Health Workers in a Public Sector Organization in Abuja, Nigeria.” Jurnal Ilmiah Ilmu Administrasi Publik 11 (1): 1.

Anand, Sudhir, and WHO. 2010. Measuring Health Workforce Inequalities: Methods and Application to China and India. World Health Organization.

Anhar, A., L. O. A. Imran, and C. S. Ismail. 2016. “Studi Komparatif Pemanfaatan Pelayanan Kesehatan Pada Masyarakat Pedesaan Di Wilayah Kerja Puskesmas Poleang Barat Dengan Masyarakat Perkotaan ….” (Jurnal Ilmiah Mahasiswa Kesehatan. http://ojs.uho.ac.id/index.php/JIMKESMAS/article/download/654/444.

Atmanti, Hastarini Dwi, and Maal Naylah. 2019. “The Efficiency of Healthcare System in Indonesia in 2014-2018.” Humanities & Social Sciences Reviews, December. https://doi.org/10.18510/hssr.2019.7696

Barber, Sarah L., Paul J. Gertler, and Pandu Harimurti. 2007. “Differences in Access to High-Quality Outpatient Care in Indonesia.” Health Affairs 26 (3): w352-66.

Bernal, Pedro, and Sebastian Martinez. 2020. “In-Kind Incentives and Health Worker Performance: Experimental Evidence from El Salvador.” Journal of Health Economics 70 (102267): 102267.

Bitton, Asaf, Hannah L. Ratcliffe, Jeremy H. Veillard, Daniel H. Kress, Shannon Barkley, Meredith Kimball, Federica Secci, et al. 2017. “Primary Health Care as a Foundation for Strengthening Health Systems in Low- and Middle-Income Countries.” Journal of General Internal Medicine 32 (5): 566–71.

Chaix-Couturier, C., I. Durand-Zaleski, D. Jolly, and P. Durieux. 2000. “Effects of Financial Incentives on Medical Practice: Results from a Systematic Review of the Literature and Methodological Issues.” International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care / ISQua 12 (2): 133–42.

Coelli, Timothy J., D. S. Prasada Rao, Christopher J. O’Donnell, and George E. Battese. 2005. An Introduction to Efficiency and Productivity Analysis. Second Edi. New York: the written permission of the publisher.

Cooper, William W., Lawrence M. Seiford, and Joe Zhu. 2004. “Data Envelopment Analysis.” In Handbook on Data Envelopment Analysis, edited by William W. Cooper, Lawrence M. Seiford, and Joe Zhu, 1–39. Boston, MA: Springer US.

Eboreime, Ejemai, Seye Abimbola, and Fiammetta Bozzani. 2015. “Access to Routine Immunization: A Comparative Analysis of Supply-Side Disparities between Northern and Southern Nigeria.” PloS One 10 (12): e0144876.

Ensor, Tim, and Stephanie Cooper. 2004. “Overcoming Barriers to Health Service Access: Influencing the Demand Side.” Health Policy and Planning 19 (2): 69–79.

Hafidz, Firdaus, Tim Ensor, and Sandy Tubeuf. 2018. “Efficiency Measurement in Health Facilities: A Systematic Review in Low- and Middle-Income Countries.” Applied Health Economics and Health Policy 16 (4): 465–80.

Heywood, Peter, and Yoonjoung Choi. 2010. “Health System Performance at the District Level in Indonesia after Decentralization.” BMC International Health and Human Rights 10 (March): 3.

Heywood, Peter, and Nida P. Harahap. 2009. “Health Facilities at the District Level in Indonesia.” Australia and New Zealand Health Policy 6 (May): 13.

Hikmah, Nurul, Harpiana Rahman, and Ayu Puspitasari. 2020. “Membandingkan Ketimpangan Ketersediaan Tenaga Kesehatan Puskesmas Di Wilayah Indonesia Timur.” Window of Public Health Journal, April, 31–37.

Hollingsworth, Bruce. 2008. “The Measurement of Efficiency and Productivity of Health Care Delivery.” Health Economics 17 (10): 1107–28.

