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Indonesia

Developing an Investment Case

for Financing Equitable Progress

towards MDGs 4 and 5 in the Asia

Pacific Region

Phase 1: Mapping Report

Laksono Trisnantoro

Soewarta Kosen Eliana Jimenez Soto

Sonja Firth Samantha Hollingworth

October 2009

Investment Case MDGs 4 & 5 - Country Mapping Report – Indonesia ii

Table of Contents

Table of Contents ............................................................................................................................. ii

List of Tables .................................................................................................................................... iii

List of Figures .................................................................................................................................. iii

Abbreviations .................................................................................................................................. iv

Acknowledgements ........................................................................................................................ vii

Preface .......................................................................................................................................... viii

Executive Summary .......................................................................................................................... x

1. Introduction ........................................................................................................................... 1

2. Background and Context ........................................................................................................ 2

2.1 Profile of Indonesia ...................................................................................................... 2 2.2 The Status of Maternal and Child Mortality ................................................................ 3

3. Review of Key Policy and Planning Processes and Documents ........................................... 11

3.1 Maternal and Child Health ......................................................................................... 11 3.2 Strategic Planning and Financing for Maternal and Child Health .............................. 14

4. Review of Key Datasets ........................................................................................................ 18

4.1 Indonesia Demographic Health Surveys (IDHS) ......................................................... 18 4.2 Sub-Survey: Young Adult Reproductive Health Survey (IYARHS) ............................. 19 4.3 National Socio-Economic Survey (SUSENAS) ............................................................. 19 4.4 Village Potential Statistics (PODES) ........................................................................... 20 4.5 Population Census ..................................................................................................... 20 4.6 The Intercensal Population Surveys (SUPAS)............................................................. 21 4.7 The Indonesian Family Life Survey ............................................................................ 21 4.8 Governance and Decentralisation Survey (GDS) ....................................................... 22 4.9 Baseline Health Survey .............................................................................................. 23 4.10 Indonesia Health Profiles (IHP) .................................................................................. 24 4.11 Indonesia Mortality Registration System Strengthening Project (IMRSSP)............... 24 4.12 Data Sources on Health Workforce ........................................................................... 25

5. Review of Key Analytical Work ............................................................................................ 30

5.1 Burden of MNCH Mortality ........................................................................................ 30 5.2 Priority MNCH interventions ..................................................................................... 37 5.3 Equitable Progress towards MDGs 4 and 5 ............................................................... 53 5.4 Health Systems Constraints and Strategies ............................................................... 59 5.5 Allocation of Financial Resources to MNCH and Resource Requirements for Scale-

up of Interventions .................................................................................................... 66

6. Recommendations ............................................................................................................... 71

References ...................................................................................................................................... 72

Appendix 1 – Annotated Bibliography ........................................................................................... 78

Investment Case MDGs 4 & 5 - Country Mapping Report – Indonesia iii

List of Tables

Table 4.1: Summary of Key Datasets .......................................................................................... 27 Table 5.1: Summary of information Related to MNCH Mortality .............................................. 34 Table 5.2: Summary of Information Related to Priority MNCH Interventions ........................... 47 Table 5.3: Summary of Information Related to Equitable Progress towards MDGs 4 ............... 56 Table 5.4: Summary of Information Related to Allocation of Financial Resources .................... 67 Table 5.5: Summary of Information Related to Resource Requirements for

Scale-up of Interventions .......................................................................................... 70

List of Figures

Figure 2.1: Map of Indonesia [3] .................................................................................................. 2 Figure 2.2: Infant Mortality Rates, Selected Sources, Indonesia 1971-2007 ............................... 3 Figure 2.3: Health System Delivery in Indonesia .......................................................................... 9 Figure 3.1: Share of Government Spending on MNCH Financing .............................................. 16 Figure 3.2: Local Government Budget for MNCH ....................................................................... 17 Figure 5.1: Financial Gaps and Financial Space .......................................................................... 68

Investment Case MDGs 4 & 5 - Country Mapping Report – Indonesia iv

Abbreviations

ABPD District Municipality

ABPN Central Government

AMMP Adult Morbidity and Mortality Project

ANC Antenatal Care

APBD Total Government Budget

APBD-KES Total Regional Government Health Budget

APBD-KIA Total Regional Government MNCH Budget

APBN State Revenue & Expenditure Budget

APN Asuhan Persalinan Normal/Normal birth care

ARI Acute Respiratory Infection

Askeskin Asuransi Kesehatan Masyarakat Miskin (National Health Insurance for Poor Population)

AusAID Australian Agency for International Development

BMGF Bill and Melinda Gates Foundation

BPPSDMK Board for Health Human Resources

BPS Badan Pusat Statistik (Statistics Indonesia)

CBs Census Blocks

CICH Centre for International Child Health

CMC Conventional Mother Care

CPPS Centre for Population and Policy Studies

DALY Disability Adjusted Life Year

DI Daerah Istimewa

DOH Department of Health

DTPS-MPS District Team Problem Solving – Making Pregnancy Safer

GDS Governance and Decentralisation Survey

IC Investment Case

IDHS Indonesia Demographic Health Surveys

IDI Indonesian Doctors Association

IFA Iron,Folic Acid Supplementation

IFLS Indonesian Family Life Survey

IHPs Indonesia Health Profile

IMCI Integrated Management of Childhood Illness

IMR Infant Mortality Rate

IMRSSP Indonesia Mortality Registration System Strengthening Project

IYARHS Indonesia Young Adult Reproductive Health

Jamkesda Local Government Health Insurance Scheme

Jamkesmas Jaminan Kesehatan Masyarakat (Health Insurance Scheme for the Population)

Jamsostek Jaminan Sosial Tenaga Kerja (Workforce Social Security

Investment Case MDGs 4 & 5 - Country Mapping Report – Indonesia v

JPSBK Jaring Pengamanan Sosial Bidang Kesehatan

KAP Knowledge, Attitude and Practices

KIP/K Komunikasi Interpersonal dan Konseling

KKI Indonesian Medical Council

KMC Kangaroo Mother Care

LSS Life Saving Skills

MDG Millennium Development Goal

MMN Multiple Micronutrients

MMR Maternal Mortality Ratio

MNCH Maternal, Newborn and Child Health

MoF Ministry of Finance

MoH Ministry of Health

MoHMoH Centre for Health Data & Information

MSS Minimum Service Standards

NHHS National Household Health Survey

NHS National Health Survey

NIHRD National Institute of Health Research and Development

NTB Nusa Tenggara Barat

NTT Nusa Tenggara Timur

OB/GYN Obstetrician/Gynaecologist

ORS Oral Rehydration Solution

PATH Program for Appropriate Technology in Health

PMTCT Prevention of Mother to Child Transmission

PODES Potensi Desa (Survey of Village Potential -Village Potential Statistics)

PONED Neonatal Emergency Service

PONEK Neonatal Emergency Service Program

PT Parastatal Agency

PWS-KIA Pemantauan Wilayah Setempat Kesehatan Ibu-Anak MCH surveillance

RCT Randomised Control Trial

RKP Government Annual Plans

RPJM Rencana Pembangunan Jangka Menengah (Medium Term Plan)

SBA Skilled Birth Attendant

SEARO’s South-East Asia Region Organisation

SIKD Sistem Informasi Keuangan Daerah (Local Government Expenditure database)

SIM PPSDM Health Human Resources Information System

SKTIR Survei Khusus Tabungan Dan Investasi Rumahtangga (survey on savings and household investments)

SUPAS The Intercensal Population Surveys

SUSENAS Susenas Survei Sosial Ekonomi Nasional (National Socioeconomic Survey)

TB Tuberculosis

TBA Traditional Birth Attendant

Investment Case MDGs 4 & 5 - Country Mapping Report – Indonesia vi

UCLA University of California, Los Angeles

UGM University of Gadjah Mada

Under-5 Under Five Years

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

UNIJECT Uniject® Autodisable Injection Device

WHO World Health Organisation

Investment Case MDGs 4 & 5 - Country Mapping Report – Indonesia vii

Acknowledgements

We gratefully acknowledge the support and timely assistance of several individuals within BAPPENAS, the Ministry of Health, Ministry of Home Affairs and other Government institutions in Indonesia. In particular, we would like to thank members of the Indonesian National Steering Committee and the Technical Working Group who helped establish the direction of the project and provided advice and guidance during the process, along with their experiences and insights into recent developments in the Indonesia health sector. This report would not have been possible without the support and collaboration of Anne Vincent and Fajar Arif Budinam from UNICEF Indonesia office. We would also like to thank some staff from the School of Population Health at The University of Queensland: Tim Adair for reviewing the mortality information, Zoe Dettrick for reviewing studies on child and maternal mortality and Asmat Malik for assisting with the annotated bibliography. The staff from Gadjah Mada University and the National Institute of Health Research and Development have also contributed to the compilation and review of datasets and studies. The production of the mapping reports for this multi-country study has been coordinated by Eliana Jimenez (Principal Investigator) and Sonja Firth (Project Manager) from the School of Population Health, University of Queensland.

Investment Case MDGs 4 & 5 - Country Mapping Report – Indonesia viii

Preface

The ‘Investment Case for Scaling up Equitable Progress towards MDGs 4 & 5’ (IC) is part of a multi-country initiative that aims to contribute to equitable progress on MDGs 4 & 5 by providing policymakers and development partners with the best available evidence to scale-up priority interventions that will address the burden of Maternal, Newborn and Child mortality in an equitable way. Funded by AusAID and the Bill and Melinda Gates Foundation (BMGF), the initiative is being implemented by a multi-partner consortium of the AusAID knowledge hubs and national research partners in close collaboration with UNICEF. The project will be undertaken in two phases. Phase 1 involves mapping of policy documents, analytical work and datasets relevant to Maternal, Newborn and Child Health (MNCH) and identifying gaps in information or in data availability for analysis. In addition, the engagement and consultation of government and development partners has been undertaken to ensure that the Investment Case effectively contributes to planning and budgeting for MNCH. Phase 2 involves the analysis of the equitable distribution of MNCH related variables and the study of scaling-up constraints, the associated strategies and corresponding costings. The project approach has been to tailor the Investment Case to the specific conditions and requirements in each country, including timelines for government planning and budgeting. An integral part of this mapping exercise has been identifying the major players in this area and discussing how this IC can ‘value add’ to existing activities. Phase 2 activities will therefore be informed by both the mapping exercise and the consultation with government and development partners in each country. As a consequence, the scope of the IC is different in each of the study countries and in some cases has resulted in a different emphasis in the mapping reports. In India, the IC will be undertaken in five poorly performing states (Orissa, Madhya Pradesh, Uttar Pradesh, Chhattisgarh and Jharkhand). A recent study has provided evidence for the best-buy MNCH interventions; key scaling-up strategies; and associated costings and impact in the study states. The IC will build on this analytical work to focus at district-level. This analysis will be most useful since districts are now required to produce district level plans and budgets, but a comprehensive evidence-based planning and costing exercise has not yet been done for disadvantaged districts. In Indonesia, the difficulties associated with planning and budgeting at a local (district) level have been identified as one of the key constraints to efficient provision of MNCH services. The Phase 2 analysis will be undertaken in a selection of poorly performing districts of different typologies and will be directly linked to budgets and plans in these districts. In Nepal, the need to inform the government plans for health has meant that Phase 2 activities have had to be brought forward and have been undertaken in parallel with the mapping exercise. An analysis that targets districts with poor MNCH outcomes as well as the different typologies that affect the provision of health services is currently being undertaken. In Papua New Guinea, both the National Government and Development Partners have advised that the health systems constraints and scaling-up analysis does not appear to be useful at this time. Consultation with the National Department of Health (DOH) revealed that an equity analysis to examine the distribution of, and relationships between, health outcomes,

