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What Progress is Indonesia Really Making to Improve Maternal Health?

April 1, 2009

A decade ago, when Indonesia launched an ambitious program to place a midwife in every one of Indonesia’s 70,000 villages, the country got international recognition for its bold programming move. But how quickly is Indonesia making progress on health, particularly as related to its commitment to the United Nations Millennium Development Goal (MDG) to reduce maternal mortality?

It’s election season in Indonesia, and during two recent meet-the-candidate sessions in Surabaya, East Java, women legislative candidates faced a range of tough questions on health from their constituents. They asked how would they improve access to health services? How would they address domestic violence through the health system? How would they increase budget allocations for health? They asked about family planning, about reproductive health, about child and adolescent health, as well as HIV/AIDS.

So back to my first question on maternal health: While the national midwife program certainly created some initial results, today, Indonesia’s maternal mortality rate remains one of highest in Southeast Asia. Experts closely studying the problem generally conclude that a change in course is needed for Indonesia to make further progress.

First, there are questions about whether the government has the ability – or the resources – to actually improve health. Performance and utilization of public health services is on the decline, and the private sector is now the major source of health care in Indonesia. An estimated 30-50 percent of newborn deliveries in health facilities now take place in private clinics (as compared to approximately 10 percent a decade ago). Preference for private sector services may be due, in part, to understaffing of public health facilities, and high absenteeism. The government allows “dual practice” whereby civil servant health providers are allowed to establish a private practice outside of official work hours. As a result, studies show an average of 40 percent of doctors absent from their public post during work hours.

Overall, per capita spending on health in Indonesia is much lower than other countries in the region, and insurance coverage is extremely limited. Health financing is overwhelmingly private – with individuals paying for around 80 percent of all health outlays, mostly out-of-pocket. Disturbingly, the poor utilize less of publicly-funded health services provided by the state: the poorest 20 percent of the population captures less than 10 percent of total public health subsidies, while the richest fifth captures almost 40 percent. Policy analysts also point to added problems to health financing caused by inadequate distributions in health funding among provinces, and major inefficiencies in how funds are spent.

Government health spending also occurs in the context of Indonesia’s rapid decentralization of government services, whereby local government is now the focal point for providing health care. Decentralization was meant to bring those responsible for health services closer to their constituents. In reality, districts’ limited financial resources are incredibly constraining. In another recent example from East Java, advocates from one district were elated when their legislature passed a 2009 operating budget that quadrupled the allocation for maternal and child health. But upon delving deeper, their jubilation may have been premature: even at four times the amount of funding allocated, per capita spending on maternal and child health was a paltry 13 cents per capita.

The many challenges of health financing and governance are compounded by policies that keep the health system from effectively addressing leading causes of maternal death. While Indonesia’s village midwife strategy significantly increased the number of deliveries attended by a midwife, and in so doing addressed many preventable causes of maternal death, emergency obstetric care is still difficult to access and often poor in quality. Of the 15,000 Indonesian women who die from pregnancy-related causes annually, most deaths are now related to unpreventable conditions that require access to emergency care. Yet around half of Indonesian women deliver at home – and delays during maternal emergencies that prevent women from accessing emergency care are well-documented. Clearly, Indonesia needs to adjust its policies to encourage women to make the transition to delivering in health facilities where emergency care is easy to access.

Finally, there is the challenge of getting an accurate measurement of maternal mortality. Without this, policymakers are working in the dark. As in other countries, measuring maternal mortality is difficult. Vital registration systems are not functioning, and estimates provided by population-based surveys may not be accurate, because many maternal deaths are misclassified and attributed to non-maternal causes. The most credible population-based survey in Indonesia, the Demographic Health Survey (DHS), has documented a declining trend in maternal mortality. The DHS recorded 307 deaths per 100,000 live births during the period of 2000-2004. During 2004 to 2008, the survey recorded 228 such deaths. However, a recent World Bank publication cited evidence that Indonesia’s maternal mortality rate could be as high as 420/100,000. Without more accurate data, policymakers are driving blind.

So, yes, in this election season, it’s great that citizens are putting health so prominently on the agenda. But there remains a pressing need for heightened and sharper dialogue about how the country can accelerate its progress – with inputs from government, researchers, health providers, professional associations, and broader civil society.

Laurel MacLaren is The Asia Foundation’s Deputy Country Representative in Indonesia. She can be reached at lmaclaren@tafindo.org.

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