Caught between social and market considerations: a case study of Muhammadiyah charitable health services.

A case study of Muhammadiyah's Islamic charitable health services in the islands of Java and Sumatra, Indonesia, was undertaken in 2008, to assess the impact of privatization of health care on this socially-oriented service provider, especially in terms of access for the poor. Findings presented here relate primarily to the effects on Muhammadiyah's maternal and child health and contraceptive services. In order to survive and thrive amidst private and public competitors, Muhammadiyah's primary care units, mostly consisting of maternal and child health centres and maternity clinics, when not closed altogether, have been directed toward providing curative hospital services, and more expensive and sometimes unnecessary treatment. A shift in the patient population away from the poor has also occurred, as market pressures transform this charitable enterprise into a commercial one, prejudicing reproductive health care and reducing access for those most in need. An improved stewardship role by government is needed to regulate the private sector, along with serious thinking about the future of primary and preventive care and health promotion, including for comprehensive reproductive health care. The neglect of these core primary care elements in Indonesia may worsen as privatization proceeds and profit considerations become more pressing with increased competition.