Investment Case MDGs 4 & 5 - Country Mapping Report – Indonesia ix

intervention coverage and risk factors according to equity markers would be a valuable addition to their current review and planning efforts. In the Philippines, the analysis will take place in three sub-national sites and will inform the development and/or finalisation of their 5-year plans. This initiative focuses on assisting two selected provinces and one independent city to develop MDG 4 and 5 related investment plans and proposals. These strategies will be translated into costed MNCH sub-plans. In collaboration with the DOH, sub-national findings will be used to inform the development of a national Investment Case. Multi-disciplinary teams are working on the Investment Case, including the mapping exercise, in each country. The School of Population Health, University of Queensland, is leading the multi-country implementation. The Public Health Foundation of India and the Nossal Institute are responsible for the Investment Case implementation across the five states in India. The Investment Case activities in Indonesia are coordinated by Gadjah Mada University, the National Institute of Health Research and Development (NIHRD) and the School of Population Health, University of Queensland. New ERA and the Nossal Institute have been responsible for the Investment Case work in Nepal. The University of PNG and Burnet Institute are leading the work in Papua New Guinea. The Investment Case in the Philippines is under the leadership of UPEcon, Inc., the Centre for International Child Health (CICH), University of Melbourne and Menzies School of Health Research. UNICEF offices have provided strong support to the Investment Case activities in each country.

Investment Case MDGs 4 & 5 - Country Mapping Report – Indonesia x

Executive Summary

In Indonesia mixed progress on key health indicators has been observed in recent years. Higher coverage rates for immunisation and improved access to health care for common ailments such as malaria, diarrhoea and acute respiratory infection have contributed to improved health outcomes in older children. Under-5 mortality rates fell from 69 deaths per 1000 live births in 1993-1997 to 44 in 2003-2007. Neo-natal mortality rates have also declined over the 10 year period but they have done so at a slower rate. The percentage of moderate and severely malnourished children under five years of age rose from 24.7 percent in 2000 to 28 percent in 2005. Progress in relation to MDG 5 has been weaker. The latest Indonesia Demographic Health Survey (IDHS) estimates put the Maternal Mortality Ratio (MMR) at 228 deaths per 100,000 live births in 2007 [1]. WHO, UNICEF, UNFPA and the World Bank estimated a substantially higher MMR at 420 deaths per 100,000 live births [2]. Notwithstanding the disputed figures, by any measure MMR is unacceptably high. Additionally, national indicators mask substantial inequities between provinces, districts and socio-economic groups. For example, Under-5 mortality rates range from 22 per 1,000 live births in DI Yogyakarta to 96 in West Sulawesi. Under-5 mortality is also substantially higher for children living in rural areas (60 deaths per 1,000 live births) when compared to those living in urban households (38 deaths per 1,000 live births). Nationally, 46% of births take place at a health facility, sub-nationally; this ranges from 91% in Bali to 8% in South Sulawesi. Similar differences amongst socio-economic groups are also observed: 83% of women in the highest wealth quintile give birth at a health facility, compared to only 14% of women in the lowest quintile do. This mapping report represents Phase 1 of the Investment Case (IC) in Indonesia. It provides a comprehensive overview of policy and planning documents that constitute the framework for Maternal, Newborn and Child Health (MNCH) delivery, datasets available for analysis, and key analytical work within Indonesia relevant to MDGs 4 and 5. The relatively slow progress in maternal and neonatal health indicates that a more robust health system is required. Geographical disparities highlight the different conditions and constraints under which health interventions are delivered in the country. This situation is in sharp contrast with the centrally-driven approach to MNCH policy that still persists today, in which MNCH plans and policies are not directly linked to sound implementation and health financing strategies. Such an approach in a diverse and decentralised country like Indonesia has failed to translate policies into effective implementation. Decentralisation, if well managed, could offer the opportunity for locally-driven solutions that respond to the diversity of problems and strategies to scale-up MNCH interventions faced by provinces and districts in Indonesia. On the other hand, an ill-designed and poorly implemented decentralisation program could seriously hinder the delivery of health services as it has been observed during the last decade in Indonesia. The key policy challenge is how to improve ownership of MNCH by the local government and mobilise local financing support for MNCH. So far, local governments have not been mobilised to support, prioritise and fund the MNCH agenda. The central government budget has limited capacity for financing the provision of MNCH services along the continuum of MNCH care program. Moreover, the current flow of funds from central to local government is cumbersome and funding disbursement suffers from severe delays. Financing from local governments, community and the private sector is required to scale-up the delivery of preventative and primary health care interventions.

Investment Case MDGs 4 & 5 - Country Mapping Report – Indonesia xi

Engagement of local governments is necessary to effectively address the social determinants of health in the local communities. Innovative approaches that involve an active participation of the private sector should also be explored by local governments. One key challenge for policymakers on the ground is to develop plans and budgets that set implementation and funding priorities based on evidence. This mapping exercise has found that there are gaps in data analysis and availability. There is no report available on national infant and mortality data at district level and rates are extrapolated. There are no data available for cost-effectiveness analysis in MNCH. Another gap is the lack of costing data for MNCH interventions to inform central and local government budgeting processes. There is limited research on family oriented, population oriented and individual clinical services and the scarce information available is not used for MNCH budgeting at the central, provincial or district government level. There is no analysis on the allocation of available funding to MNCH. Formidable problems exist in the use of evidence for government budgeting and planning. Although geographical and socio-economic disparities have been extensively documented, there is no comprehensive analysis of the distribution of MNCH related variables. These gaps reflect the problem for estimating the additional funding required to effectively address the constraints and bottlenecks and to scale-up the “best-buy range of interventions” to achieve such equitable progress on MDGs 4 and 5. As a result of the mapping exercise undertaken during Phase 1, recommendations for Phase 2 activities in Indonesia are as follows:

1. Perform an equity analysis of MNCH related variables with focus on Under-5 mortality and selected MNCH interventions. Taking into consideration data availability, such analysis for maternal mortality will not be feasible;

2. Perform a scaling up analysis in selected disadvantaged districts.

The health systems constraints and strategies for scaling up critical interventions for MNCH in Indonesia are likely to be heterogeneous. In addition, a report outlining the costs to reach MDGs 4 & 5 at a national level has been published. The mapping report illustrates that understanding constraints and establishing ‘ownership’ of MNCH at a local level will be important to the effective implementation of strategies in a country with a decentralised health system such as Indonesia. These analyses could be used as ‘case studies’ that could be emulated in other districts planning for MNCH and that could be used to inform the development of Minimum Service Standards (MSS);

3. Link scaling up analysis to district level budgets and plans. It has been demonstrated that currently MNCH expenditure does not reflect the real needs at a local level. A key contribution for this IC should be the linking of the costings from the scaling-up analysis of critical MNCH interventions with local and central government plans and budgets.

One intermediate outcome of the IC could be to increase the budget for MNCH from various sources (e.g. local government and community). This is the main reason why we recommend a district level approach for the IC in Indonesia. Based on the decentralisation policy and MSS, the decision making for prioritising effective interventions and investment for MNCH should be initiated at the district level. The decision making for resources allocation should use Musrenbang (local government development plan process) from district to provincial level. The principle of MSS could be used to request local governments to provide funding for maternal and child health. If the local government is not capable of financing and

Investment Case MDGs 4 & 5 - Country Mapping Report – Indonesia xii

implementing the minimum standards for maternal and child health indicators, then provincial government funding could support the districts. Central government could act as the last financier and “equalising fund” supporting the system if the province cannot meet the standards. Such a health financing strategy would contribute to increasing available funding for MNCH while improving the effectiveness of local spending. Financing from local governments is required to scale-up the delivery of preventative and primary health care interventions. Local government engagement is required to effectively address the social determinants of health in the local communities.

Investment Case MDGs 4 & 5 - Country Mapping Report – Indonesia 1

1. INTRODUCTION

The Millennium Development Goals (MDGs) 4 and 5 call for a two-third reduction in the Under-5 Mortality (U5M) rate and a 75 percent reduction in Maternal Mortality Rates (MMR) by 2015 (from 1990 levels). The Countdown to 2015 group has recently produced a report on the progress of nations towards these goals, which highlights that while effective interventions exist for the prevention of child and maternal mortality, the coverage of these interventions is not adequate.

The Bill and Melinda Gates Foundation and AusAID are funding the development of Maternal, Newborn and Child Health (MNCH) Investment Case in India, Indonesia, Nepal, Papua New Guinea and the Philippines. The Investment Cases aim to highlight the importance of investments in maternal and child health and contribute to evidence-based planning and budgeting for equitable progress on MDGs 4 and 5 in the five countries. The project aims to understand, at the sub-national level, the costs and impacts of scaling up strategies that will overcome identified constraints to equitable coverage of the “best-buy” range of MNCH interventions.

This study report for Indonesia has been prepared based on secondary information. It involved the identification, collection and review of a wide range of documents relating to maternal and child health, from health policies to district-level research studies. Emphasis was given to documents from 2000 onwards, although some key earlier documents were also retained. The documents were assessed in relation to the objectives of the IC. A preliminary assessment of the availability, reliability and validity of data and information at national and sub-national level was also conducted, leading to the identification of data gaps. Whilst comprehensive, this mapping report does not constitute an exhaustive resource of all available documents.

The report has been organised as follows. Firstly, the country context is described, including information on key demographic, health and geographic characteristics of the country, the organisation of the health system including the decentralisation of health services. The next section reviews key policy and planning for MNCH. Section 4 outlines the datasets available for the IC analysis in Indonesia and the constraints on further analysis. In section 5, key analytical work related to MNCH is reviewed according to project objectives and gaps in information identified. To supplement the review provided in this report, an Annotated Bibliography of key studies can be found in Appendix 1.

The information gathered from the mapping exercise will be used in Phase 2 to guide the strategic direction of the project, facilitate identification of constraints in the health system, and estimate the additional funding needed to overcome these. These recommendations are presented in the final section of the report.


