Abstract
The decentralization of the Indonesian healthcare system, launched in the year 2000, allowed the authorities of local community health centers (CHCs) to tailor their services to the needs of their clients. Many observers see this as an opportunity to increase CHC efficiency. Building on the Context Design Performance Framework, this paper assesses the extent to which efficiency variations between CHCs can be explained by the degree of fit between their organizational design characteristics and aspects of the communities in which they are embedded. Data envelopment analysis (DEA) was applied to construct a measure of CHC efficiency for a sample of 598 CHCs in 2011, drawn from a publicly available Ministry of Health (MoH) dataset. Tobit regression analysis was applied to assess the impact of organization design and community characteristics and their interplay on efficiency. Large variations in CHC efficiency were discovered, suggesting that not all CHCs are equally capable of finding the optimal design to operate most efficiently. A significant inverted U-shape relationship was found for the organization design-efficiency link: efficiency is highest for CHCs with 1-2 horizontal units and decreases for CHCs exceeding or not reaching this number. No significant association was found between community characteristics (proportion of poor people, remote location of CHC) and CHC efficiency. Organizational design matters for CHC efficiency, but no evidence was found for the hypothesis that a better fit between community characteristics and CHC design increases efficiency. A potential reason for this might be that CHC management's main design challenge is how to cope with the scarce availability of well-trained health personnel.
Highlights
Community health centers (CHCs) are frontline organizations in national primary healthcare systems
We argue that large variations in CHC efficiency are likely and that they can be explained by differences in the fit between CHC organization design and its context
The most important finding is that as many as 364 CHCs had a TE score of less than 0.60. This variation suggests that many CHCs were not able to find a design to operate at decent levels of efficiency and that the opportunities for substantial improvements in system performance were substantial
Summary
Community health centers (CHCs) are frontline organizations in national primary healthcare systems. They have prominent tasks in providing effective, efficient, equal, accessible and affordable healthcare to local communities.[1,2] Many countries currently invest in improving CHC capacity to improve the health of their community.[3,4]. The decentralization of the Indonesian healthcare system was launched in 2000, and further strengthened in 2004 through higher fiscal transfers of the healthcare budget from central to local governments.[5] It increased CHCs autonomy to decide on organizational function, strategy and design,[6] and the introduction of health insurance for the poor.[7] This transfer of resources and authority to local governments and CHCs was balanced by a mechanism of multi-layered decision space in which the Ministry of Health (MoH) retained some influence by defining minimum standards regarding the functions, organization design, and performance of CHCs.[6]
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