Hosseinpoor, A. R., N. Bergen, and R. Floranita. 2017. “State of Health Inequality: Indonesia.” Geneva: World Health.

Indonesia, R., 2009. Undang-undang Republik Indonesia nomor 36 tahun 2009 tentang Kesehatan. Jakarta. Republik Indonesia.

Indonesia, P.R., 2012. Peraturan Presiden Republik Indonesia Nomor 72 Tahun 2012 Tentang Sistem Kesehatan Nasional.Jacobs, Bart, Por Ir, Maryam Bigdeli, Peter Leslie Annear, and Wim Van Damme. 2012. “Addressing Access Barriers to Health Services: An Analytical Framework for Selecting Appropriate Interventions in Low-Income Asian Countries.” Health Policy and Planning 27 (4): 288–300.

Jacobs, Rowena, Peter C. Smith, and Andrew Street. 2006. Measuring Efficiency in Health Care: Analytic Techniques and Health Policy. Vol. 10. New York: Cambridge University Press.

Joint Learning Network for Universal Health Coverage. 2020. MEASURING HEALTH SYSTEM EFFICIENCY IN LOW- AND MIDDLE-INCOME COUNTRIES: A RESOURCE GUIDE. Revisiting Health Financing Technical Initiative. The World Bank.

Kemenkes. 2014. “Peraturan Menteri Kesehatan Republik Indonesia Nomor 75 Tahun 2014, Tentang Pusat Kesehatan Masyarakat.” 75. Jakarta: Kementerian Kesehatan Republik Indonesia.

Kemenkes. 2019. Peraturan Menteri Kesehatan Republik Indonesia Nomor 43 tahun 2019 tentang Pusat Kesehatan Masyarakat. Jakarta.

———. 2019. “Peraturan Menteri Kesehatan Republik Indonesia Nomor 4 Tahun 2019 Tentang Standar Teknis Pemenuhan Mutu Pelayanan Dasar Pada Standar Pelayanan Minimal Bidang Kesehatan.” Jakarta: Kementerian Kesehatan Republik Indonesia.

Kis-Katos, Krisztina, and Bambang Suharnoko Sjahrir. 2017. “The Impact of Fiscal and Political Decentralization on Local Public Investment in Indonesia.” Journal of Comparative Economics 45 (2): 344–65.

Kruk, Margaret E., Marta R. Prescott, Helen de Pinho, and Sandro Galea. 2009. “Are Doctors and Nurses Associated with Coverage of Essential Health Services in Developing Countries? A Cross-Sectional Study.” Human Resources for Health 7 (March): 27.

Kuhn, Bertolt, Kim-Sarah Kleij, Sebastian Liersch, Jost Steinhäuser, and Volker Amelung. 2017. “Which Strategies Might Improve Local Primary Healthcare in Germany? An Explorative Study from a Local Government Point of View.” BMC Family Practice 18 (1): 105.

Levesque, Jean-Frederic, Mark F. Harris, and Grant Russell. 2013. “Patient-Centred Access to Health Care: Conceptualising Access at the Interface of Health Systems and Populations.” International Journal for Equity in Health 12 (March): 18.

Macinko, James, Barbara Starfield, and Temitope Erinosho. 2009. “The Impact of Primary Healthcare on Population Health in Low- and Middle-Income Countries.” The Journal of Ambulatory Care Management 32 (2): 150–71.

Maharani, Asri, Devi Femina, and Gindo Tampubolon. 2015. “Decentralization in Indonesia: Lessons from Cost Recovery Rate of District Hospitals.” Health Policy and Planning 30 (6): 718–27.

Mahendradhata, Yodi, Laksono Trisnantoro, Shita Listyadewi, Prastuti Soewondo, Tiara Marthias, Pandu Harimurti, and John Prawira. 2017. “The Republic of Indonesia Health System Review.” https://apps.who.int/iris/handle/10665/254716.

McDonald, J. (2009). Using least squares and Tobit in second stage DEA efficiency analyses. European Journal of Operational Research, 197, 792–798.