2. BACKGROUND AND CONTEXT

2.1 Profile of Indonesia The Republic of Indonesia is the largest archipelago and the fourth most populous country in the world (Figure 2.1). According to the 2000 Population Census, the population of Indonesia was 205.8 million in 2000 and projected to reach 225.6 million in 2007. The country has over 17,000 islands, of which only 6,000 are inhabited. Located at the meeting point of two tectonic plates, the population is highly vulnerable to natural disasters such as earthquakes and tsunamis. The country is ethnically diverse with hundreds of ethnic groups, each with its own language. The Indonesian motto, “Unity in Diversity” reflects the country’s heterogeneity. Figure 2.1: Map of Indonesia [3]

At the beginning of the 1970s, Indonesia was one of the poorest countries in the world with a per capita income of U$50 and 60% of the population living below the poverty line[3]. The international oil boom of the 1970s and a successful industrialisation process in the following two decades led to a period of impressive economic growth. The Asian financial crisis of 1997 brought to a halt the economic miracle in Indonesia. The economic recovery started in the year 2000 and has been accompanied by lower poverty rates, although they are yet to reach the pre-Asian financial crisis levels. The country has made substantial human capital gains in the last four decades. Data from the Population Censuses and the National Socio-Economic Survey (SUSENAS) show that literacy rates among persons age 10 years and older increased from 61 percent in 1971 to 93 percent in 2007. Even more impressively, at all levels the improvement in education indicators has been higher for females than males. Along with the education gains for women, other indicators of women’s welfare have also improved, including mean age at first marriage, labour force participation and female wages [4]. Improvements in women’s status along with poverty alleviation highlight some of the substantial advancements in the social determinants of maternal and child health that Indonesia has made during the last decades. Key health indicators for women and children have also improved steadily, although substantial challenges remain.


2.2 The Status of Maternal and Child Mortality Policymakers acknowledge that notwithstanding progress in the last four decades, high MNCH mortality rates and persistent inequalities are a priority. If constraints to the scale-up of priority health services are not addressed, the ambitious targets set in the latest draft of the National Development Plan 2010–2014 may not be achieved. Additionally, progress made is likely to be inequitable, unless the specific constraints facing provinces and districts with high MNCH mortality are targeted with sound strategic implementation and financing plans. The Under-5 mortality rate declined from 69 deaths per 1,000 live births in the period 1993-1997 to 44 in the period 2003-2007 [1]. The latest estimates of child mortality for Indonesia also show a reduction from 16 to 10 deaths per 1,000 live births over the same period [1]. It is argued that higher coverage rates for immunisation and higher access to health care for common ailments such as malaria, diarrhoea and acute respiratory infection have contributed to reductions of mortality in older children. The Indonesia Demographic Health Surveys (IDHS) 2007 presents a trend analysis of Infant Mortality Rates (IMR) [1]. As observed in Figure 2.2, the Infant Mortality Rate (IMR) sharply decreased from 142 in 1967 to 68 in 1992. However, since the late 1990s this rate has declined very slowly. Moreover, the decline of infant mortality in the last years might have been overstated. After correcting for potential biases in the calculation of the annual reduction rate of mortality, the IDHS estimates that for 2007, the IMR would be 37 deaths per 1000 live births (10% higher than the observed 34% rate). Figure 2.2: Infant Mortality Rates, Selected Sources, Indonesia 1971-2007

Source: IDHS 2007 [1]

Neonatal mortality rates have also declined over the 10 year period (1993/1997 – 2003/2007), but they have done so at a slower rate. While post neonatal mortality rate was reduced by 40%, the neonatal rate declined 32%. The proportion of infants who died during the first 28 days has increased. Furthermore, the proportion of the newborns that died in the first day and the first week has also increased.


Access to health services during pregnancy and birth delivery are major determinants of newborn health outcomes. A recent analysis of determinants of neonatal death during 1997-2002 found that availability and use of perinatal health services such as Skilled Birth Attendants (SBA) and postnatal care were associated with reduced odds of neonatal deaths [5]. The relatively slow progress in neonatal health indicates that a more robust health system is required to meet the MDGs target. Indicators of national progress mask substantial inequities between provinces and socio-economic groups [1]. Under-5 mortality is substantially higher for children living in rural areas (60 deaths per 1,000 live births) when compared to those living in urban households (38 deaths per 1,000 live births). This might reflect better access to health facilities and services in urban areas. Provincial disparities in neo-natal, infant, child and Under-5 mortality rates for the 10-year period preceding the survey have also been observed. Infant Mortality is the lowest in DI Yogyakarta (19 deaths per 1,000 live births) and highest in West Sulawesi (74 deaths per 1,000 live births). Likewise, children in West Sulawesi are over four times more likely to die before their fifth birthday than children in DI Yogyakarta. A similar situation is observed with neonatal mortality rates [1]. As a consequence of complications during pregnancy and childbirth, a substantial number of mothers continue to die each year. According to the latest IDHS analysis [1], the MMR declined from 334 deaths per 100,000 live deliveries in the 1993-1997 period to 307 in the 1998-2003. A faster decline seems to have taken place in the following years, which brought the MMR down to 228 in 2007. However the observed differences in MMR across time might not be statistically significant [1]. Furthermore, according to the global datasets and analysis by WHO, UNICEF, UNFPA and the World Bank, the MMR in Indonesia appears to stand at 420 [2]. Notwithstanding the disparity in MMR estimates, the general agreement is that by any measure they are unacceptably high. Indonesia faces an enormous challenge to meet the international MDG 5 target, which calls for a three quarters reduction in MMR between 1990 and 2015. This puts the 2015 target at 110 deaths per 100,000 live births. Very few studies on causes of maternal death are available (see Section 5). The World Bank notes that over the last 14 years, the causes of maternal death have changed [6]. Whilst 43 percent of deaths were attributable to haemorrhage in 1995, estimates for 2002 attributed a 30 percent An increasing number of women are accessing the services of Skilled Birth Attendants (SBAs) in Indonesia. The latest IDHS estimates show that the proportion of births assisted at delivery by health professionals, increased from 66% in 2002-2003 to 79% in 2007. However, several caveats should be noted. First, this indicator is still low when compared to other Asian countries like Malaysia (100%), China (97.3%) and Vietnam (90%)[6]. Second, substantial inequities still remain [1]. In 2007, 86% of mothers in the highest wealth quintile were assisted by a skilled birth provider, but only 65% of those in the lowest quintile were assisted. The national figures also mask sharp geographical inequalities. The percentage of births assisted by SBAs were 97% for DKI Jakarta and 93% for Bali, which is in sharp contrast with the situation observed in Maluku (32.8%) and West Sulawesi (43.8%). Third, even amongst women that gave birth with assistance from health professionals, mortality ratios are excessively high, which might reflect the large proportion of women that give birth at home [7]. Nationally, 46% of births take place at a health facility. But, sub-nationally the proportion ranges from 91% in Bali to 8% in South Sulawesi.


The latest draft of the National Development Plan (2010-2014) sets ambitious targets for MDGs 4 and 5. It aims at achieving a MMR of 118 deaths per 100,000 live births and an IMR of 24 deaths per 1,000 live births [8]. Unfortunately, the plan fails to set out a clear strategy to achieve these targets and the well documented geographical disparities are not addressed. Without setting out a clear strategic vision and implementation plan supported by a sound health financing scheme, such ambitious targets may not be realised. The IC in Indonesia is occurring at a time when key strategic decisions are taking place. It thus has the potential to make an important contribution to the MDGs 4 and 5 agenda in the country. However, a cautionary note should be made. The added value of the IC in Indonesia hinges on the extent to which it can be tailor-suited to the diversity of the country and the challenges of decentralisation.

2.2.1 The Indonesian Health System This section presents a summary overview of the health system in Indonesia. A more detailed assessment of key policy documents and the analytical work on the various health system components related to MNCH is provided elsewhere.

2.2.2 Social Health Insurance In the wake of the Asian financial crisis of 1997, Indonesia and other countries in the region sought to revamp their social protection systems, including health [9]. A government Social Safety Net in Health program, known as Jaring Pengamanan Sosial Bidang Kesehatan (JPSBK) was introduced in 1998. This was the first comprehensive national policy aimed at providing social protection health to the poor. A constitutional amendment mandated the government to provide social protection coverage to all Indonesians in 2002, which led to the implementation of a Health Insurance for Poor Population program known as Askeskin in 2004. The primary objective was to provide health coverage, including MNCH services, to the poor and near poor and protect them from catastrophic health expenditures. The Askeskin program provided: (i) primary health care, including basic MNCH, at health centres and sub-health centres; (ii) secondary care in case of emergency or prior referral from a primary health care provider; and (iii) health care at a provincial hospital with prior referral from the district hospital [10]. Due to geographical barriers to access health facilities, midwives continued with the responsibility of providing primary maternity care, including Antenatal Care (ANC) and birth delivery in each village. The Askeskin scheme was replaced by Jamkesmas (Health Insurance scheme for the poor) in 2008. The role of the parastatal agency, PT Askes Indonesia, was dramatically transformed from provision of health insurance to manager of the scheme. Jamkesmas is financed by the national budget through a complex fund channelling mechanism, with Rp 4.6 trillion allocated in 2008. Alongside Jamkesmas, local governments in various provinces and districts have organised Jamkesda (Local Government Health Insurance Scheme). These sub-national insurance schemes aim at providing coverage for the vulnerable population who do not qualify for Jamkesmas or for those that qualify but are yet to be enrolled in Jamkesmas [6]. The new Jamkesmas program continues to provide free-of-charge health care services, including MNCH. The number of beneficiaries has increased sharply from 36 million in 2004 to 76.4 million in 2007 [6]. Utilisation of health services has also increased dramatically, as reported by Mukti [11]. Notwithstanding the impressive achievements of the health


insurance for the poor program, substantial challenges still remain [10, 12, 13]. Non-medical costs, such as transport, still prevent the sick from receiving health care, especially in remote areas. Due to lack of information about their rights to free health care, the poor still fail to use health services. Supply side constraints to delivery of health services will need to be addressed in order to meet the increasing demand of health care and improve the quality of services provided. A considerable proportion of the population still remains without health insurance coverage and substantial increases in health expenditure would be required over the next few years to achieve the goal of universal coverage.

2.2.3 Public and Private Health Care Providers Dual practice is widespread in the country. An estimated 60-70% of civil servant health workers either have a private solo practice or work in private facilities [14]. Dual practice was introduced in the early 1970s with the expectation that private income could supplement the low salaries of publicly employed health staff. This policy was assumed to be an effective instrument to minimise the risk of human resource shortages in remote locations. However, a recent review of the evidence shows that the incentives for health workers to live in remote areas did not have the expected effect. Furthermore, the dual practice set up created perverse incentives that affected the quality and number of services provided in public facilities. It resulted in absenteeism, diversion of public patients to private practice where higher user fees apply and misallocation of resources [14]. Recent deregulation policies have also encouraged the role of the private sector, including private practices and large international hospitals. The vast majority of private providers deliver curative care with only a few providing primary health care and preventative services. Private hospitals are currently growing at a faster rate than the public ones. The number of private hospitals increased from 352 in 1990 to 626 in 2005, which led to a 70% increase in the number of private hospital beds. During the same period the number of public hospitals increased from 404 and about 59,000 beds to 452 hospitals and approximately 66,700 beds [15]. The for-profit private health services sector has shown the fastest growth in recent years, with some non-profit hospitals now changing the status to for-profit. The number of for-profit hospitals increased from 49 in 2003 to 85 in 2008 [16]. The majority of the new for-profit hospitals are established in Jakarta and other big cities. One of the potential implications of this process is increasing inequality in access to health care. The for-profit providers might concentrate the supply of obstetric/gynaecologist services to the detriment of the poor who cannot afford private health insurance or high out-of-pocket expenses.

