REGENCY LEVEL HOSPITAL UTILIZATION IN

Bulletin Penelitian Kesehatan
Health Studies in Indonesia

Vol. V No. 1

1977

REGENCY LEVEL HOSPITAL UTILIZATION IN INDONESIA
,

M.H.W. Soetopo, Partiwi Soemana', N. ~ a h a r j o ' ,Haryadi Soepartol,
W. ~ j i n d a r b u m i ~M.
, ast tarn an^, Sarwantol , Lestari ~ a n t i w i l u j e n ~and
' C. Handdo'.

Atlalz.ra rlrrllah sakit titzgkat kabuf~atenadalah nterupakan tcmpat perawatan pertamu untuk para
penderita dan karena itu harus dapat memberikan perawatan minimal kepada para penderita.
Rumah sakit sekurang-kurangnya memiliki seorang dokter umum yang bekerja penuh wnlaupun tidak
terdapat tenaga specialist. Kapasitas tempat tidur pada rumah sakit kabupaten bervariasi antara 40
dan 300 t.t.
Latar belakang penelitian ini dilakukan karena adanya pemanfaatan rumah sakit yang sangat kurang

sehingga peladvananyang diberikan oleh rumah sakit tidak ada manfaamya. Untuk itu maka perlu dilakukan usaha-usaha guna memperbaiki effiiensi dan effektivittas pelayanan dirumah sakit berdasar atas
sumber-sumber da ya yann ada.
Per~lan.faatarrpelq~anan rzrrnah sakit oleh masyarakat diperzgaruhi beberapa faktor seperti berikut :
faktotor-faktor yang berhubungan dengan penderita dan faktor-faktor yang berhubungan dengan kesempatan misalnya tersedianya waktu, jarak dan keuangan. Oleh karena itu dalam penelitian ini dilakukan
analisa mengenai faktor-faktor yang mempengaruhi penderita seperti umur, jenis kelamin, pendidikan,
kebiasah, agama, penilaian tugas-tugak dan pelayanan kesehatan oleh musyarakat. Selanjumya hasil
penelitian ini diharapkan dapat dipergunakan sebagai dasar untuk keperluan perencanaan program
pelayanan kesehatan.
The regency level hospital in Indonesia is
the first place of referral for inpatient care,
and should be able to provide hasic emergency
care. This type of hospital has at least one
full time general practioner (physician) but
no specialists attached to it. Capacity ranges
between 40 and 300 beds. This study was
conducted because there were indications
that many of this type of hospitals were underutilized, giving thus 'art impression that most
of the already scarce resources for producing
these services are being wasted. Since hospitals
absorb most of the already limited.;resources

of the health field, it seems juktified that
efforts should be concentrated in improving
the efficiency and effectiveness of these services.
'Health services Research and Development Centre.
Surabaya.
'~irectorate General CDC, Jakarta.
'Health Emlogy Research Centre. Jakarta.,
Received 2 February 1 9 7 6 .

The term hospital utilization denotes the
manner in which a certain comntunity makes
use of its hospital resources Utilization of
hospitals as well as other types of health services by the community.are influenced by :
factors associated with patients decision making (objective need and perception that need
exists), factors associated with patients
opportunity for action (availability and accesibility in ternis of cost, time and distagce)
Utilization analysis must therefore incorporate
the ' study of various variables which may
influence utilization, such as : age, sex, educational level, habits, custom, religion and
appre.ciation of the work of available health

service institution (s) by the community.
The above mentioned analysis is one of the
basic requirements for the proper planning
and organization of health servi*ces. It is within
this framework that this study on the utilization of regency level hospitals ,was carried
out by the Ministry of Health's. Healthservices
Research and Development Centre in Surabava.

Type of hospital

Regency level hospital
(no specialist attached
t o the hospital).

Owner's state

I.

Private (Philantropic)

II. Regency Government

Location of hospitals

1. Mojowarno
2. Lebak

3. Kabanjahe
4.
5.
6.
7.

8.
9.
10.
11.
12.

Ill. Provincial Government

Intermediate level hospital
(with at least one specialists
attach t o the hospital).

Provincial Governrncnt

Figure I Location of the various hospitals studied.

