Chapter 4

The Indonesian Health Care System

Maternal and newborn care practices in Indonesia are strongly influenced by diverse local belief systems. Central among these beliefs is the role of fate or God’s will in the outcomes of pregnancy and delivery. Indeed, multiple anthropological studies in Indonesia have revealed deep-rooted belief systems in which maternal and child deaths are influenced by magic, fate, and God’s will. Several inquiries into maternal deaths have uncovered community-held beliefs that little can be done to save the life of a pregnant woman or newborn (UNFPA, 2008; Agus, Horiuchi, and Porter, 2012). In some cases, the use of traditional birth attendants (TBAs) is still dominant because women believe that following traditional beliefs and relatives’ suggestions will lead to a healthy pregnancy and birth (Agus, Horiuchi, and Porter, 2012).

Nevertheless, there has been growing recognition of the benefits of skilled medical care, and yet persistent barriers affect perceptions of quality, cost, and access. Family members of deceased women or children cite problems with health care access, fees, and inattentive medical personnel as factors contributing to deaths. These views suggest that there is recognition that some deaths are indeed preventable and are consistent with pregnant women seeking improved care and resources when barriers are removed.

Despite progress in reducing maternal deaths in Indonesia, pregnancy still puts the health of women at risk. This chapter describes Indonesia’s health system, whose primary purpose is to promote, restore, and maintain health, including maternal and neonatal health. The system includes all public and private health services, professional medical attention, traditional healers and birth attendants, and all public health activities (WHO, 2000).

Overview of Indonesia’s Health Care System for Maternal and Child Health

Any description of Indonesia’s health care system must be prefaced by a physical description of the country itself. Consisting of more than 13,000 islands spread over 1.9 million square kilometers and home to some 240 million people, Indonesia is the second most populous country in Asia and the fourth largest in the world. Its population is characterized by its wide diversity: demographic, economic, social, political, and cultural. About 56 percent of the population lives in rural areas. The country is divided into 34 provinces, each of which has a legislative council headed by a governor. The provinces comprise some 500 districts, divided into nearly 7,000 subdistricts in which there are almost 80,000 villages (Badan Pusat Statistik, 2012).

The Indonesian National Health Development Program is based on a primary health care concept: the community health center is the basic health care facility, supported by hospitals and other community-based health care facilities. The Ministry of Health (MoH) has overall responsibility for the nation’s health care policy. It manages and operates health care programs, including staffing, education and training, and health services.



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Chapter 4 The Indonesian Health Care System Maternal and newborn care practices in Indonesia are strongly influenced by diverse local belief systems. Central among these beliefs is the role of fate or God’s will in the outcomes of pregnancy and delivery. Indeed, multiple anthropological studies in Indonesia have revealed deep-rooted belief systems in which maternal and child deaths are influenced by magic, fate, and God’s will. Several inquiries into maternal deaths have uncovered community-held beliefs that little can be done to save the life of a preg- nant woman or newborn (UNFPA, 2008; Agus, Horiuchi, and Porter, 2012). In some cases, the use of traditional birth attendants (TBAs) is still dominant because women believe that following traditional be- liefs and relatives’ suggestions will lead to a healthy pregnancy and birth (Agus, Horiuchi, and Porter, 2012). Nevertheless, there has been growing recognition of the benefits of skilled medical care, and yet persistent barriers affect perceptions of quality, cost, and access. Family members of deceased women or children cite problems with health care access, fees, and inattentive medical personnel as factors contrib- uting to deaths. These views suggest that there is recognition that some deaths are indeed preventable and are consistent with pregnant women seeking improved care and resources when barriers are removed. Despite progress in reducing maternal deaths in Indonesia, pregnancy still puts the health of women at risk. This chapter describes Indonesia’s health system, whose primary purpose is to promote, restore, and maintain health, including maternal and neonatal health. The system includes all public and private health services, professional medical attention, traditional healers and birth attendants, and all public health activities (WHO, 2000). Overview of Indonesia’s Health Care System for Maternal and Child Health Any description of Indonesia’s health care system must be prefaced by a physical description of the country itself. Consisting of more than 13,000 islands spread over 1.9 million square kilometers and home to some 240 million people, Indonesia is the second most populous country in Asia and the fourth largest in the world. Its population is characterized by its wide diversity: demographic, economic, social, politi- cal, and cultural. About 56 percent of the population lives in rural areas. The country is divided into 34 provinces, each of which has a legislative council headed by a governor. The provinces comprise some 500 districts, divided into nearly 7,000 subdistricts in which there are almost 80,000 villages (Badan Pusat Statistik, 2012). The Indonesian National Health Development Program is based on a primary health care concept: the community health center is the basic health care facility, supported by hospitals and other community- based health care facilities. The Ministry of Health (MoH) has overall responsibility for the nation’s health care policy. It manages and operates health care programs, including staffing, education and train- ing, and health services. 39