2.2.4 Health Decentralisation The health decentralisation reform in Indonesia can be described as a pendulum that first moved swiftly to decentralision and then slightly shifted back towards re-centralisation [17].. In 1999 the central government was under strong pressure to devolve power to local governments. Political instability and several provinces demanding independence led to the so called “big bang” decentralisation. Within a year, districts were transferred 70% of central civil servants and most of the responsibility for public services and facilities [18]. The reform also devolved substantial funds to local governments.


The devolution of responsibilities and funding to the local governments was rather ad-hoc. Many districts declared that they did not need to coordinate the implementation of policies with the provinces. The distribution of roles and responsibilities within districts and between districts and provinces was obscure. Each department in each district and province set out its own roles and responsibilities, which often overlapped with those of other authorities. This lack of coordination was compounded by inadequate staffing structures [19]. The new roles of local governments under decentralisation required a different set of skills for policy, planning and budgeting. However, no transfer of technical skills accompanied the transfer of responsibilities and funding. While increasing financial resources were made available to local governments, the health sector was experiencing financial shortages. The amount of resources allocated to health in the General Allocation Fund and the Local Revenue & Expense Budget were not adequate to finance health services. Shortages in funding also occurred in areas with high fiscal capacity, which would be in a position to adequately finance the provision of health services to the population. Disruptions to the delivery of health services across the country were threatening to undermine the improvements in health indicators of the last decades. Central funding from the Ministry of Health was substantially increased and a slight shift towards “re-centralisation” occurred in 2004. Law 32/2004 attempted to clarify and strengthen the role of central and provincial governments. The central government also moved to regain control over human resources in the public sector and substantially reduced the already weak power of districts so that almost all staff expenditure can now be considered fixed costs [20]. The central government budget has limited capacity for financing the provision of MNCH services along the continuum of MNCH care. The current flow of funds from central to local government is cumbersome and funding disbursement suffers from severe delays. The process for the allocation of the de-concentration budget across provinces is not aligned with the health needs of the population and does not take into account the fiscal capacity of local governments. Provinces with more skilled staff are better equipped to present robust planning proposals and so are more likely to obtain additional funding resources than those with weak capacity but greater needs [19]. So far, local governments have not been mobilised to support, prioritise and fund the MNCH agenda. Even provinces and districts with high fiscal capacity rely on funding from the central government, while the formulae for inter-fiscal transfers lack incentives to encourage local government financing for priority health services such as MNCH. The ill-designed and poorly implemented decentralisation reform has seriously hindered the delivery of health services in the country. However, such a heterogeneous country like Indonesia demands locally-driven strategies that acknowledge the diversity among provinces and districts and encourage local government funding for MNCH. One of the key policy challenges for Indonesia is how to improve ‘ownership’ of MNCH by the local government and mobilise local financing support for MNCH.

2.2.5 The Organisation of Public Health At the central government level the organisation of Public Health has two main arms: National Development Planning Agency, BAPPENAS, is the national unit responsible for policy, planning and budgeting of all sectors, including health. The technical leadership of health planning and implementation is the responsibility of the Ministry of Health (MoH).


The MoH has structured the national health system on the basis of major programmatic areas: Health Programs and Activities, which includes MNCH; Health Care Financing; Human Resources; Pharmaceuticals, Supplies, and Health Equipment; Management and Health Information, and Community Empowerment. A key area of MNCH, reproductive health, is within the scope of the Family Planning Coordination Board (Badan Koordinasi Keluarga Berencana Nasional). The Board is independent from the MoH. However, with a view of facilitating coordination with the MoH, the appointment of the Board head should be consulted with the Ministry. At local level, BAPPEDA (the local counterpart of BAPPENAS) is in charge of overall policy, planning and budgeting, while Dinkes (the local counterpart of the Department of Health) are responsible for the formulation of technical standards. The complexity of the institutional arrangements governing the health sector is compounded by the sprawling number of cross-sectoral stakeholders, including Finance, Education and Social Affairs, at the various levels of national and sub-national government. After decentralisation, the Provincial Health Offices are responsible for coordination among districts, while the District Health Offices are responsible for implementation of family and community programs and the operationalisation of health policy. As previously noted there is often confusion about the responsibilities of the different levels of governments. In an attempt to provide clear guidelines for the implementation of health policy at the local government level, the MoH developed the Minimum Service Standards (MSS). The standards provide the indicators under which the performance of local health offices and local governments will be measured (see the following sub-section). The delivery of health care services in the country has traditionally been organised under a multi-tiered hierarchical system as described in Figure 2.3. The first level, primary health care, is provided by the health centre (Puskesmas), the integrated village health post (Posyandu), the village maternity post (Pondok bersalin) and a village midwife (bidan di desa) [21]. The Posyandu is the backbone of community participation in health services. They were originally organised as nutrition posts providing basic nutrition and growth monitoring services. By 1984, they provided nutrition services to over 10 million children in the country. This is regarded as one of the most successful examples of large scale nutrition projects in the country [19]. During the mid 1980s, the scope of activities of the Posyandus was expanded to include community activities related to the family planning program as well as the provision of basic medical services such immunisation and diarrhoeal disease control with the support of health workers [22].


The role of the Posyandus has been in decline during the last decade. Community participation has dropped dramatically; many Posyandus have not been regularly served; health workers do not provide the required support and the cadres of volunteers lack basic skills including how to record and interpret weights. Recently, a Posyandu revitalisation program has been launched. The objective is to take advantage of its extended national coverage, address its shortcomings and provide government support for those activities that cannot be undertaken by the community. Notwithstanding the limitations of community participation, it would be a mistake to dismiss the important role that communities have in addressing the burden of MNCH mortality. Some of the priority MNCH interventions identified in recent systematic reviews of the evidence can be delivered through communities, while others require effective linkages between community-based strategies and facility-based health services [23]. The Community Health Centre (Puskesmas) delivers a comprehensive package of health services, including those related to MNCH. They are the backbone of the delivery of primary health care services in the subdistricts. Due to the geographical barriers to accessing health centres and sub-centres, the Village Midwives have been assigned the responsibility of providing primary maternity care, including ANC and birth delivery in each village. Public health facilities, including puskesmas are officially owned by the local government. However after decentralisation, local governments failed to allocate adequate resources. As a result, facilities have been relying on central subsidies and user fees to cover their expenses

Posyandu

Hospital Type A

Community

Traditional Healing

Hospital Type B

Hospital Type C/D

Pustu

u Private Practice Midwife

Health Center

Figure 2.3: Health System Delivery in Indonesia


[15]. Their reliance on user charges has led to increasing financial barriers for the poor. It has also created perverse incentives for facilities not to deliver public health interventions, including preventative care, which are less profitable than curative interventions. Additionally, utilisation of health facilities, including Puskesmas and hospitals, dropped substantially since the Asian financial crisis of 1997. In 1997, 53% of the population that reported morbidity sought treatment in a health facility. By 2006, this proportion had dropped to only 34%, which could partly be explained by absenteeism and the low quality of services provided [15]. However, as previously discussed the introduction of Jamkesmas has led to a recent upsurge on utilisation of health services. Although disparities in access to health facilities among provinces is still an issue, overall the 8,000 Puskesmas and the 22,000 health subcentres available in the country provide the population with physical access to health services. Secondary health services are provided by district hospitals, so called type C and D, which are served by at least four specialists [21]. Referral from a primary health care provider is required to access hospital services, except in case of emergency. Tertiary health services are delivered by provincial hospitals (type B and C).


3. REVIEW OF KEY POLICY AND PLANNING PROCESSES AND DOCUMENTS

The Reproductive and Child Health Programme is part of the so called vertical programmes group, which includes tuberculosis, TB, malaria and nutrition. Historically, most of the activities related to these vertical programmes were initiated, planned, and implemented by the central government. As a result the large majority of MNCH policies in Indonesia, such as Village Midwives, Making Pregnancy Safer and IMCI have been national initiatives driven by the central government. They have also been strongly influenced by international agendas. At central level, MNCH policies are a priority area in key policy plans and documents. They are the object of regulation in Health Acts and a core set of targets for the Medium and Long-term Plans are related to MNCH. A prominent place is given to maternal and child health in the strategic documents of BAPPENAS and the MoH. This is in sharp contrast with the weak performance of MNCH services. Such a gap is partly explained by the lack of sound implementation and health financing strategies that acknowledge the diversity of the country and mobilise the support from local governments. Under decentralisation, local governments are responsible for the delivery of health services, including MNCH. However, the majority of provinces and districts fail to address MNCH priorities in their plans and budgets.

3.1 Maternal and Child Health A comprehensive review of policies and programs in the area of maternal health is presented by the World Bank Report on Maternal Health Policy [6]. This section provides only a summary outline of the most prominent policy and planning documents directly related to maternal health. Maternal health policy in Indonesia has been strongly influenced by the international agenda. Following the 1987 Nairobi Conference, the country leaders gave prominence to the Safe Motherhood program [24]. The following year, a target for maternal mortality reduction was adopted in the national development plan. Safe Motherhood In 1996, the Gerakan Sayang Ibu or Mother Friendly Movement was initiated by the Vice-Minister for Women’s Affairs and launched by the Indonesian President with a view of promoting maternal health. The WHO Making Pregnancy Safer policy was adopted as the key strategy for maternal health in Indonesia in the year 2002. The policy was established as a continuation of the Government’s Safe Motherhood programme and has focused on four main strategies, which are consistent with the “Healthy Indonesia Plan 2010”: (a) improving access to and coverage of quality maternal and neonatal health services; (b) building effective partnerships across programmes and sectors; (c) empowering women and families by providing them with the required knowledge to adopt a healthy behaviour and use health services; and (d) encouraging community involvement in the provision and utilisation of maternal and neonatal health services. The translation of the Safe Motherhood policy into effective implementation and more importantly into improvements in maternal and neonatal health suffered from serious shortcomings. First, the timing of the Making Pregnancy Safer policy did not seem right. It was adopted during the transition stage of decentralisation policy in health (2000–2007). The


