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Using a representative cross-section of health care providers in Indonesia, we describe variations in prenatal, child, and adult care quality. Quality is measured as knowledge about clinical guidelines. Public health centers offer above-average-quality prenatal care, and private physicians provide high-quality curative care. Private nurses offer below-average care, as do most providers in the more remote regions of Outer Java-Bali. The poor and wealthy have access to the same levels of quality; however, the poorest women report receiving fewer prenatal procedures. Recommendations include improving the professional development of nurses in private settings, testing quality improvements in Outer Java-Bali, and investigating wealth disparities in quality received.

Country studies from Indonesia, Tanzania, India, Paraguay, and Mexico document the quality of medical advice and variation in practice quality across a number of dimensions. This overview paper serves three purposes. First, the studies use several different measures; we contextualize these measures and discuss how they relate to each other. Second, we propose a three-way decomposition to analyze variations in the quality of care. These variations can arise from inequalities in access, inequalities in choices, or inequalities arising from discrimination. We discuss common elements across the studies and draw policy implications for future research and advocacy.

Quality is high on the Mexican health policy agenda. In this paper we evaluate the quality of prenatal care for rural low-income women. Women who obtained care from private practitioners and non-MDs received fewer procedures on average. Poverty predicts poor quality; however, indigenous women in private settings received fewer procedures, after household wealth was controlled for. We recommend strengthening clinical skills and providing incentives to adhere to quality standards. Quality reporting could promote informed employer care-purchasing and individual care-seeking choices. The national health reforms should be monitored to determine their success in not only increasing access among the poor and indigenous but also ensuring that such care meets quality norms.

Using a representative sample of public facilities surveyed in 1993 and 1997, we took advantage of exogenous changes imposed on the Indonesian health system to evaluate the contribution of physicians, nurses, and midwives to the quality of primary care. We found that quality depends on the availability, type, and number of health workers, which, in turn, is affected by public policies about deployment. We conclude that staff deployment could be refined by analyses of the skill-mix needed to provide quality care. Professional nurses in particular could play an important role in promoting quality.

The past decade has seen profound changes in how the hospital industry has organized itself, including the rising importance of hospital systems. Theoretically, system consolidation can have positive effects from improved efficiency and quality or negative effects from greater market power. This study examines which hospitals consolidate and finds that hospitals were more likely to join systems if they were for-profit institutions, were located in urban areas, or had high managed care loads. Furthermore, the evidence suggests that system formation has primarily served to increase market power, not improve patient care quality or hospital efficiency, at least in the short run.

During the past decade the hospital industry has made profound organizational changes, including the extensive consolidation of hospitals through merger and the formation of hospital systems. Although the rate of hospital system acquisitions may be slowing, the local presence of hospital systems is growing. Locally concentrated systems have been formed by both for-profit and nonprofit hospitals. Researchers have tended to ignore acquisitions or have portrayed system formation as primarily an issue of hospital ownership conversion, thereby focusing on the expansion of national, for-profit systems. This has left a large gap in policymakers' understanding of how locally concentrated systems may affect patient care and competition.