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40 Reducing Maternal and Neonatal Mortality in Indonesia Community-based health care has been a cornerstone of the public health system in Indonesia since its inception. Early initiatives in maternal and newborn care focused on the provision of care through community health care centers (puskesmas) and village health posts (pustu), all aimed at supplanting the widespread use of traditional birth attendants (dukun) who, though unskilled, were part of the cultural fab- ric of pregnancy and childbirth throughout the country. However, it was quickly evident that more direct access was needed between trained health providers and the community for better maternal and newborn care. This led to the creation in 1989 of the village midwife program (Bidan di Desa) in which a trained midwife was placed in each village along with a village birth facility (polindes). The village midwife pro- gram also became an integrated part of the monthly community health extension post (posyandu) held in each village, thereby offering antenatal care and reproductive health consultations at the village level. These steps were accompanied by the engagement of community health volunteers (kaders)—a measure intended to facilitate outreach to the community and mobilization to promote the utilization of health care services. Since the establishment of integrated health services, several initiatives have been adopted in attempts to enhance this core system of community health care centers, village health posts, village mid- wives and birth facilities, community health extension posts, and community health volunteers. In addi- tion, efforts have been made to overcome the traditional and sometimes deleterious practices fostered by local tradition and the use of the traditional birth attendants. This system is described in detail in this chapter. Continuum of Care: From Primary Care (Health Centers) to Hospitals The lowest level of primary care is found in the villages, where most facilities are community-based and provide service for primary health care and prevention programs. In each subdistrict, at least one health center is supposed to be headed by a doctor, supported by two or three subcenters of which the ma- jority are headed by nurses. Health centers focus on health promotion, sanitation, mother and child health and family planning, community nutrition, disease prevention, and minor emergencies (Ministry of Health, 2004). Some health care centers, especially those in rural areas, have not succeeded in carrying out both curative and preventive tasks because the doctors who are supposed to work in these centers do not stay in rural areas. Large numbers of nurses posted to rural areas also open private practices in villag- es or cities (Webster, 2012). Few training centers for midwives are located in villages, and only 70 per- cent of midwives remain in villages; others migrate to cities (WHO, 2012). Table 4-1 shows the organization of health service delivery in Indonesia at five levels: village, sub- district, district, province, and central. The services and ratings listed are those required by government, but, as described later, not all levels of government comply with the requirements. Box 4-1 describes the facilities mentioned in Table 4-1. Standards of emergency obstetric and newborn care were set forth in the early 1990s by the World Health Organization, UNICEF, and United Nations Population Fund. These are the interventions that must be undertaken at the time of birth in order to address the sometimes unpredictable causes of mater- nal and neonatal mortality. These “signal functions” define the capabilities of facilities that must be avail- able to birthing mothers to save lives in the event of common birthplace medical emergencies (Table 4-2). The lack of basic and comprehensive emergency obstetric and newborn care came to the public’s notice in February 2013 in the press reports of baby Dera (Box 4-2). Aside from the lack of beds, few hospitals can provide the skilled health care workers, medicines, and equipment needed to meet the minimum standards of the World Health Organization (WHO) for emergency care. BEmONC health centers do not provide blood transfusions or cesarean sections, and pa- tients requiring them must be referred to a hospital with CEmONC capabilities. Table 4-3 shows the read- iness of public hospitals to provide CEmONC services.

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The Indonesian Health Care System 41 TABLE 4-1 Health Facilities at Different Levels of Service Delivery, Indonesia Administrative level Facilities Schedule of service Function Village Community based-facilities: 1 day per month All facilities in villages (posyandu, polindes,  Integrated health post (pos pustu, pusling) focus on primary care pelayanan terpadu—posyandu) (promotion and prevention). Posyandus are volunteer-based.   Maternity hut (pondok bersalin Daily office hours Monitoring growth charts; health education desa—polindes) and immunization. Sub-health centers (puskesmas Daily office hours Pustus extend the services of the puskesmas pembantu—pustu) (health centers) to remote areas. They provide services similar to those of the puskesmas, except for dental. There are no inpatient facilities. Mobile service units (puskesmas 1-4 times per month A pusling is a mobile unit (car) that visits keliling—pusling) villages, usually on market day. It often stops in a big field (soccer pitch) where it offers routine services similar to those offered by puskesmas. Private clinics (physicians and Daily services, usually open Private health services where patients consult midwives) after working hours doctors or midwives for a fee. Subdistrict Health centers (puskesmas) with Daily office hours There are two types of health centers: (kecamatan) or without an inpatient facility  Inpatient facility (including simple laboratory facility) o Open 24 hours o Specialist team o Simple surgery  Outpatient facility o Daily clinic, open during office hours. These provide promotion and prevention for primary health care and a simple laboratory facility. Some puskesmas (especially with inpatient facilities) are designated BEmONCs for maternity services. Private clinics (physicians Daily services, usually open after Services for a fee. and midwives) working hours District First-referral hospitals (CEmONC) Daily office hours for 24-hour emergency unit. consultation with doctors Focus on clinical services (surgery, etc.); provide daily consultation with specialist doctors, laboratory facilities, emergency maternity services. Private hospitals (some are Daily Usually exist in a big district. Some private designated CEmONC) hospitals are built only for mother and child (rumah sakit bersalin dan anak, women’s and children’s hospital). Private clinics (physicians and Weekdays, after working hours Services for a fee. midwives) Province Second-referral hospitals 24 hours a day, seven days a week 24-hour emergency unit. (CEmONC) Focus on clinical services with more advanced medical equipment than hospitals at the district level. Private hospitals (CEmONC) More specialist doctors. Central Tertiary or top-referral hospitals 24 hours a day, seven days a week 24-hour emergency unit. Hospital as center of excellence Advanced medical technology with complete (CEmONC) team of specialists. NOTE: BEmONC = basic emergency obstetric and newborn care; CEmONC = comprehensive emergency obstetric and newborn care, which includes cesarean section and blood transfusion. SOURCES: Ministry of Health (2003, 2010b).