centrally-led policy, which could have been successfully implemented in the previous years under the leadership of the national government, was at odds with the decentralisation reform. Second, as previously discussed in a decentralised and diverse country like Indonesia, the support from central authorities is necessary, but not sufficient. Local governments have not been mobilised to support, prioritise and fund the MNCH agenda. That is so, notwithstanding the limited capacity of the central government for both: (a) financing the provision of MNCH services along the continuum of care; and (b) addressing the social determinants of health in the local communities. Village Midwife Program In order to improve access to SBAs, the Village Midwife program was introduced by the central government in 1989. The program aimed at placing midwives in every village that would provide antenatal care and assistance during birth delivery. The main objective of the program was to have a positive impact on the process of childbirth itself, especially in communities without access to health facilities. However, it was also expected that the introduction of midwives could lead to other positive effects, such as higher antenatal care coverage, better nutrition outcomes and lower infant mortality risks. By 2006, there were 80,000 midwives in Indonesia [14]. Although only 40% of Indonesian villages had midwives in place, overall they are equally distributed. Rural and remote areas show a higher number of midwives per population compared to urban areas. A review of the evidence available on the impact of the Village Midwife program shows mixed results, although the program has indeed contributed to increasing access to SBAs. According to the latest estimates, the proportion of births assisted at delivery by health professionals has increased to 79%, with 68% assisted by a nurse/midwife/village midwife; 10% by an OB/GYN and 2% by a doctor [1]. However, substantial barriers, including cultural and financial, still prevent many women, especially the poor, from using the services of SBAs. As noted by Mukherjee [25], the poor are more satisfied with the services of Traditional Birth Attendants (TBAs), which they perceive as good value for money [25]. In order to encourage the increasing use of SBAs, the current national policy encourages a partnership between the midwife and the TBA [6]. More troublesome is the fact that MMR remain excessively high, even among women with access to skilled birth attendants (SBAs) [7]. This is partly explained by the poor quality of health care provided and the large number of mothers not having access to facility-based delivery (54%). Additionally, the strong reliance on the Village Midwife program presents serious limitations for the strategic development and implementation of maternal health policy in Indonesia. Midwives are usually young and have limited leadership capacity. However, they have been assigned the responsibility of leading maternal health in the community with very limited support. The potential leadership role of OB/GYN specialists has recently been discussed in various meetings involving the MNCH officers of the MoH; the Indonesian Midwives Associations, OB/GYN Association; the Pediatric Association and some provincial and district health officers. The unequal distribution of OB/GYN specialists among provinces presents serious challenges. However, the importance of their leadership role cannot be underestimated. Medical doctors and OB/GYN specialists are well respected professionals in their districts and can be very influential in the development and organization of maternal health policy and programmes. Some provinces are currently developing strategies to involve OB/GYNs in the development and implementation of maternal health policy, such as NTT (with support from AusAID) and DI Yogyakarta provinces. Strong commitment from OB/GYN specialists, especially from the newly established Association of Social OB/GYN (HOGSI,


Perhimpunan Obstetri dan Ginekologi Sosial Indonesia) would be required for their successful involvement in the design and implementation of maternal health policy. The World Bank review highlights the limitations of the current maternal health policy, which is narrowly focused on midwives and community-based interventions [6]. The utilization of critical health facility-based services during labor and delivery, but also during the antenatal and postnatal periods, is a major determinant of maternal health outcomes. An overhaul of maternal health policy and programmes would be required to give priority to the most cost-effective interventions and overcome the system constraints that prevent the scaling up of the identified priority interventions. These changes would need to be supported by additional evidence on the determinants of maternal mortality and the effectiveness of the various policy alternatives. The untapped potential of the lessons from the best performing provinces and districts should also be explored. For example, anecdotal evidence in Bantul District (Yogyakarta province) shows the vast potential of innovative and locally-grounded approaches to improve the nutritional status of high risk mothers and the use of incentives to reward villages which have not had any maternal deaths. Child Health Policy The government with the support of development partners has been working on the Child Health Policy strategic document in the last few years. This policy is still in draft form, although it should be noted that some maternal health programmes such as the Village Midwife also cover child health. The IMCI program was adopted and launched by the MoH in 1997 with a view of reducing childhood mortality and morbidity. IMCI has three components: improving health worker skills; strengthening the health system; and improving family and community practices. Only a few studies have assessed the implementation of this program and to the best of our knowledge, there is no evaluation of the impact of this program on child mortality and morbidity. An evaluation study conducted in the Puskesma Kabupaten Bungo Propinsi Jambi found a positive impact of the standard IMCI services on pneumonia treatment in Under-5 children [26]. Another study assessing the effect of hospital based IMCI training in a disaster area, Aceh, found the training improved the competences of nurses in assessing emergency signs and management of sick children. This study shows that IMCI can be effectively implemented as part of the rebuilding process after natural disasters or internal conflicts, provided that there is strong management support and a motivated workforce [27]. Healthy Start Plus Programme and Healthy start for Healthy Life/ASUH (awal sehat untuk hidup sehat) The Healthy Start Programme aimed to ensure a visit by a village midwife between one to seven days after the birth of a child to provide hepatitis B immunisation, iron, folic acid, and vitamin A to the mother and examine the baby. Counselling was also provided to encourage good cord care, exclusive breastfeeding, and adoption of Kangaroo approach, to recognise sick neonates and educate the mothers about nutrition. A pilot project was implemented in West Nusatenggara from 1991-1996 and the outcomes reported in SEARO’s ‘Improving Neonatal Health in South-East Asia Region- Special Success Stories’ [28]. The outcomes were a decline in infant mortality (73 to 55/1000 live births), an increase in exclusive breastfeeding rates (42-58%) and in Hepatitis B immunisation from 0% in 1990 to 71% in 1993 and to 84% in 1996. Hepatitis B immunisation is given by Uniject and the quality is monitored.


An expansion of elements of the healthy start program was conducted in four districts in West Java and East Java, from November 2000-2003 supported by Program for Appropriate Technology in Health (PATH). The major program components included: building midwife capacity to provide newborn care; empowering families and communities and reinforcing project message of newborn care (community notification of midwife on pregnancies and births, home visit in first seven days, Hepatitis B vaccination in first seven days, early initiation of breastfeeding and exclusive breastfeeding); and strengthening the functions of district health offices. The results of this programme are detailed in the PATH Indonesia final programme report: Improving the Health of Newborn in Indonesia [29]. The report reveals a significant increase of a first week neonatal visit (KN-1), increased coverage of Hepatitis B vaccine in the first seven days of life, improved nutritional status of U5 children, and increased number of mothers knowing the importance of immediate breastfeeding. However, little or no improvement was achieved in the knowledge, attitude and practice (KAP) of breastfeeding. This program also mobilised more than 3000 community facilitators. No analysis was conducted to evaluate the impact of this programme on morbidity and mortality.

3.2 Strategic Planning and Financing for Maternal and Child Health

3.2.1 Medium-Term Plan 2004-2009

The key strategic planning document in Indonesia is the Medium Term Plan (Rencana Pembangunan Jangka Menengah, RPJM), which provides the outline for the Government Annual Plans (RKP) for each five year period. Human development, equity and the eight MDGs are at the core of the current 2004-2009 RPJM. In regard to health, the plan aims at increasing the quality of services, improving social protection and reducing disparities in inter-regional development [4]. Two out of the four health targets are related to reductions in maternal and child mortality. The targets for 2015 are an IMR of 23 and a MMR of 102.

Specific targets for improvement in equitable access and quality of MNCH services, including nutrition, immunisation and family planning, have been included in the RKP. However, they have failed to set out sound implementation strategies to achieve those targets and some of them might not have been realistic. For example, the 2008 plan aimed at increasing exclusive breastfeeding to 65%, while the 2007 IDHS survey shows that only 32% of children under six months of age are exclusively breastfed. Similarly, the RKP set a target of 95% villages with Universal Child Immunisation. However according to the 2007 IDHS only 59% of children receive all basic vaccinations before their first birthday and sharp geographical disparities persist [1].

3.2.2 Minimum Service Standards (MSS)

The national government policy is further developed in the MoHMOH Strategic Plan and operationalised by the MSS. As previously observed, the decentralisation reform failed to provide clear guidance on the actual functional responsibility of different levels of government. Each department in each district and province established its own roles and responsibilities, which often overlapped with those of other authorities. This was partly caused by the delays in the expedition of the government regulation on MSS. The situation prompted the MoH to issue a decree on MSS for the health sector in 2003. The MSS aimed at setting the standards for the delivery of services that should be funded by local governments. They also set standard goals, targets and indicators to be used in measuring the performance of local governments. The 2003 MSS included an excessively long and unrealistic list of indicators that


could neither be used as guidance to prioritise resource allocation nor was affordable by local governments. It is barely surprising that the 2003 MSS were not implemented. Unfortunately, the failure to set the parameters for the delivery of services to be funded out of local government sources led to insufficient resource allocation to MNCH.

After the so-called 2004 “re-centralisation” Laws, Government Regulation No. 65 on MSS was issued. It requires the Line Ministries, including the MoH, to set minimum standards based on evidence and linked to both, availability of funding and measurable performance indicators. After long debates, in 2008 the MoH produced a substantially shorter list of MSS indicators (MoH decree no 741/MENKES/PER/VIII/2008). Out of the 18 MSS indicators included in the MoH decree, 12 are devoted to MNCHA: including extending coverage of MNCH services to poor families; antenatal care; the treatment of obstetric complications; birth delivery assisted by a skilled provider; postnatal and neonatal care; family planning; immunisation; breastfeeding; and nutrition. However, for all practical effects, the MSS are yet to be implemented. Furthermore, the shortcomings of the health information system cast serious doubts on the extent to which the MSS can effectively be used to monitor and evaluate the performance of local governments.

3.2.3 Medium-Term Plan 2010-2014

A new RPJMN 2010-2014 is currently under development. The broad policy directions include: improving health financing; responding to the demographic and epidemiological transition; strengthening promotional and preventative health services; and adopting a cross-sectoral approach to address the nutrition challenges. The new RPJM also includes ambitious targets for MNCH. It aims at reducing maternal mortality (from 228 to 118 per 100,000 live births); infant mortality (from 34 to 24 per 1,000 live births), neonatal mortality (from 20 to 15.5 per 1,000 live births) and underweight malnutrition in Under-5 children (from 18.4 % to 15.0%).

The lessons from the past suggest that the successful implementation of the new medium term policies and plans depend on: strong support from local governments; sound annual planning and budgeting mechanisms; adequate financing resources; and proper fund channeling [17].

