The unequal distribution of health care workers between urban and rural areas—and across subnational regions—has been a persistent policy challenge in many low- to middle-income countries, including Indonesia. Previous studies in other country settings have suggested that although the types of diseases and severity of illness experienced by rural residents are becoming increasingly similar to those found in urban populations, the access to and patterns of use of medical specialist services are very different. That is, amid increasing prevalence of non-communicable diseases and chronic illness, a significant share of the rural and regional population in the Global South continues to have limited access to medical specialist care (DeBenedectis et al. 2022; Duke et al. 2021; Lorch et al. 2021; Nguyen-Pham et al. 2014). Studies have shown that patients with chronic diseases such as diabetes, congestive heart failure, cancers and obstructive pulmonary disease who live in rural areas with fewer doctors per capita have fewer consultations and diagnostic tests (Corallo et al. 2014). Further, the lack of access to medical specialist services has a compounding impact on the quality of care for rural patients. For example, prehospital time for rural patients is prolonged compared to that for urban patients (Ashburn et al. 2022). Patients who live in regions with fewer beds will experience fewer hospitalisations and a lower likelihood of being treated in intensive care units (Wennberg 2002).

This chapter addresses the issue of regional disparities in access to and use of medical specialist services in Indonesia. While the unequal distribution of specialist physicians has been a longstanding problem in Indonesia, we argue that the required policy response to address this issue has become more complex because of decentralisation. In the context of increasing complexity in the planning and management of human resources for health following decentralisation, we present our assessment of the two broad strategies that have so far been employed by the government: the attempts to produce more doctors, and strategies to invite the private sector and foreign investment to meet the demand for private hospitals with specialist doctors.