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42 Reducing Maternal and Neonatal Mortality in Indonesia BOX 4-1 Indonesian Health Care Facilities: Health Posts, Health Centers, and Hospitals Integrated Health Posts (Posyandus) At the village level, the integrated health post serves as the first line of care, followed by basic pro- fessional care at health centers and clinics, and then higher referrals to district and advanced hospi- tals. The concept of such a center was part of the fourth five-year development plan issued in the early 1980s. About 270,000 posyandus are in place across Indonesia (Ministry of Health, 2010a). Among other things, they register births, weigh babies, maintain growth charts, and provide nutrition education and immunizations. Open once a month and serviced by a skilled health worker, these centers, it is hoped, are helping the women and children of Indonesia overcome major health problems. Indeed, the posyandu was a critical component of the Health for All 2000 initiative because it brought an integrat- ed program of maternal and child health, family planning, nutrition, immunization, and diarrheal control to the village level. Health Centers (Puskesmas) Since the 1970s, basic health services, especially primary care, have been centered on the puskesmas, or community health centers. Most health centers are equipped with four-wheel-drive ve- hicles or motorboats so that they can serve as mobile health centers and provide transportation to un- derserved populations in urban and remote rural areas. Several midwives are typically stationed at the puskesmas, and obstetrical exam and birthing rooms equipped with the basic equipment are available. Antenatal care at the puskesmas typically includes pregnancy testing, counseling, monitoring of weight gain and fetal development via palpation and a Pinard stethoscope, assessments of maternal hemoglobin levels, blood pressure monitoring, and biochemical tests for proteinuria, although the latter is not consistently available. Birthing facilities include a clean delivery room and basic equipment and supplies such as oxytocin, but they do not fulfill the requirements for basic emergency obstetric and newborn care (BEmONC). Patients with complications are referred to either the district hospital or an- other facility, possibly a more fully equipped puskesmas for BEmONC or comprehensive emergency obstetric and newborn care (CEmONC). Regulations in Indonesia require a minimum of four BEmONC health centers (designated puskesmas) in each district. Based on the 2011 Health Facility Survey (Rifaskes), only 61 percent of districts in Indonesia have at least four BEmONC facilities, and the ma- jority of these facilities are on Java or Bali (Ministry of Health, 2011b). Only 42 percent of the districts located in the eastern part of Indonesia (excluding Sulawesi) have at least four BEmONC-designated health centers. The figures for other regions are Kalimantan, 54 percent; Sumatra, 55 percent; Sula- wesi, 66 percent; and Java-Bali, 75 percent (Ministry of Health and UNFPA, 2012). The 2011 Health Facility Survey also reported that 28 percent of BEmONC-designated facilities do not operate 24 hours a day, and those facilities are located mostly in eastern Indonesia (Ministry of Health, 2011b; WHO, 2012). In Indonesia, only 45 percent of BEmONC facilities meet the personnel requirement, and only 12 percent have the required equipment. Finally, only 3 percent of BEmONC facilities have all the medications required (Ministry of Health and UNFPA, 2012). Eastern Indonesia (excluding Sulawesi) falls at the lower end. Hospitals Hospitals are the main providers of curative care. Indonesia has four types of hospitals, ranging from teaching hospitals in the country’s major cities to district-level hospitals, where all basic services are provided and the more complicated cases are referred to the higher-level hospitals. Hospitals are open 24 hours a day. However, admission of all patients to a facility is not guaranteed, especially if the patient lacks the ability to pay. In an article published in The Lancet, the director of Indonesia’s oldest maternity hospital, Budi Kemulyaan, admitted that, even in Jakarta, there are not enough hospital beds and not enough financial support for women facing catastrophic health costs (Webster, 2012).

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The Indonesian Health Care System 43 TABLE 4-2 Signal Functions for Emergency Obstetric and Newborn Care SOURCE: Jhpiego (2012). BOX 4-2 The Case of Baby Dera In February 2013, a baby named Dera, less than one month old, died after being refused admission to 10 hospitals in Jakarta. The reasons given were that the hospitals were full and that there were not enough neonatal intensive care units. This case, which was covered widely in the press (BBC, 2013; Jakarta Globe, 2013; www.news.com.au, 2013), raised awareness of the need to improve health facili- ties and coverage for the community. But the introduction of health insurance alone, if not supported by a good referral system and the availability of skilled personnel, will not prevent deaths. In Jakarta, all low-income families receive health cards that give them access to free health services. Since the introduction of health cards in Jakarta in November 2012, there has been a 70 percent in- crease in the demand for hospital services. However, this initiative was not followed by an increase in the number of health personnel or beds. Jakarta has only 143 neonatal intensive care beds for a population of about 10 million (Tempo, 2013). After the media reported the death of baby Dera, the Jakarta gov- ernment began to take action by changing class 3 wards towards designated for patients with health cards. Hospitals, with assistance from the Ministry of Health, are also devoting more resources to neona- tal intensive care units. And additional health workers are being deployed by means of collaboration among hospitals, the Ministry of Health, and the Faculty of Medicine of the University of Indonesia. SOURCE: Jakarta Globe (2013). TABLE 4-3 Readiness of Public Hospitals to Provide Comprehensive Emergency Obstetric and Newborn Care (CEmONC) Indicator Coverage (%) Public hospitals that meet the nine criteria for CEmONC 21.0 Public hospitals with obstetrician 82.9 Public hospitals with pediatrician 75.5 Public hospitals with anesthesiologist 48.8 Public hospitals ready for obstetric operation in less than 30 minutes 59.1 Public hospitals with 24-hour blood service 54.2 Public hospitals with 24-hour laboratory service 63.9 SOURCE: WHO (2012).