Mitchell, Andrew D., Thomas J. Bossert, Winnie Yip, and Salih Mollahaliloglu. 2008. “Health Worker Densities and Immunization Coverage in Turkey: A Panel Data Analysis.” Human Resources for Health 6 (December): 29.

Mujasi, Paschal N., Eyob Z. Asbu, and Jaume Puig-Junoy. 2016. “How Efficient Are Referral Hospitals in Uganda? A Data Envelopment Analysis and Tobit Regression Approach.” BMC Health Services Research 16 (1). https://doi.org/10.1186/s12913-016-1472-9.

Mujasi, P.N., Asbu, E.Z. & Puig-Junoy, J. (2016). How efficient are referral hospitals in Uganda? a data envelopment analysis and Tobit regression approach. BMC Health Services Research, 16, 230.Mulyanto, Joko, Dionne S. Kringos, and Anton E. Kunst. 2019. “Socioeconomic Inequalities in Healthcare Utilisation in Indonesia: A Comprehensive Survey-Based Overview.” BMJ Open 9 (7): e026164.

Mulyanto, Joko, Anton E. Kunst, and Dionne S. Kringos. 2019. “Geographical Inequalities in Healthcare Utilisation and the Contribution of Compositional Factors: A Multilevel Analysis of 497 Districts in Indonesia.” Health & Place 60 (November): 102236.

Mustara, and Sri Nani Purwaningrum. 2018. “ANALISIS KETERSEDIAAN TENAGA KESEHATAN DALAM CAPAIAN INDIKATOR KINERJA PUSKESMAS.” Buletin Media Informasi Kesehatan. https://doi.org/10.37160/bmi.v14i2.179.

O’Donnell, Owen. 2007. “Access to Health Care in Developing Countries: Breaking down Demand Side Barriers.” Cadernos de Saude Publica 23 (12): 2820–34.

Peters, David H., Anu Garg, Gerry Bloom, Damian G. Walker, William R. Brieger, and M. Hafizur Rahman. 2008. “Poverty and Access to Health Care in Developing Countries.” Annals of the New York Academy of Sciences 1136: 161–71.

Rabbaniyah, Fairuz, and Mardiati Nadjib. 2019. “Analisis Sosial Ekonomi Dalam Pemanfaatan Fasilitas Kesehatan Untuk Berobat Jalan Di Provinsi Jawa Barat : Analisis Data Susenas Tahun 2017.” Media Kesehatan Masyarakat Indonesia 15 (1): 73.

Republik Indonesia. 2009. “Undang-Undang Republik Indonesia Nomor 36 Tahun 2009 Tentang Kesehatan.” Jakarta: Pemerintah Pusat.

———. 2012. “Peraturan Presiden Republik Indonesia Nomor 72 Tahun 2012 Tentang Sistem Kesehatan Nasional.” Jakarta: Pemerintah Pusat.

Rokx, Claudia Schieber, George Harimurti, Pandu Tandon, Ajay Somanathan, and Aparnaa. 2009. Health Financing in Indonesia. Directions in Development - Human Development. The World Bank.

Salafsky, B., M. Glasser, and J. Ha. 2005. “Addressing Issues of Maldistribution of Health Care Workers.” Annals of the Academy of Medicine, Singapore 34 (8): 520–26.

Utomo, Budi, Purwa K. Sucahya, and Fita R. Utami. 2011. “Priorities and Realities: Addressing the Rich-Poor Gaps in Health Status and Service Access in Indonesia.” International Journal for Equity in Health 10 (November): 47.

World Health Organization. 1978. “Declaration of Alma-Ata.” In . https://www.who.int/publications/almaata_declaration_en.pdf.

———. 2016. “Health Workforce Requirements for Universal Health Coverage and the Sustainable Development Goals.(Human Resources for Health Observer, 17).” https://apps.who.int/iris/bitstream/handle/10665/250330/9789241511407-eng.pdf.

World Health Organizations. 2018. “Declaration of Astana.” In . https://apps.who.int/iris/bitstream/handle/10665/328123/WHO-HIS-SDS-2018.61-eng.pdf?sequence=1&isAllowed=y.

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DOI: 10.7454/eki.v7i1.5397


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