Surnedang
lndrarnayu
Wonosobo
Wonogiri
Lurnajang
Parnekasan
Singaraja
Tondano
Marta~ura

13. Tarakan
14. Kupang

15. Purwokerto

I < E G E N C Y HOSPITAI, UTI1,IZATION IN I N D O N E S I A

PAATERIALS AND METHODS.
This study was conducted prospectively in
fifteen regency level !lospitals in Indonesia for
a period of six nionths (June - November
1972), in order t o cope with possible seasonal
variations of diseases.
Hospitals included in the study werc.: (Fig I).
Several criteria were used in the selection of
hospitals siuclicd, these werc: I t must be a
regency level hospital with at least one physician :~tacl~cd
to it. One intermediate level
hospital was chosen additionally as comparison, it sl~ouid liave a capacity of at least 8 0
beds, it should be located within the 150
kilometers radius from the provincial capital,
because of linlited time available t o supervise
data collection.

Data collected for this study were: Extract of
patient records, which were put on a specially
designed form for this study (a.0. central
register number for possible trace back, age,
sex, address, occupation, diagnosis, length of
stay, various examinations carried out, treatment and cost paid by the patient at discharge), data about the hospital, lay out, beds
available, equipments. manpower (by category) and running cost of the hospital, data
about the overall activities output o f the
hospital (including out-patient and other ac-

tivities if present), availability of other types
of health services in the area, population data
of the regencies, assessment o f the overall
capability of regency level hospital staff in
relation with availability of equipment, was
carried out by a teain of medical specialists of
the Airlangga University Medical School. This
team consisted of a pediatrician, obstetrician
and gynaecologist, a surgeon and a specialist
in Internal Medicine.

Data were collected by the hospital staff on
specially designed f o r ~ n sprepared for tlus study. Instructions and supervision of data collection were carried out by members of h e
study group. Processing was carried out at the
Health Services Research and Development
Centre in Surabaya. For classification of diseases, the International Classification of Diseases, 1965 revised edition was used.

RESULTS
Analysis of data obtained showed that
during the period of the study a total of
16429 patients were hospitalized in all hospitals. Nuniber of patients admitted into the
various hospitals varied between 370 and 1843
in the regency level liospitals and 'between
1590 and 3 1 1 0 in the provincial level hos-

Table I Hospital Capacity in relation with average length of stay and occupancy ratio
-

~

H o s p i t a l

1. Mojowarno
2. Misi Lebak
3. Kabanjahe
4. Sumedang
_ 5. lndramayu **I
6. Wonosobo
7. Wonogiri
8. Lumajang
9. Pamekasan
10. Singaraja
11. Tondano
12. Martapura
13. Tarakan
14. Kupang
15. Puwokerto

All

Hospitals

Registered
Capacity

Actual
Capacity

140
89
300
100
160
135
100
150
100
2 50
150
50
110

200
350

161
100
300
85
83
135
68
154
67
190
89
52
72
165
350

3384

307 1

Number
of
Patients

Total
Patientdays

Average length Occupancy -*I
of
rate
stay
(in percentage)

9444
7872
12296
9301

10.84
10.90
10.05
6.79

32
43
23
60

2835
7829

5.70
7.37

19
32

783
982
378
1843
804
525
669
1590
31 10

5088
7796
292 1
13831
8463
2559
61 10
13940
30185

6.50
7.94
7.73
7e.50
10.53
4.87
9.13
8.77
9.71

41
26
24
40
52
27
47
46
47

16429

140470

8.55

37

871
722
1223
1370
497
1062

'

M.H.W. SOETOPO ET A L

Note:
Code age group

A 0- 4
B 5-.14
C 1 5 - 55
D 55 +

Fig. I I Age distribution by disease category of patients in all hospitals studied.
pitals. Average length of stay in all hospitals
studied were found to be ranging between 6
and 11 days with an average of 9 days.
Occupancy ranged between 18 and 60 percent.
Detailed data about the various hospitals is
~utlinedin Table 1.
Disease pattern in hospitals studied showed, that
four main group of disease constituted the main
:ase load of these hospitals which were: Fig 11.
Complications of pregnancy, childbirth and
puerperium (23 percent of all cases, while if
normal deliveries were omitted; it constituted
only 10 percent of all cases), infective and
parasitic diseases (19 percent of all cases),
accidents, violence and poisoning (16 percent

of all cases), diseases of the respiratory system
(12 percent of all cases).
These four disease categories seemed to be
consistently the major case load in all hospitals studied, although some differences in
the order of magnitude were observed in some
hospitals.
In the infective and parasitic disease
group, it was generally found that the highest
case load in this group was diarrheal diseases
(34 percent of all cases in this group) followed by pulmonary tuberculosis (24 percent of
all cases in this group), typhoid fever (10
percent of all cases in this group), tetanus (6
percent of all cases in this group) and malaria