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44 Reducing Maternal and Neonatal Mortality in Indonesia Community Involvement Community involvement has a long history in maternal health in Indonesia. That involvement in- cludes family, community, and midwives, as well as the traditional birth attendants. The integrated health post (posyandu) was introduced to facilitate access to services in the villages. Its primary health care workers are volunteers, kaders, who are selected by the head of the village or a village committee. They are typically literate and have completed primary school, but few have a secondary school education. They are supervised at the posyandu by staff from the health centers (puskesmas), who are in turn guided by a working group composed of representatives of the Ministry of Home Affairs, Ministry of Health, National Development and Planning Bureau, local government, Family Planning Coordination Board, and Women’s Empowerment Movement (PKK). The kaders’ primary task is to make it easier for villagers to visit the posyandu, to mobilize campaigns for immunization or vitamin A distribution, and to promote and educate the community about the importance of antenatal care and skilled attendance at birth. In many cases, kaders may be hired by nongovernmental organizations (NGOs) or receive short-term government stipends for specific health promotion programs or activities at the village level. Current evidence sug- gests that kaders are generally ineffective in fulfilling their roles in the community because they are not professionals and they serve as volunteers with little accountability. Several studies in Indonesia and elsewhere have indicated that well-trained community health promoters can have a substantial impact on maternal and newborn health. These findings thus emphasize another recurring theme: investment in hu- man resources at all levels has been suboptimal in Indonesia. During the joint committee’s visit in September 2012 to one posyandu in Makassar, South Sulawesi, some volunteers related how they record all pregnant women in their area, taking specific note of high- risk pregnancies. One volunteer usually covers 10 households. The volunteers encourage women with high-risk pregnancies to seek prenatal care in due time, and they help these women to arrange transporta- tion to a health facility. The volunteers are essential to the operations of the posyandus. Even so, some posyandus cannot recruit enough volunteers to serve the community, and in some places and cases the services provided are inadequate. Since 1989, the Bidan di Desa (BDD) program has been the focus of the Indonesian effort to im- prove maternal and child health and offer family planning services. The plan was to put a midwife and village birth center (polindes) in every village. However, in many areas this has not yet been achieved. In this program, the existing trained nurses were given an additional year of training in midwifery skills, with the expectation that they would significantly improve the quality and quantity of antenatal, obstetric, postnatal, and contraceptive services in the villages, thereby reducing the morbidity and mortality rates for mothers and infants. Midwives employed in the public sector would be contracted by central, provin- cial, or district governments, or directly by health facilities. Most midwives work in hospitals, health cen- ters, and village birth centers. They may also offer services in a home or in a structure that is the property of or was built by the village government for the specific purpose of serving as a birth center (polindes)— see Rokx et al. (2010). Although midwives are expected to use the village birth centers to provide ser- vices, many of these centers are poorly constructed, substandard structures that are poorly equipped (Hull, Rusman, and Hayes, 1998). The role of the traditional birth attendant (dukun) continues to be an important one at the community level. Qualitative studies indicate that for many women the dukun is the preferred community-based pro- vider to consult for assistance during delivery. This preference stems from both the perception that the majority of birth outcomes are positive and the role of the dukun in providing support services for house- hold chores in the week after delivery. The role of the dukun in invoking the blessing of the spiritual an- cestors of the community and family is also thought to be important. Though initially discouraged by the Ministry of Health, joint engagement of both a dukun and midwife is now gaining acceptance among midwives and the Ministry of Health, who recognize that these figures may provide a path toward facili- ty-based deliveries and more extensive postnatal care.

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The Indonesian Health Care System 45 Public versus Private A main feature of the health care situation in Indonesia is the inequity between rich and poor and urban and rural. A 2010 study by the World Bank reported that the richest people, and those living in ur- ban settings, are seven times more likely to access health facilities, public or private, than their poorest counterparts (World Bank, 2010). In Indonesia, public health facilities such as public hospitals and health centers (puskesmas) are meant to be sources of revenue for local governments. These facilities receive subsidies from the central government for salaries and operational costs, but they are required to adopt the self-supporting (swadana) principle, which means relying on user fees to finance the nonsalary costs of medical care. However, they have never been allocated the resources they need to manage themselves profitably. The swadana principle forces local governments to raise revenue by any means, including contracting out ser- vices to the private sector. The system has led to growth in the number of private sector health institu- tions, and two-thirds of the financing and more than half of the services are now in private hands (Hey- wood and Choi, 2010). Of the 1,800 hospitals in Indonesia, some 650 are private. Only about 50 percent of the private hos- pitals are accredited by the Ministry of Health, and only five hospitals have received international accredi- tation (Ministry of Health, 2012). Of the five, three hospitals are affiliated with internationally branded organizations: Siloam, Gleneagles, and Mount Elizabeth’s. The Ministry of Health does not regularly supervise the operational activities of hospitals or the quality of care offered by hospitals. In general, the private hospitals are profit-based medical institutions and are usually not considered agents for carrying out community health programs, including those aimed at reducing maternal and neonatal mortality. Only 300 of the 650 private hospitals participate in the government-based health insurance (Jamkesmas). In Jakarta, where the municipality provides health insurance to the poor through the distri- bution of health cards, private hospitals are only required to offer 10 percent of their beds to health card holders, compared with 60 percent of public hospitals (Ministry of Health, 2011a). Some private hospitals have an associated midwifery school, but the quality of the training depends on the quality of the hospital and the organization or the owners behind it. The private midwifery school graduates can work in public hospitals or health centers after graduating, in the same way that the public midwifery school graduates can work in private hospitals or health centers. At public medical institutions such as health centers and hospitals, all midwives, either publicly or privately trained, must enter the government employment sys- tem. Similarly, both public and private midwifery school graduates must pass the private medical institu- tion exam to work in the private sector. To supplement their low government salaries, doctors, nurses, and midwives deployed at the local level are encouraged to open their own private practices in the areas in which they work. However, most of them leave the rural areas where they supposed to work on a daily basis and move to nearby urban are- as for better private practice. Thereafter, they only occasionally visit their workplaces in rural areas. Health Personnel Since the mid-1970s, the windfall profits of the oil boom have allowed the Indonesian government to build health centers (puskesmas) with the goal of providing at least one per subdistrict. Many of these health centers were (and some still are) located in relatively isolated areas with limited infrastructure and access. Such health facilities are not considered ideal places to begin a professional career, especially for doctors who have already spent many years completing their studies and much money on their education. To staff these centers, the government turned to Law No. 8 (1961), Compulsory Labor for University Graduates (Wajib Kerja Sarjana), and applied it to a number of professions, including health personnel. In 1991 the government introduced Presidential Decree No. 37, which forced new medical school graduates to spend three years in a rural post as a dokter PTT (nonpermanent or contract staff doctor) as a condition