3.2.4 Health Financing for MNCH

One of the key challenges for policymakers and planners is to ensure adequate financing resources for priority interventions such as MNCH. The prominent place of MNCH in the strategic plans and documents of both the Presidential Office and the Ministry of Health has not guaranteed that MNCH is given a priority during budget negotiations. In theory, the national budget should be developed in line with these strategic plans. However, the national health budget has not followed the core recommendations of the strategic plan. In the last five years, the allocated resources for health programmes other than the health insurance for the poor have been reduced in order to meet the increasing funding requirements of Jamkesmas. Notwithstanding the well documented problems with central funding, after excluding curative care financed through Jamkesmas, it can be seen that MNCH programmes rely heavily on central government funds. A preliminary assessment of available data shows that the largest share of MNCH funding comes from Central Government (ABPN), whereas the proportion funded from local sources, District Municipality, (ABPD) is relativity low. This is illustrated in


Figure 3.1, which uses data from the Ministry of Health (MoH), local government (Provinces and Districts), and reports from BAPPENAS. Figure 3.1: Share of Government Spending on MNCH Financing

The current health financing arrangements pose serious challenges to the effective implementation of MNCH policies and strategies. According to the regulatory framework for decentralisation, the central budget uses a de-concentration mechanism to fund the implementation of health services. Resources from the de-concentration fund are first directed from the central government to the provinces. The provincial government redirects the funding to the district/municipality or to the program activities. This flow of funds from central to provincial to districts/programmes often encounters several problems, including: insufficient time to spend the resources and report on their use; improper use of central budget by provincial government officers; and mismatch between allocation and local needs [30]. For example, in the fiscal year January-December 2007, the central budget was disbursed around July-August. This situation was aggravated by the reductions of central funding that were required to finance Askeskin. Similar funding shortages occurred again in 2008, which were aggravated by the oil price hike. The central government experienced difficulties to realise the State Revenue & Expenditure Budget (APBN). The budget was disbursed around August. Anecdotal evidence suggests that the situation has not improved in 2009. The late disbursement of central government funds partly explains the low absorption of central government budget, which is one of the major problems facing the delivery of health services, including MNCH. For example, in 2006, data from the MoH show that the maximum amount of central government fund absorbed by the provinces was 95% in North Sulawesi. This is in sharp contrast with 46% in West Irian Jaya and 53% in (DKI) Jakarta. While the reliance of MNCH programmes on the central government fund poses serious problems to the scale-up of priority interventions, insufficient funding from local governments is allocated to MNCH. Figure 3.2 shows the comparison of total government budget (APBD), total regional government health budget (APBD-KES), and total regional government MNCH budget (APBD-KIA). In absolute terms most local governments allocate insufficient funding for MNCH, although regional disparities can be observed. Jakarta and East Kalimantan, two provinces with high fiscal capacity show the highest allocation. However, some high fiscal capacity provinces show lower resource allocation, compared with other low-fiscal capacity provinces. The insufficient allocation to MNCH shows the lack of ownership by the local

APBN (exclude JAMKESMAS)

57%APBN (Social

health insurance)0%

APBN (Imunizations)13%

APBN (Nutrition)7%

APBD14%

Donor (non APBN)*9%


government. This is particularly problematic in the current decentralised system under which local governments are responsible for the delivery of health services, including MNCH. Figure 3.2: Local Government Budget for MNCH

Source: MoH, MoF

A recent study by BAPPENAS [31] revealed that the annual funding shortage for achieving the MDG targets in Indonesia stands at approximately nine trillion Rupiah. Mobilisation of local sources of funding supporting MNCH programmes would therefore be required if the MDGs 4 & 5 targets are to be achieved in Indonesia.

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2.00

3.00

4.00

5.00

6.00

7.00

Trill

ion

s

APBD TOTAL

APBD Kes

APBD KES KIA


4. REVIEW OF KEY DATASETS

4.1 Indonesia Demographic Health Surveys (IDHS) There have been six IDHS surveys with the first survey in 1987 called the National Indonesia Contraceptive Prevalence Survey. Five subsequent IDHSs were undertaken in 1991, 1994, 1997, 2002-03 and 2007. The 2007 IDHS is a nationally representative survey of 40,701 households, 32,895 ever married women age 15-49, and 8,758 currently married men age 15-54. It was conducted in all 33 provinces in Indonesia. The main objective of 2007 IDHS was to provide detailed information on population, family planning and health for policymakers and program managers. The survey collected information on respondents’ socioeconomic background, fertility levels, marriage and sexual activity, fertility preferences, knowledge and use of family planning methods, breastfeeding practices, childhood and adult mortality including maternal mortality, maternal and child health, and awareness and behaviour regarding HIV/AIDS and other sexually-transmitted infections. Mortality analysis can be conducted for the national level and several provinces with large populations (e.g. East Java). As in previous surveys, the 2007 IDHS sample was designed to produce estimates at the national, urban-rural, and provincial levels. Some additional data was collected in specified districts as follows: 15 districts/cities in Central and East Java; all districts of Naggroe Aceh Darussalam; and Nias District and South Nias District in North Sumatra. Analysing trends using IDHS data should be conducted cautiously due to differences in geographic coverage, as follows:

IDHS before 2002-2003 included Timor Leste (East Timor);

IDHS 2002-2003 excluded the provinces of Nanggroe Aceh Darussalam, Maluku, North Maluku and Papua;

IDHS 2007 included all current provinces in Indonesia (33).

The sampling methods used Census Blocks (CBs) which are the primary sampling unit. Household listing was done in all CBs covered in the 2007 Sakernas (National Labour Force Survey). A minimum of 40 CBs per province was imposed in the 2007 IDHS design. Since the sample was designed to provide reliable indicators for each province, the number of CBs in each province was not allocated proportional to the population of the province or proportional by urban-rural classification. Therefore, a final weighing adjustment procedure was done to obtain estimates for all domains. The sample was selected using a stratified two-stage design consisting of 1,694 CBs. Once the number of households was allocated to each province by urban and rural areas, the number of CBs was calculated based on an average sample of 25 selected households. All ever married women age 15-49 and all unmarried persons age 15-24 in these households were eligible for individual interview. All currently married men age 15-54 identified in the selected households were interviewed. In each province, the selection of CBs in urban and rural areas was done using multistage stratified sampling. In urban areas, in the first stage, CBs were selected using systematic sampling. In each selected CB, 25 households were randomly selected. In rural areas, the household selection was done in three stages. In the first stage, sub districts were selected with probability proportional to the number of households. In the second stage, from each selected sub district, CBs were selected using systematic sampling. In the third stage, in each


cluster, 25 households were randomly selected. In each of the 15 districts in Java, clusters were selected systematically with probability proportional to the number of households. In the second stage, in each CB, 25 households were randomly selected to allow estimates at the individual district. Estimates were made in individual districts in Nanggroe Aceh Darussalam Province and two districts in North Sumatera Province, Nias and South Nias. (Source: Appendix B, IDHS 2007). The household response rate was 99% (96% for individual women and 90% for individual men). IDHSs are implemented by Statistics Indonesia (BPS). Data is available at: http://www.measureIDHS.com/. All Indonesian IDHS reports are available at: http://www.measureIDHS.com/pubs/Search/search_results.cfm?newSrch=1&srchTp=advanced&Country=Indonesia.

4.2 Sub-Survey: Young Adult Reproductive Health Survey (IYARHS) The 2007 Indonesia IYARHS is the second national survey on Adolescent Reproductive Health in Indonesia. The survey is a sub-sample of IDHS 2007. The survey provides data and information on KAP of adolescents on human reproductive aspects including sexual activities, HIV and AIDS, as well as other sexually transmitted diseases. There are two differences between the 2007 and 2002-2003 surveys. First, the sampling design for 2002-2003, whose respondents were single men and women age 15-24, provides estimates for various parameters for the national level, while the 2007 survey allows estimates for the provincial level. The second difference is associated with location of the survey. While the 2002-03 survey was conducted in 15 of 26 provinces, the 2007 survey covered all 33 provinces in the country. The 2007 IYHRS (2008) is available at: http://www.measureIDHS.com/pubs/pdf/FR219/FR219.pdf. and the 2002-2003 IYHRS at: http://www.measureIDHS.com/pubs/pub_details.cfm?ID=471&srchTp=advanced There was a simultaneous survey conducted in Jayapura city (capital of Papua province) where one in four people is aged 15-24. The survey aimed at providing baseline data on issues related to KAPs of young unmarried women and men regarding sexual activity, reproductive health, family planning and HIV/AIDS prevention. This report is available at: http://www.measureIDHS.com/pubs/pub_details.cfm?ID=546&srchTp=advanced

4.3 National Socio-Economic Survey (SUSENAS) SUSENAS is a series of large-scale multi-purpose socioeconomic surveys initiated in 1963-1964. It is implemented by Badan Pusat Statistik (Statistics Indonesia) (BPS) annually. The instruments are formulated together within related sectors (e.g. health, family planning, public works, agriculture, labour, education, etc). Since 1993, SUSENAS surveys cover a nationally representative sample typically composed of 270,000 households. Each survey contains a core questionnaire which consists of a household roster listing the sex, age, marital status and

http://www.measuredhs.com/

http://www.measureidhs.com/pubs/Search/search_results.cfm?newSrch=1&srchTp=advanced&Country=Indonesia

http://www.measureidhs.com/pubs/Search/search_results.cfm?newSrch=1&srchTp=advanced&Country=Indonesia

http://www.measuredhs.com/pubs/pdf/FR219/FR219.pdf

http://www.measureidhs.com/pubs/pub_details.cfm?ID=546&srchTp=advanced


educational attainment of all household members. The survey is supplemented by modules covering about 70,000 households that are rotated over time to collect additional information such as health care and nutrition, household income and expenditure and labour force experience (see NHS and RisKesDas below). The Under-5 mortality rate can be estimated from children ever born data. Coverage of selected interventions may represent district/cities with the Health Modules instrument surveyed every three years: 1992, 1995, 1998, 2001, and 2004. Basic mortality analysis can be conducted for national level and several provinces with large populations. The website is: http://www.rand.org/labor/bps.data/susenas/. The latest survey listed on the website is for 2003 and the five volumes are only available in an Indonesian version: http://www.rand.org/labor/bps.data/susenas/2003.html.

4.4 Village Potential Statistics (PODES) PODES (http://www.rand.org/labor/bps.data/podes/) is conducted in the context of periodic censuses (agriculture, economy and population) and provides information about village (desa) physical infrastructure characteristics for all of Indonesia, with a sample of about 70,000 villages. PODES data is gathered by interviewing desa (village) and kelurahan (city block) heads using detailed questionnaires. Each desa and kelurahan head represents a population of approximately 3,000 and they are knowledgable on the workforce and people living in their jurisdictions. It covers data on health facilities (health centre, sub health centre, village maternity hut), health staff (public and private at the district level) education facilities (schools), market and other public facilities as well as the available related manpower. It provides data on the availability and distribution of public facilities in villages. It may describe the “equity situation” on access to public facilities (health, education, markets, etc). PODES has been implemented in 1983 (agriculture), 1986 (economy), 1990 (population census), 1993 (agriculture), 1996 (economy), 2000 (population census) and 2007. It is possible to distinguish trends, as multiple rounds of the same survey have taken place since the early 1990s. However, one World Bank report only focused on PODES 1996 and 2006 [14]. The other two rounds, PODES 2000 and 2003, suffer from anomalies that cannot be explained by policy changes that occurred before and after the surveys. PODES would provide some of the better information on health workforce aspects, although there are some limitations (e.g. assumed that all workers were active, no differentiation of public and private providers, potential under-reporting of health worker numbers, health worker residence - not workplace). Latest survey listed on the website is for 2000: http://www.rand.org/labor/bps.data/podes/2000pop.html The questionnaire is available as an Indonesian version. http://www.rand.org/labor/bps.data/datadocpdf/podes/sp2000-podes.pdf 4.5 Population Census The Population Census aims to gather characteristics of the Indonesian population such as gender, age, marital status, educational attainment, migration, occupation, religion, etc. As regulated by national law, the census is taken every ten years (years ending in zero). They were

http://www.rand.org/labor/bps.data/susenas/

http://www.rand.org/labor/bps.data/susenas/2003.html

http://www.rand.org/labor/bps.data/podes/

http://www.rand.org/labor/bps.data/podes/2000pop.html

http://www.rand.org/labor/bps.data/datadocpdf/podes/sp2000-podes.pdfP


conducted in 1961, 1971, 1980, 1990 and 2000. The next Population Census will be carried out in 2010. The 1961, 1971, 1980 and 1990, Censuses applied complete enumeration and sample survey while the 2000 Census only applied complete enumeration. In the first four Censuses (1961, 1971, 1980, 1990) a short form of questionnaire covered basic information such as age, sex, and relation to the head of household. The long form of questionnaire used in 2000 covered more detailed information such as age, sex, place of birth, occupation, religion, educational attainment, migration status and fertility. Mortality related questions were applied to collect data from a number of selected households. Therefore, the Census results were published in two publications. The first one was based on complete enumeration and the second one was based on the sample survey of selected households. Due to the sampling errors, the sample survey will provide less accurate information on mortality. The links to censuses for 1990 and 2000 are available at: http://www.rand.org/labor/bps.data/censuses/1990pop.html http://www.rand.org/labor/bps.data/censuses/2000pop.html The questionnaire is available as an Indonesian version at: http://www.rand.org/labor/bps.data/datadocpdf/popcen00/SP2000-m.pdfT