Number of surgical interventions

Endocrine, n
tabolic disease
Misi b b a k
Kabanjahe
Sumedang
lndramayu
Wonodm
Wonogiri
Lumajang
Pamekasan
Singaraja

Neoplasms

Mental disord

Dis of the m
letal WSt &
Diseases of
system
Infective &

seases
Diseases 'of
Urinary system
Deseases of t
blood forming
Diseases of
system & s
Diseases of
subcutaneous
Acciden, p
violence
Diseases of t
svstem

$/ , ,

Tondano

&genital

Martapura

Symptoms 81
conditions.

Tarakan

Diseases of
tory system

an

morbid. & mo

tions.
Compl. of pre
Childbirth &
perium

R1.1l.tV.

SOETOPO ET A L

(5 percent of all cases in this group).
The analysis of the type of treatment given
in the various liospitals showed that in 77
percent of al! cases it was medical treatnlent,
in 8 percent of all cases it was surgical
treatment. and in 15 percent of all cases ii
was for maternity and gyrlaecological trcatment. N~umber and type of some surgical
interventions performed in the various hospitals studied are outlined in I'igi11.c IV.
The analysis of the valious age groups
utilizing tlie v a ~ i o u shospitals ~ h o w c d t h a t 22
percent of all C;I\C\ were children up t o fifteen
years. consisting of 13 pcrcent of al! cases of
children below five years, and 9 percent of
children between five and fifteen years. Productive population group (15 - 45 years)
c o ~ i s l i t ~ ~ t111c
c r l main age group utilic.in,g the
hospitals ( 6 i percent of all cases).
Since no official strztificntion exist in Indonesia, for the purpose of this study it was tried
to group the patients into occupational groups
( o c c u p a t i o ~ of
~ head of household). Analysis
showed that 44 percent of all patients were
farnicrs. ti~rnilianrls and labourc~s: civil ser-

vants (23 percent of all patients): retired and
dependants ( 1 7 percent of al! patients)Figl~re

v.

Source of referrals of cases admitted to the
various hospitals were found to be mostly
their relatives/friends of the patients, in 61
percent of all patients, while medical doctors
(16 percent all patients) and health facilities
( 1 3 percent of all patients) we)-e second and
third source ofrefcrral to the 11ospi1alsf'ig~~rc
VI.
Outcome of hospitalizatioli showed that 72
percent o r all cases were discharged as cured,
19 percent of all cases ivere discharged as
relieved, while only 1 percent of al! cases were
not cured. Figurc VII.
The mortality in all these Ilospitals was 6
percent of all cases (range between 3 - '1
percent). RelL.1.1.;1ls to s higher echelon 110spita1 which were better equipped and staffed.
constitilted only Z percent of a11 adlnittance.
llospital rcsolll Les and operations! cost.
Studying t l ~ eope~ntingcosts of the 110spitals can not be scperatcd from tlie study of
the resources of the hospital (~nanpower,matcrial and money). The study on the operation

Fig V. Occupat~ondlstatus of patients a d ~ n ~ t t e In
d all hospitals studied

= c
5'

-

,
O f
".
3.&

Relativefriends
or neighbors

,

w

- O"

-

-. ,
,
1
(1

="
L

"

7

Medical doctors
Clinics. health
centres, others
hospitals
Paramedical
personnels
Police
(visum et re-

government,

R

officials

3

-

2

2.2

Cured

rt

rt

$

$ . Releived

-.