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46 Reducing Maternal and Neonatal Mortality in Indonesia for eligibility to earn their license to practice, most of them in the city, or to return to school to specialize. However, the program suffered from a variety of design problems. This forced labor for doctors was discontinued when Indonesia ratified ILO Convention No. 105, Abolition of Forced Labor, as Law No. 19 on May 7, 1999. Since then, recruitment of doctors for place- ment in remote areas has been on a voluntary basis with reasonably attractive, and expensive, benefits. This change places greater pressure on local budgets, especially since decentralization when the recruit- ment and placement of doctors in community health centers became the responsibility of local govern- ments with limited revenue. The village midwives program (Bidan di Desa) was initiated in 1989 when the government was still highly centralized and only one policy decision was needed for the nation. At the time, it was regarded as an imaginative and successful program because over 50,000 midwives were placed in villages throughout the archipelago in less than a decade (Shankar et al., 2008). The midwives were under contract to the cen- tral government as nonpermanent staff (Heywood and Choi, 2010). When decentralization was adopted, the central government was no longer required to provide health staff for local communities, and delivery of services became the responsibility of local govern- ments. However, not all local governments consider midwives a priority (Heywood and Choi, 2010). Many village midwives have therefore left for urban centers, where opportunities in private practice are far greater. Regional Variation in Health Services As in most countries, in Indonesia doctors tend to be concentrated in the cities, and midwives tend to follow a similar path, seeking more urbanized areas to practice their profession. In terms of number of doctors per unit of population, Jakarta’s position with respect to that of less densely populated provinces is not clear.1 Jakarta covers only some 660 square kilometers, and yet it is home to almost 10 million peo- ple, according to the population census of 2010. On the basis of population, Jakarta is not overly supplied with health services providers and facilities; it has 39 medical staff, 87 nurses and midwives, and 4 com- munity health centers per 100,000 population. Some other provinces are better served, such as Yogyakar- ta, which has 68 medical staff, 182 nurses and midwives, and 3 community health centers per 100,000 population. However, in terms of geographic density, Jakarta has more than 5,000 doctors, more than 12,000 nurses and midwives, and more than 500 puskesmas per 1,000 square kilometers, implying a well- developed demand for health services. The second-highest density of health services is found in Yogya- karta, and the third-highest in Bali. Both of these provinces are small and relatively well developed. Yog- yakarta is known as an educational center, and Bali is world renown as a tourist destination, where avail- ability of quality health care is important. Most other provinces fall far below, especially the rural provinces in Eastern Indonesia (Table 4-4). These data show that the nature of the regional imbalance in health care delivery in Indonesia is not simply a matter of distribution of facilities among provinces and districts, but of geography. The provinc- es are much larger than Jakarta, and although they may have a comparable number of health providers per capita, those providers are sparsely distributed, and, for women, reaching the necessary facilities during childbirth may be extremely difficult in many areas. Reducing the practical effects of this imbalance would require more than simply adding health providers to existing facilities, because many of the facili- ties themselves are inaccessible to many families. This problem is inherent in a country with more than 13,000 islands, and it must be addressed with commensurate actions. 1 Jakarta has special status (like Washington, DC). Even though in terms of geography it is more resembles a municipality, it is treated more like a province.