4.6 The Intercensal Population Surveys (SUPAS) SUPAS ((http://www.rand.org/labor/bps.data/supas/) are carried out in the mid-period between the Population Censuses (e.g. 1976, 1985, 1995). Selected households are interviewed in order to obtain information regarding demographic details such as fertility, mortality and migration, birth history and deaths of children from ever married women. Data on labour aspects include the type of occupation and occupational status. Socio-cultural characteristics include educational level, housing condition and activity of the elderly. The 2005 SUPAS also included births, deaths and migration. Estimation of mortality based on SUPAS is discouraged due to less accurate data than in the Census. Therefore, most long term projections are calculated only from the Population Census, although the IDHS and SUSENAS might also be used for trend analysis and projections. There are no collected data on intervention coverage. The link for the 1995 census is: http://www.rand.org/labor/bps.data/supas/1995.html

4.7 The Indonesian Family Life Survey IFLS (http://www.rand.org/labor/FLS/IFLS/) is an ongoing longitudinal cohort survey representative of about 83% of the population. It surveys over 30,000 individuals living in 13 of the 33 provinces. The first one (IFLS1) was conducted in 1993/94 by RAND in collaboration with Lembaga Demografi, University of Indonesia. I FLS2 and IFLS2+ were conducted in 1997 and 1998, respectively, by RAND in collaboration with UCLA and Lembaga Demografi, University of Indonesia. IFLS2+ covered a 25% sub-sample of the IFLS households. IFLS3 in 2000 covered the full sample and was conducted by RAND in collaboration with the Population Research Centre, University of Gadjah Mada. IFLS4 in 2007/2008 covered the full sample and was conducted by RAND, the Centre for Population and Policy Studies (CPPS) of the University of Gadjah Mada and Survey METRE.

http://www.rand.org/labor/bps.data/supas/

http://www.rand.org/labor/FLS/IFLS/


The IFLS is the only large-scale longitudinal survey publicly available for Indonesia. Because data is available for the same individuals from multiple points in time, the IFLS provides an opportunity to understand the dynamics of behaviour at the individual, household and family and community levels. The survey contains information collected at the individual and household levels including multiple indicators of economic well-being (consumption, income, and assets); education, migration, and labour market outcomes; marriage, fertility, and contraceptive use; health status, use of health care, and health insurance; relationships among co-resident and non co-resident family members; processes underlying household decision-making; transfers among family members and inter-generational mobility; and participation in community activities.

In addition, the IFLS provides detailed information on the communities in which IFLS households are located and from the facilities that serve residents of those communities. These data cover aspects of the physical and social environment, infrastructure, employment opportunities, food prices, access to health and educational facilities, and the quality and prices of services available at those facilities. Hence, IFLS data provide opportunities to assess the impact of policies on the lives of the respondents as well as document the effects of social, economic, and environmental change on the population.

The IFLS collected extensive measures of health including indicators, self-reported measures of general health status, symptoms, pain, doctor diagnosed chronic conditions, time spent on different physical activities, and biomarker measurements conducted by a nurse (height, weight, leg length, blood pressure, pulse, waist and hip circumference, haemoglobin level, total and HDL cholesterol, grip strength, lung capacity, and time required to repeatedly rise from a sitting position). These data provide a much richer picture of health status than it is typically available in Indonesia. Detailed data were collected about respondents’ communities and public/private facilities available for their health care and schooling. The community-facility data can be combined with household and individual data to examine the relationship between, for example, access to health services (or changes in access) and various aspects of health care use and health status. The IFLS is useful to examine the trends of MNCH intervention coverage in relation to changes of access and input of health providers.

In IFLS1, 7,224 households were interviewed and detailed individual level data was collected from over 22,000 individuals. In IFLS2, 94% of IFLS1 households and 91% of IFLS1 target individuals were reinterviewed. In IFLS3, 95.3% of IFLS1 households were re-contacted and in IFLS4 the re-contact rate was 93.6%. Among IFLS1, dynasty households (any part of the original IFLS1 households) 90.3% were either interviewed in all four waves or died, and 87.6% were actually interviewed in all four waves. High re-interview rates contribute significantly to data quality in a longitudinal survey because they lessen the risk of bias due to non-random attrition.

The IFLS4 is in initial public release. Questionnaires (English and Bahasa Indonesian) are available at http://www.rand.org/labor/FLS/IFLS/ifls4.html

4.8 Governance and Decentralisation Survey (GDS) The World Bank has invested in collecting data to monitor the implementation of decentralisation, including its outcomes on local governance and service delivery. GDS is an integrated survey of households, public health and education facilities, and district and village level officials. The survey is designed to assemble detailed information on the provision of and use of local public services, as well as the governance environment in which those services are delivered and used. The various survey ‘levels’ include health units (dinas), private health

http://www.rand.org/labor/FLS/IFLS/cf.html

http://www.rand.org/labor/FLS/IFLS/cf.html

http://www.rand.org/labor/FLS/IFLS/ifls4.html


providers, heads of public hospitals, heads of Puskesmas, secondary Puskesmas and household data. The GDS has been designed to complement a core of secondary data such as the Central Bureau of Statistics’ household survey (SUSENAS), village census (PODES), and manufacturing census (Survey Industri) as well as the Ministry of Finance’s local government finance data (SIKD). Three versions of the GDS (GDS1, GDS1+ and GDS2) have already been implemented by Centre for Population and Policy Studies at the University of Gadjah Mada (CPPS-UGM). GDS1 was implemented in 2002 in 177 districts in Indonesia (150 randomly and 27 World Bank project related), and encompassed 10,620 households and 6,372 non-household respondents. GDS2 builds on the large-scale pilot GDS1+, fielded across 32 kabupaten/kota and 8 provinces in May-June 2004. Evidence from the GDS1+ household survey highlights the various dimensions of service delivery affected by the 2001 Big Bang Decentralisation. Fielded after three years of decentralisation processes, the survey provides interesting indications for the emerging trends in public service delivery. One major limitation is its non-representative sampling. For example, GDS-2 only sampled 139 out of more than 400 districts in 2006 and those that were sampled were not necessarily representative across Indonesia. GDS-2 did not sample any kabupaten/kota in four provinces (DKI Jakarta, Southeast Sulawesi, West Sulawesi and West Papua). The website has an interactive data analysis capacity at three levels:

a) Basic: This type of analysis allows you to display the survey result for certain province/district from selected dataset. Results can then be displayed in chart and compared with other comparators such as geographical or socio-economic characteristics;

b) Dual: Use this to determine correlation between two variables. Results are in scatter-type chart with a trend line; and

c) Multi: See score for each province/district for up to five selected variables.

Questionnaires are available in English and Bahasa Indonesia. Numerous datasets for different interviewees are available at: http://gds-indonesia.org/doclist.aspx?id=6

4.9 Baseline Health Survey

4.9.1 National [Household] Health Surveys 1980-2004 The National Institute of Health Research and Development implemented the National Household Health Survey (NHHS) in 1980, 1986, 1992, 1995 and the National Health Survey (NHS) 2001 and 2004 using samples of the SUSENAS module (68,000 households). Mortality surveys (using the verbal autopsy method) were conducted in 1986, 1992, 1995 and 2001 as follow up visits to households where deaths had occurred in the last 12 months as identified by SUSENAS interviewers.

4.9.2 RisKesDas 2007 RisKesDas 2007 was a nationwide community-based cross-sectional survey covering 258,366 households and 987,205 respondents in all 33 provinces (440 districts and cities). The samples are the same as the core samples of SUSENAS. Hence, both data sets were merged and

http://gds-indonesia.org/doclist.aspx?id=6


analysed. With the merged dataset almost all variables can be classified by province, city/district, age group, sex, education level, and quintile level of household expenditures. The objectives were to provide baseline data on nutritional status, access and utilisation of health care services, environmental sanitation, food consumption, prevalence of common diseases and injuries, responsiveness of health services, KAPs on healthy behaviour, disabilities, mental health, immunisation, child health, anthropometric measurement, blood pressure measurement, dental and vision examination, and causes of death based on ICD-10. Data was collected on 900 variables. In addition, blood samples (n=36,357) were collected from people living in the cities. Samples of kitchen salt from households in 30 districts identify as goitre endemic areas and samples of urine of school children were also examined for iodine. Identified limitations (non-random error) include the formation of new districts. Reports (mostly Bahasa with one English version) available at: http://www.litbang.depkes.go.id/riskesdas/download.htm

4.10 Indonesia Health Profiles (IHP) The annual Indonesia Health Profile is published by MoHMoH (Centre for Health Data & Information) and the Indonesian Medical Council (KKI). The administrative data is gathered by the central level MoH administration from district and provincial health administrators. There are also annual Provincial/District/City Health Profiles. These profiles provide data on the trends of health data (facility based and community based). The IHPs provide information on demography, environment, health status, health effort, health resources and a comparison with neighbouring countries. According to the World Bank [6], IHPs report the number of public doctors, nurses and midwives by province. However, an analysis of this data shows many discrepancies and missing data points. Districts are no longer legally responsible for submitting human resources information to the province or central governments [14]. Most recently was authorised to require the registration of all medical doctors before licensing. Whether doctors register as public or private providers is not known and the registry information is not allowed for disaggregation. Although this source is considered very reliable, the registration data is only available for 2007 and there may be over registration – non practicing doctors who have registered to preserve the opportunity to practice in the future. Available at: http://www.depkes.go.id/downloads/profil/en2005.pdf

4.11 Indonesia Mortality Registration System Strengthening Project (IMRSSP)

This project was designed to support the revised framework for mortality registration to enable the collection of timely and reliable mortality and cause of death data at different levels of government. A critical element is a scientific mechanism to register causes of death which was lacking in the previous system. Different approaches are implemented to address cause of death assignment for deaths within and outside health facilities based on ICD-10. The objectives include:

Design of revised death registration forms to incorporate standard cause of death certification protocols as recommended by the United Nations;

http://www.litbang.depkes.go.id/riskesdas/download.htm

http://www.depkes.go.id/downloads/profil/en2005.pdf


Adaptation of standard verbal autopsy questionnaires for household enquiry into cause of death developed by the Adult Morbidity and Mortality Project, Tanzania (AMMP-Tanzania 2003) to the Indonesian context;

Provision of intensive training to field operatives in the use of revised forms and procedures (e.g. paramedical staff in verbal autopsy, physicians in cause of death certification, and medical records staff in coding cause of death data) with adequate ‘on the job’ support during field activities; and

Development of data management protocols, quality control checks, and descriptive analysis of cause of death data.