2

3

" 0-

G. zr

Died
Referred to higher

g 2 echelon hospital

-

z.
rt

,r~
7,

C

a

Not cured

-'

% Ran away from

'F $'

the hospital

5' Transferred

2

Referred to
lower echelon

a

w

p

fi

I&
It

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I

DISCUSSIONS

The regency level Iwsp~tal in Indonesia, is
an institution providing outpatient as well as
in-patient accomodation for medical and
nursing care and have at least one general
1 practitioncr as its pernianent staff.
This type of Iiospital is the first place of
1
referral for in-patient care, and should be able
to provide basic emergency care, because ofI ten
it is the only hospital available in the area.
One of tlie hospitals studied was situated on an
island. Tarakan hospit:~l. l~tilizationof health
ty
i facilities tliat is t l ~ cway the c o m m ~ ~ n i uscd
its health facility rcsourc.c w:ts determined by
1
I
the existe~iccof needs (vnhierability to disc; ase, injury and disability) wllicl~was in turn
greatly influenced by barriers t o access (predisposing and enabling factors).
The need for services: A household survey in
Indonesia (Sulianti. et a1 1972) showed that
50 out of 1000 persons are found t o have a
I morbid condition, of wliich 25 percent O L , C L I ~
in children below live years. Most p r c v a l e ~ ~ t
disease found wcw. acute upper respiratory
tract diseases; skin diseases, tuberculosis, acute
lower respiratory tract infections, diarrheal
/ diseases, nialaria and eye infectint~.About 2 2
/ percent of diseases found could be grouped as
diseases. These finding wel-L,:~lso
j infectious
reflected in findings of this study. whereby it
i
was found that the main case load of the
i
hospitals studied were mainly belonging t o
I four categories of diseases namely.
!
Infective and parasitic diseases (19 percent
I
of all cases); aaccidents, violence and poisonII ing (16 percent of all cases): diseases o f the
! respiratory systeln (12 percent of all cases);
I : and complications of pregnancy, childbirth
; and puerperium (10 percent of al! cases, after
1 deliveries have been oriiitted from the
ition).
st. of the diseases occuring in the infec,
.,ld parasitic diseases category belong t o
j a group of diseases which can be considered as.
i prcvcntable diseases.
It c h therefore be concluded that the main
case load of those hospitals were infectious
; diseases, which type, one way or the other
i was associated with harmful ecological and
environn~entalconditions. .
I
/ It wa!E further found that tlie disease paten1
in tht: regency level hospitals did not differ
1

1
'

:

I/
/

/

I

:
I

very much 'from the interniediate level 110spitals where more spccialistic care \\.as available or were being provided.
rhe utili~ationof hospital reqources: F i ~ ~ i l i ~ ~ g
of the present study that iii general the bed
occupancy rates found were low, ranging between 18 and 60 percent.
Ilowevcr it should be kept in mind that this
rate or any other indices of hospital utilization alone or by itsclf can not give a full
picture of the utili~ationpatern rn a certaln
area. This was also mentioned earlier, tliat
needs, need not r e f l ~ .i~t td f in utilization, but
there are still barr1t.r~ to access in between
these two poles. This deeincd tlie study team
necessary t o probe furtlicr on these matter.
The barriers t o access to any I ~ c a l t lservices
~
as was mentioned earlier are:
Predisposing Factors
This factor has more or less to d o with
demographic characteristics of tlie person or
population (age. sex, ethnic group, education
econoniic level) and the social, psychological
characteristics of the person or coni~iiunity
(knowledge, attitude/satisfaction with previous
services).
Results of thus study showed that in general as
many males were admitted into hospitals as
females. t-Iowevcr it was observed tliat Inore
111ale cluldren age less than five years werc
admitted, while Itlore females were adnutted than males in tlie productive age
group which rnay be causcd by the high
proportion of normal deliveries being carried
out in nlost of the hospitals.
Concerning tlie social, psychological characteristics o f persons or conlmunity, the household
survey (Sulianti et. al. 1972) found that reasons for not coming t o the health facilities
were: distance 15 percent, financial 28 percent,
non availability 7 percent, not statisfied 3 percent, n o t necessary 27 percent, others 1 percent. intended t o visit 19 percent.
The same study found that patterns of seeking
care (type of treatment for illnesses) werc as
follows: medical and paramedical treattilent
37 percent, medicine man (dukun) and other
5 percent, self treatment 1 4 percent, n o treatnient 4 4 percent. The beforc mentioned pat-'
tern o f seeking care may give some indications