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The Indonesian Health Care System 47 TABLE 4-4 Number of Health Providers and Facilities per 100,000 Population and per 1,000 Square Kilometers, Indonesia Number of Health Providers and Facilities Per 100,000 Population Per 1,000 square kilometers Province MS N&M CHC MS N&M CHC MS N&M CHC Aceh 1,600 16,000 310 38 370 7 29 280 5 North Sumatra 4,400 16,000 500 33 120 4 60 220 7 West Sumatra 1,700 9,300 240 36 190 5 41 220 6 Riau 1,600 9,600 180 30 180 3 18 110 2 Riau Islands 770 4,900 61 51 320 4 94 600 7 Jambi 780 5,800 160 27 200 6 16 120 3 South Sumatra 370 4,900 280 5 68 4 4 53 3 Bangka-Belitung 300 2,500 55 26 220 5 18 150 3 Bengkulu 500 4,700 170 30 280 10 25 240 8 Lampung 1,200 5,200 260 16 70 4 35 150 8 Sumatra 13,300 79,400 2,200 27 160 4 28 160 5 Jakarta 3,600 8,000 340 39 87 4 5,400 12,100 510 West Java 5,100 24,600 1,000 12 59 2 140 700 28 Banten 840 9,600 200 9 98 2 87 990 20 Central Java 6,200 35,400 850 19 100 3 190 1,100 26 Yogyakarta 2,400 6,400 120 68 180 3 7603 2,0008 38 East Java 8,200 33,800 940 22 91 3 170 700 20 Java 26,400 117,900 3,500 20 88 3 200 910 27 Bali 2,000 8,900 110 56 250 3 340 1,500 20 West Nusa Tenggara 710 4,500 140 16 100 3 38 240 8 East Nusa Tenggara 710 8,900 290 15 190 6 15 180 6 Bali + Nusa Tenggara 3,400 22,200 550 27 180 4 47 300 7 West Kalimantan 900 6,500 230 21 150 5 6 44 2 Central Kalimantan 600 4,800 170 29 230 8 4 31 1 South Kalimantan 820 6,100 210 24 170 6 21 160 5 East Kalimantan 1,400 7,000 200 44 220 7 7 34 1 Kalimantan 3,700 24,500 820 29 190 6 7 45 2 North Sulawesi 740 5,200 160 33 230 7 53 370 11 Gorontalo 230 1,60 75 24 160 8 21 140 7 Central Sulawesi 500 3,000 160 20 120 7 8 49 3 South Sulawesi 1,500 5,000 400 20 64 5 33 100 8 West Sulawesi 270 1,300 77 26 120 7 16 75 5 Southeast Sulawesi 320 4,300 220 15 200 11 8 110 6 Sulawesi 3,600 20,400 1,100 22 120 7 19 110 6 Maluku 480 3,900 130 36 290 10 10 83 3 North Maluku 280 2,900 96 29 290 10 9 90 3 Papua 300 4,100 270 14 190 13 1 13 1 West Papua 270 3,000 100 32 350 12 3 31 1 Maluku + Papua 1,300 13,900 600 25 260 11 3 28 1 Indonesia 51,800 278,000 8,700 22 120 4 27 150 5 NOTE: MS = medical staff; N&M = nurses and midwives; CHC = community health center. SOURCES: Badan Pusat Statistik (2011); Ministry of Health, http://www.depkes.go.id.

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48 Reducing Maternal and Neonatal Mortality in Indonesia Demand for Maternal Health Services Demand for maternal health services, particularly for services more commonly associated with safe and secure delivery remains an issue in much of Indonesia. According to the 2012 Indonesia Demograph- ic and Health Survey, or IDHS (Badan Pusat Statistik et al., 2012), about 37 percent of births in the five years preceding the survey occurred “outside of a medical facility, almost all of these being within the woman’s own home” (Table 4-5). This figure represents a significant improvement over the 2002 IDHS when closer to 60 percent of births were recorded as taking place outside a medical facility and the level recorded in the 2007 IDHS of about 54 percent. However, even these figures need to be treated with cau- tion because. as in Table 4-5, the term medical facilities includes not just organized hospitals or clinics but also places such as the home of a nurse or qualified midwife. Changes in classification of birth loca- tion also make comparison to earlier rounds of the IDHS difficult, although it is worth noting that surveys in the 1990s in which the homes of local midwives were in the same classification as those of the preg- nant women seeking their services showed closer to three-quarters of births occurring “at home.” Attendance at birth is also an issue, with only a small proportion of births attended by doctors or ob- stetrician/gynecologists. The latter, in particular, are mainly confined to urban areas (Table 4-6). There has been a fairly steady shift over the years from use of traditional birth attendants to mid- wives, but the use of TBAs remains strong among less educated women and those in rural areas. As well, it should be noted that here midwives include village midwives, many of whom are unable to offer much in terms of service when any significant complications occur. Although dealing more with neonatal mor- tality than with maternal mortality, a 2009 study by Hatt et al. (2009) using pooled IDHS data between 1991 and 2002 concluded that they could find no measurable relationship between overall declines in ne- onatal mortality and the increased availability of health personnel, notably through the village midwife program that got under way in 1989 and in theory provided for replacements for less trained birth attend- ants for deliveries in the home elsewhere in the village. Interestingly, this situation can be contrasted with the demand for antenatal care, which has appar- ently benefitted from long-standing public programs to encourage at least four check-ups during pregnan- cy. According to the just released 2012 IDHS (Badan Pusat Statistik et al., 2012), during the five years preceding the IDHS more than 95 percent of women received at least one check-up from doctors, nurses, or trained midwives (Table 4-7). The same survey also found that nearly three-quarters reported the requi- site four visits or more. TABLE 4-5 Percent Distribution of Live Births in the Five Years Preceding the IDHS by Place of Deliv- ery and Place of Residence, Indonesia: IDHS, 2002, 2007, 2012 Health Facility Place of Residence Year of IDHS Government Private House Other Not Stated Urban 2002 13.1 46.5 39.5 0.3 0.6 2007 12.9 57.4 28.6 0.7 0.4 2012 20.4 59.5 19.3 0.0 0,6 Rural 2002 5.9 16.6 76.1 0.5 1.0 2007 7.4 21.5 69.6 0.6 0.8 2012 14.2 32.5 52.4 0.3 0.6 Total 2002 9.2 30.5 59.0 0.4 0.8 2007 9.7 36.4 52.7 0.7 0.6 2012 17.3 45.9 36.0 0.2 0.6 SOURCE: Indonesia Demographic and Health Survey (IDHS), 2002, 2007, 2012.

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The Indonesian Health Care System 49 TABLE 4-6 Percent Distribution of Live Births in the Five Years Preceding the IDHS by Type of Assistance at Birth and Place of Residence, Indonesia: IDHS, 2002, 2007, 2012 Place of General Nurse/ Traditional No one/ residence Year of IDHS practitioner Ob-gyn midwife birth attendant Relative/other missing Most qualified attendant Urban 2002 0.6 16.6 61,8 19.9 0.5 0.6 2007 1.0 20.8 65.7 11.3 0.8 0.3 2012 1.3 27.7 62.8 6.7 0.8 0.8 Rural 2002 0.9 4.6 49.7 41.6 1.9 1.4 2007 1.0 6.8 54.9 33.1 3.3 0.9 2012 0.7 12.4 61.5 20.2 4.1 1.1 Total 2002 0.8 10.2 55.3 31.5 1.3 1.1 2007 1.0 12.6 59,4 24.0 2,3 0.7 2012 1.0 20.0 62.2 13.5 2.5 1.0 NOTE: Following the IDHS format, the table includes data on the most qualified attendant at the birth. SOURCE: Indonesia Demographic and Health Survey (IDHS), 2002, 2007, 2012. TABLE 4-7 Percent Distribution of Live Births in the Five Years Preceding the IDHS by Antenatal Care Provider during Pregnancy for the Most Recent Birth and Place of Residence, Indonesia: IDHS, 2002, 2007, 2012 Place of General Traditional birth No one/ residence Year of IDHS practitioner Ob-gyn Nurse/ midwife attendant/other missing Urban 2002 1.7 16.0 79.0 0.9 2.4 2007 2.0 20.8 74.9 0.8 1.5 2012 1.2 27.9 69.1 0.4 1.4 Rural 2002 1.2 3.9 81.9 6.5 6.9 2007 1.9 5,7 82,5 3.8 6.1 2012 1.7 10.2 81.3 1.9 4.9 Total 2002 1.4 9.6 80.5 3.9 4,6 2007 1.9 12.0 79,3 2.5 4.2 2012 1.4 19.0 75.3 1.2 3.1 NOTE: If more than one source of care is provided only the most qualified provider is considered in the table. SOURCE: Indonesia Demographic and Health Survey (IDHS), 2002, 2007, 2012. Cost and distance are among the most obvious factors affecting the use of trained attendance and in- stitutional deliveries (Titaley et al., 2010). Particularly in more isolated regions and among poorer and less educated women, even carrying out an effective referral for difficult deliveries is far from easy. As shown in Table 4-6, the change in the most qualified attendant in rural areas is largely reflected in shifts from TBAs to trained midwives—still largely in a community setting. In urban areas, the shift is more from midwives toward doctors and ob-gyn’s, which is one indication, among others, of the much easier access to health personnel and particularly to more professional care when it is needed. Some recent initiatives designed to increase the use of health institutions include the maternity in- surance scheme, Jampersal. It is specifically designed to ameliorate the cost implications of institutional deliveries as well as encourage an increase in the number of community health centers with a capacity for basic emergency services in neonatal obstetrics (BEmONC)—see Faizal (2011). The data in Table 4-5 are supportive of these initiatives, showing a recent marked increase in the demand for institutional deliver- ies, along with a more moderate increase in the use of highly qualified providers such as ob-gyn’s (Table 4-6). The results also tie in with international experience in the positive impact of some of these supply- side initiatives, particularly in the use of health insurance.