about the knowledge and attitude of a person
or con~munity.
It can be concluded from tlie above findings
that barriers of cost and distance andpeople's
attitude in health & disease seemed t o play an
important role patiknts decision in seeking
health care.
In trying t o understand what people did
prior t o admission t o the hospital, a special
cluestionnaire was added t o the study, whereby patients were asked about their first contacts with various kind of medical services
(stress was put on the person not the institution), and how long they had been ill prior to
admission.
The total' questionnaire returns were 9863
out of the expected 16429 (total patients in
all hospitals), 6 0 percent returns.
The percentage of questionnaire returns varied
fro111 hospital t o hospital, between 30 and 72
percent (see table). One hospital did not return the questionnaires (Kupang Hospital).
The following findings about previous contact
with medical services prior t o admission, were
found: n o contact 38 percent, contacted medical doctor 25 percent, contacted paramedical 3 1 percent, contacted traditional
medical practitioner 5 percent, contacted
others not mentioned above 1 percent.
Results furtlicr showed that 7 7 percent of the
patients tendctl to contact one of the above
~nentionedservices within the first week prior
to adniission,
In trying t o understand what group of
diseases moved the people t o seek a particular
medical service mentioned above, an analysis
was done on the type of diseases of the
questionnaire returns.
Findings were as follows:
Complications of Pregnancy
Childbirth and Puerperium
Infective and Parasitic Disease
Accidents, Poisoning and Violence
Diseases of the Respiratory System
Diseases of the Digestive System
Diseases of the Genito-Urinary
System
Symptoms and ill Defined
Conditions
Others

2 0 percent
20 percent
17 percent
12 percent
6 percent

5 percent
5 percent
15 percent

All the above mentioned findings iricluding
the findings on the source of referrals of

patients coming to tlie I~ospitals. enahlcd to
conclude that people's decisions t o utilize tlie
hospital resources was a delayed process, and
niostly dependent or influenced by relatives.
This was ~>robaklya reflection of the so called
"interrupted ~eferral systen~", whereby pal t e c l type of meditients 11iigllt I I ~ V C c o ~ ~ s ~ ~ sottle
cal service on tinie, but decisions to be admitted were tlcl;~yerl.
Enabling Factors

,

Socio economic characteristics ~f patients:
This was ;in itifluencial factor in motivating
patients t o utilize health facilities resources.
Analysis showed that most of the patients
admitted were farmers, farmhands and labourers, and civil servants (67 percent). Cost of
medical services of civil servants in Indonesia
are however partially covered by an insurance
system for civil servants. The other groups
have t o pay fully from their own resources for
services rendered by the hospital.
Health service availability: Population coverage
found in hospitals studied (omiting other hospitals, if present) were calculated using the
assumed population at risk for hospitalization
as denominator (derived froni the household
survey findings, Sulianti et al., 1972 as denominator, where it was found that only one
third of patients which in reality needed hospitalization are hospitalized) were found to be
low.
Most of the people utiiizing the hospitals
came froni the same town where the hospit3ls
wcrc situated or the immediate neiglibouring
districts, table 3
This supports the previous conclusion that
distance played an important role in a persons
decision t o use a health facility resource.
Other factors which might contribute to
this low coverage may be related to:
Hospital beds availability. Bed- population
ratio, were found t o be generally low (omit:
ting other hospitals, if present, in the area), I
ranging between 0.14 - 1.65 per thousand
population, an6 the .people admitted to the
hospitals in areas where they are situated,
constitute 0.10 - 1.34% of the population
(based o n presumed annual admission divided
by the total population of the area).
Hospital recources. It has been shown in this ,
study that the regency level hospitals have a 1

Table 3 Percentage of admissions coming
from the same towns where hospitals located,
were as follows:

11

Total
Number
Number of p a of Patients cotients admitted ming from the
Same town

Percentage

Mojowarno
Misi Lebak
Kabanjahe
Sumedang
lndramayu
Wonosobo
Wonogiri
Lumajang
Pamekasan
Singaraia
Tondano
Martapura
Tarakan
Kupang
Purwokerto
All hospitals