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50 Reducing Maternal and Neonatal Mortality in Indonesia However, another factor noted by Titaley et al. (2010) and others as well (e.g., Faizel, 2011) is simp- ly the preference of women who have a normal pregnancy to give birth in more familiar surroundings, According to this view, trained attendants and institutional deliveries are in effect aimed primarily at women experiencing obstetric complications. This finding is in some ways of greater concern because it suggests that purely supply-side measures may not be sufficient in and of themselves to bring all deliver- ies into fully safe and secure surroundings. It is also of interest that, although public efforts appear to have been largely successful in convincing women of the importance of regular antenatal check-ups more or less irrespective of how they feel, the same cannot be said of institutional deliveries, even where they in- volve institutions such as health clinics where the quality of service may still be relatively low. Thus, although the emphasis on supply-side interventions designed to address concerns related to access and cost remain critical, there also appears to be a need for a greater focus on the demand side, particularly at the community level. It should include efforts to educate families about the importance of giving birth under safe conditions and to inform them that a normal pregnancy without obstetric issues is no guarantee that a medical emergency during childbirth affecting the health of either the mother or the newborn child will not arise.2 References Agus, Y., S. Horiuchi, and S. E. Porter. 2012. Rural Indonesia women's traditional beliefs about antenatal care. BMC Research Notes, October 29, 589. Badan Pusat Statistik (Statistics Indonesia). 2011. Statistical Yearbook of Indonesia 2011. Jakarta. ______. 2012. Statistical Yearbook of Indonesia 2012. Jakarta. Badan Pusat Statistik (Statistics Indonesia), National Population and Family Planning Board, Ministry of Health, and Measures DHS ICF International. 2012. Indonesia Demographic and Health Survey 2012 (Preliminary Report). Jakarta: Badan Pusat Statistik. BBC. 2013. Row over Indonesia new-born “denied treatment.” February 19. Available at http://www.bbc.co.uk/ news/world-asia-21502407. Faizal, Elly Burhaini. 2011. Indonesian women prefer “risky” home birth: Official. Jakarta Post, November 14. Hatt, L., C. Stanton, C. Ronsmans, K. Makowiecka, and A. Adisasmita. 2009. Did professional attendance at home births improve early neonatal survival in Indonesia? Health Policy Planning 24(4):270-278. Heywood, Peter, and Yoonjoung Choi. 2010. Health system performance at the district level in Indonesia after de- centralization. BMC International Health and Human Rights, 1-12. Hull, T. H., R. Rusman, and A. C. Hayes. 1998. Village Midwives and the Improvement of Maternal and Infant Health in NTT and NTB. Report prepared for the Australian Agency for International Development (AusAID). Jakarta Globe. 2013. Baby case shows Jakarta hospitals can’t cope. March 1. Available at http://www.thejakarta globe.com/archive/baby-case-shows-jakarta-hospitals-cant-cope/575526/. Jhpiego. 2012. Guidelines for In-Service Training in Basic and Comprehensive Emergency Obstetric and Newborn Care. Johns Hopkins University, Baltimore. Ministry of Health. 2003. National Health System. National draft. Jakarta, August. ______. 2004. MOH Decree 128/2004, Basic Policy for Health Center, Jakarta. ______. 2010a. Data and Information. Jakarta. ______. 2010b. Technical Guidance of DAK in Health 2010 (Petunjuk Teknis Penggunaan DAK Bidang Kesehatan Tahun 2010). Jakarta. ______. 2011a. Coordination meeting for health care program operationalization. Hotel Bidakara, Jakarta, October. ______. 2011b. Risfaskes/Health Facility Survey. National Institute of Health Research and Development, Ministry of Health, Jakarta. ______. 2012. Pengumpulan Data dan Kajian Kualitas Pelayanan Kesehatan Ibu Pada Tingkat Pelayanan Kesehatan Dasar dan Rujukan di Indonesia Tahun 2012. Factsheet: Direktorat Bina Kesehatan Ibu, Ditjen Bina Gizi dan 2 The 2012 IDHS noted, for example, that while nearly all women who undertook antenatal check-ups received basic checks such as weight, blood pressure, stomach exam and consultation, only about half said they had received any specific information on symptoms of pregnancy complications or about the dangers of childbirth outside of surroundings where basic emergency services are not available (Badan Pusat Statistik et al., 2012).

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The Indonesian Health Care System 51 Kesehatan Ibu dan Anak, Kementerian Kesehatan RI. Available at http://www.kesehatanibu.depkes.go.id/wp- content/uploads/downloads/2013/01/Factsheet_Assessment.pdf. Ministry of Health and UNFPA (United Nations Population Fund). 2012. Disparity versus Access and Quality. Ma- ternal Mortality Study in Five Regions in Indonesia (Disparitas VS Akses serta Kualitas Kajian Kematian Ma- ternal di 5 Region Indonesia). Jakarta. Rokx, Claudia, John Giles, Elan Satriawan, Puti Marzoeki, Pandu Harimurti, and Elif Yavuz. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study (Directions in Development). Washington, DC: World Bank. Shankar, A., et al. 2008. The village-based midwife programme in Indonesia. Lancet 371:1226-1229. Tempo. 2013. Baby Dera case: Hospitals required increase third-class capacity (Kasus Dera: RS diminta tambah Kapasitas Kelas III). Tempo, February 22. Available at http://id.berita.yahoo.com/kasus-dera-rs-diminta-tambah- kapasitas-kelas-iii-015206906.html. Titaley, Christiana R., Cynthia L. Hunter, Michael J. Dibley, and Peter Heywood. 2010. Why do some women still prefer traditional birth attendants and home delivery? A qualitative study on delivery care services in West Ja- va Province, Indonesia. BMC Pregnancy and Childbirth 10:43. UNFPA (United Nations Population Fund). 2008. UNFPA: New Report Shows Cultural Sensitivity Critical to Success- ful Development Strategies, Women’s Equality. Available at http://www.unfpa.org/public/lang/en/News/pid/ 1375. Webster, P. C. 2012. Indonesia makes maternal health a national priority. Lancet 380:1981-1982. WHO (World Health Organization). 2000. Health System: Improving Performance. The World Health Report 2000. Available at http://www.who.int/whr/2000/en/whr00_en.pdf. ______. 2012. Briefing Note. Asia-Pacific Leadership and Policy Dialogue for Women’s and Children’s Health, Ma- nila, November 7-9. Available at http://www.who.int/pmnch/media/press_materials/pr/2012/20120717_asia_ pacific_dialogue/en/index2.html. World Bank. 2010. Indonesia Health Sector Review—Accelerating Improvement in Maternal Health: Why Reform Is Needed. Washington, DC: World Bank, UKAid, 2010. www.news.com.au. 2013. Baby turned away by 10 hospitals in Indonesia dies. February 19. Available at http://www. news.com.au/lifestyle/health-fitness/baby-turned-away-by-10-hospitals-in-indonesia-dies/story-fneuzlbd- 1226580727818#ixzz2MgaUnZPd.

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