16429

8393

51

low bed-occupancy rates and a low population
coverage, while costs t o operate these hospitals ranges between Rp. 13 million (in small
hospitals) to Rp. 45 million annually. which
will certainly increase in the years t o come.
Efficiency and effectiveness in running these
hospitals are therefore a prerequisite effort.
Hospital stal': From observations made by
four specialists of the Airlangga University
Medical School in four of the fifteen hospitals
it was concluded that although in these four
hospitals observed, the equipment were adequate (although some needed replacements) t o
cope with emergency care, tlle ability and
initiative varies considerably from hospital t o
hospital.
This seemed. t o be also true in the other hospitals-in the study.
They summarized their findings by stating
that what is needed is some arrangement t o
train the medical 4 paramedical staff on the
spot in order t o improve the capability of the
whole hospital staff, which may result in an
increase of the quality of services. Attention
should also be given t o administrative personnel.
Although
of the services in these hospitals also determine the rate of utilization, it

is not the main arid sole factor.
Hospitals operate in what economists call
"sellers niarket". Consumers are not influential, in fi~ctthey arc largely ignorant of the
services they "desire" and cannot dictate what
supplier provide. Theorists even argue over
whether patients are, in fact, the true consuluers of hospital services. In many ways
physicians,'because they requisition most hospital carc. fit the fonnal definition of "consumers" *).
Hospital equipment: Although it can be stated
that most hospitals are adequately equipped, a
nu~ilber of these equipments may need replacenients.
It is desirable t o have a standard list of
regency level llospitals equipment ( t o be able
t o cope with emergency cases).
Much attention should also be made in
improving its supporting services such as, laboratory, kitchen and laundry and water supply
system.
Hospital operational cost: Findings in this
study have shown that thcrc arc great differences between income and expenditure o f
these regency level hospitals, the gap of whicli
nlust be closed by Government or other sources.
Possible other sources of income, such as
Health Insurance Scheme, or other means
should be looked upon t o lessen the big gaps
the l~ospitals/government has t o overcome.
Hospitals supplies: As a result of the above
mentioned gap in funding, it can be stated
that all hospitals have problems in securing
supplies for tlic c u n u n u i r ~of
~ t.l~eirservices.
In most cases patients ,had to get their prcscriptions from local drugstores.
The availability and utilization of other
means of health services are also influential in
determining the flow of patienis to these
hospitals, table 4.
These above .n~entionedfigures were i'o; 1972.
Although names and typing has recently been
changed and standardized, the above figures
might give sonle idea about the density o f ,
various facilities in each regency where the
hospitals studied are situated..
Unfortunately data about utilization of the

*) Blum, Hendrik. L. editor: Health Planning 1969

Publisher: A.P.H.A. Western Regional Office
San Fransisco, U.S.A.

t

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' I V L 3 OdOL3OS 'I\\'II'CU

REGENCY HOSPITAL UTILIZATION IN INDONESIA

Jentre in Surabaya during the months
June to November 1972.
Results obtained showed, that: the four most
commoli diseases treated in these hospitals
werc: I1nfective and Parasitic Diseases (19 perIccidents, Violence and Poisoning (16
percent:), Diseases of the Respiratory System
(12 Percent), Complications of Pregnancy,
~L?I>L!LNlUl~11thand the Puerperium (10 percent,
after normal deliveries were deducted); the
POPU~ation coverage of these hospitals were
found! to be low (0,lO -- 1,34) percent; the
aea-occupancy rate was found to be low (18
- 60) percent; the average length of stay was
in general 8.55 days (minus normal deliveries
I1' --.-s
wa: 9.15 days); the hospitals were mainly
:
serving people of the town and area (districts)
where the hospitalis situated; the operational
cost Iof these hospitals were found) to range
between Rp. 13 million (in small hospitals)
and Rp. 45 million (in bigger hospitals).
Further it was found that the difference between the expenditure and income of these
hospitals ranged between 75 to 91 percent of

..

, '

the annual opcrafional cost.
An attempt was made to analyze the various
factors which might contribute to the cause of
under utilization of these regency level hospitals. These factors range from. a need for
services to actual utilization of hospital services and the influence of the barriers to
access (demographic, social psychological factors, educational, economical factors, the organization of health services/availabilabify and
the price to consu~i~ers
of hospital services).
ACKNOWLEDGEMENTS
The Health Services Research and Development Centre in Surabaya and the authors
would like to express their sincere gratitude to
all Provincial Health Officers and staff, Regency Medical Officers and staff, Directors and
staff of the hospitals where this study was
conducted, without whose cooperation and
assistance this study could not have been
carried out.

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