The provinces currently covered by the system are Lampung, Jakarta, Central Java, Bali, West Kalimantan, Gorontalo, East Nusa Tenggara, and Papua.

4.12 Data Sources on Health Workforce This section provides a summary of data sources on health workforce and draws on the information examined by the World Bank [14].

4.12.1 SAKERNAS The National Labor Force Survey (SAKERNAS) would have been another good data source to estimate the stock of health workers, however there have been changes in the sampling methodology and occupation code that make it difficult to compare the number of health workers before and after 2000. One possible explanation of why the 2000 and 2003 rounds of PODES produced inconsistent numbers across periods is that there were changes in geographical boundaries of the village due to merging/splitting, changes of status, or reassignment of a village to a new kabupaten or province. PODES data indicates that some villages no longer existed in the following rounds while there are also new villages that did not exist in a previous round. This caveat should be kept in mind when comparing the distribution of health workers across provinces from the 1996 and 2006 rounds. A decline in the number of doctors, for example, could be due to one of these geographical reasons and not necessarily due to a policy change. The website is: http://www.rand.org/labor/bps.data/sakernas/ The latest survey (1999): http://www.rand.org/labor/bps.data/sakernas/1999.html

4.12.2 Other A number of other agencies and institutions also maintain information on the health workforce. The Board for Health Human Resources (BPPSDMK), together with the Bureau of Personnel at the MoH and the Indonesian Doctors Association (IDI) all maintain databases. The midwives and nurses’ associations, IBI and PPNI, are in the process of putting together databases. However, these databases include information on a voluntary membership. Basic information on workforce numbers by category are contained in these Health Management Information Systems. The Health Human Resources Information System (SIM PPSDMK) database on the stock of the health workforce in Indonesia is primarily obtained from administrative data from MoH and local governments. In summary, the main source of data and statistics is BPS: (http://www.bps.go.id/eng/).

http://www.rand.org/labor/bps.data/sakernas/1999.html

http://www.bps.go.id/eng/


There is also the Institute of Statistics at: http://www.stis.ac.id/. The RAND Corporation also holds much data on Indonesia: http://www.rand.org/labor/bps.data/. All Indonesia reports at IDHS website: http://www.measureIDHS.com/aboutsurveys/search/listmodules_main.cfm.

http://www.stis.ac.id/

http://www.rand.org/labor/bps.data/

http://www.measureidhs.com/aboutsurveys/search/listmodules_main.cfm


Table 4.1: Summary of Key Datasets

NAME DESCRIPTION AND SURVEY

DESIGN

USE IN IC AND ACCESS

LIMITATIONS QUESTIONNAIRES ERRORS

REPORTED

IDHS Source: BPS and MOH (+ ORC Macro International) Young Adult Reproductive Health Surveys IYARHS 2002-03 2007

Sample Survey 1994, 1997, 2002-03, 2007 2007 - 40,701 households & 32,895 ever married women age 15-49, done in all 33 provinces. Data on SES, fertility levels, marriage and sexual activity, fertility preferences, knowledge and use of family planning methods, breastfeeding practices, childhood, maternal & adult mortality maternal and child health, etc.

Report available National, provincial and urban-rural. Some data at district level for Java (15), Nanggroe Aceh Darussalam Province and two districts in North Sumatera Province, Nias and South Nias.

Sampling errors. Analysing trends using IDHS data should be conducted cautiously due to differences in geographic coverage, as follows: * IDHS before 2002-2003 included Timor Leste (East Timor). * IDHS 2002-2003 excluded the provinces of Nanggroe Aceh Darussalam, Maluku, North Maluku and Papua. * IDHS 2007 included all current provinces in Indonesia (33). Citation: Statistics Indonesia (Badan Pusat Statistik—BPS) and Macro International. 2008. Indonesia Demographic and Health Survey 2007. Calverton, Maryland, USA: BPS and Macro International.

Yes Appendix F of report

Sampling errors in Appendix B of report. Non sampling errors difficult to quantify statistically.

SUSENAS Large-scale multi-purpose socioeconomic surveys every year. Under-5 mortality rates can be indirectly estimated from children ever born data

Nationally representative, typically composed of 270,000 households, 70,000 households for health modules. Mortality can only be estimated at provincial level

Latest year 2003 from RAND website. Sampling errors

Yes (Bahasa Indonesian)

Possibly in manuals Some documentation

PODES Information on village infra-structure characteristics + staff. Conducted in

About 70,000 villages nationwide (e.g. every village in the country) May help with equity

Data from 2000 and 2003 have anomalies. Latest year 2000 from RAND website

Yes (Bahasa) Possibly in manuals Some documentation



DESIGN



REPORTED

context of censuses (agriculture, economy and population). 1983, 1986, 1990, 1993, 1996, 2000, 2007

situation on access to public facilities

Population census 1961, 1971, 1980, 1990, 2000

Nationally representative. Next census in 2010

Latest year 2000 from RAND website. Some documentation. 2000 complete enumeration. There was a module in the 2000 Census using the SUSENAS sample

Yes (Bahasa). Possibly in manuals

SUPAS Mid-period between census. Demographics, labour, SES, etc 1976, 1985, 1995, 2005

Selected households are interviewed

Has children ever born data to indirectly estimate Under-5 mortality Latest year 1995 from RAND website

Yes (Bahasa).

Possibly in manuals Some documentation

IFLS Household and community - longitudinal cohort survey 4 waves in 1993-4, 1997-8, 2000, 2007-8

Representative of about 83% of population. It surveys > 30 000 individuals living in 13/33 provinces.

2007 survey report “initial public release” Register for data download link from RAND website

Yes (Bahasa and English).

Possibly in manuals or website

GDS Integrated survey of households, public health and education facilities + district & village officials. GDS1 2002 GDS2 2004

IFLS-2 in 2004 - 32 kabupaten/kota and 8 provinces. Complements Susenas and Podes Stata datasets available

Non-representative sampling. GDS2 - only 139/400+ districts; no districts in 4 provinces (incl DKI Jakarta) http://gds-indonesia.org/gds.aspx

Yes (Bahasa and English).

Likely at website

NHS & RisKesDas 2007: community-based cross-sectional survey (merged with Susenas)

Nationwide, 33 provinces, 440 districts and cities; 258,366 households and 987,205 respondents

Formation of new districts, difficult access to census blocks and the blood specimens were collected only in the cities. http://www.litbang.depkes.go.id/ riskesdas/index.htm

2007 (Bahasa and English likely).

Likely at website

http://www.litbang.depkes.go.id/



DESIGN



REPORTED

IHPIHP 2005, 2008? Trends of health data (facility & community based: Demography; environment; health status, effort & resources; comparison neighbouring countries.

Very important for Phase II

Working link to 2005 but not 2004 or 2005 reports Likely IHP presentation for 2008 http://www.depkes.go.id

2005 (Bahasa and English likely).

Unknown


5. REVIEW OF KEY ANALYTICAL WORK

5.1 Burden of MNCH Mortality Indonesia has recognised that, notwithstanding progress in the last four decades, high infant and maternal mortality rates are a major health priority. However, due to lack of vital registration systems, ongoing data collection is difficult and relies upon data from IDHS and other selected data sources. Most often this data has been used to monitor trends subsequent to large-scale public health interventions such as the “Village Midwife” program. Correspondingly, much of the literature analyses the impact of this intervention as well as factors associated with its implementation. As far as child mortality is concerned there has been much less in the way of published literature. While estimates of total Under-5s are available, breakdowns as to the causes of death are not. Where data is available, it is limited to specific-cause estimates, usually obtained as a result of assessing specific nutritional interventions and vaccination programs. This section reviews a selection of the key analytical work regarding maternal and child mortality in Indonesia. It should be noted that those related to equity are discussed below.

5.1.1 Neonatal and Child Mortality The rate and causes of neonatal and child mortality have changed over time with the introduction of vaccination and other intervention programs. Among the earliest studies of perinatal mortality are those from rural West Java based on cross sectional surveys [32] and a longitudinal survey of pregnant women [33]. These surveys reported a perinatal mortality rate of 48 per thousand, with the main causes of death being infections (primarily tetanus) and birth hypoxia/asphyxia. Mortality was significantly associated with a young age of mother, low birth interval, twins and low birth weight. While small in size and relatively obsolete in regards to data, these studies give an insight into the pre-intervention state of neonatal mortality in Indonesia. Titaley et al [5] indentified determinants of neonatal death during 1997-2002 using IDHS data. Availability and use of perinatal health care services such as trained birth attendants (TBAs) and postnatal care were associated with reduced odds of neonatal deaths. High birth rank and short birth interval, small birth size, complications during delivery, and male infants were associated with an increased risk, as were maternal occupation outside the home and paternal unemployment. At the community level, particular regional areas were associated with increased odds of neonatal death. The study used IDHS data and it was unable to examine causes of death due to lack of qualitative data and potential endogeneity biases. While neonatal mortality can be studied in conjunction with maternal health programs the broader area of Under-5 mortality has been much more difficult to assess. While overall mortality estimates are available through IDHS, analyses of causes of death are limited to data collected as part of specific investigations. These are usually localised and small scale studies. One such study published in 1985 examined the incidence and related mortality of diarrhoeal diseases in rural Sumatra [34]. Diarrhoeal diseases accounted for 22% of total Under-5 mortality and 37% of mortality among those aged 1-4. These data are reasonably consistent with more recent estimates of the burden of diarrhoea, shigellosis and cholera in North Jakarta from 24 months surveillance [35]. Although the study did not report mortality, it found that the greatest burden of diarrhoeal disease is still found in older infants and young children.


One of the few papers that describe a broader range of causes of death is the report of Sutrisna and colleagues [36] who examined the causes of death and choices in treatment for 141 deaths under the age of five in Indramayu, West Java. At this time overall infant mortality was 74.3/1000 live births, and overall Under-5 mortality was 80.7/1000 live births. Half (51%) of the deaths were ascribed to pneumonia, 10% to diarrhoea, 8.5% to measles, 4.2% to neonatal tetanus, 2.1 % to convulsions/encephalopathy, 1.4% to trauma and 22% to “others” and “unclassifiable”. The decision to seek western medical care was positively associated with the age of the child, the duration of the terminal illness and the previous attendance of the mother at a community-based maternal and child health facility. More recently the age and cause specific childhood mortality was investigated in Lombok in order to determine the appropriateness of introducing Haemophilus influenzae type b and pneumococcal vaccines [37]. This paper provides some of the more recent data on cause of childhood death. The infant (2-23 months) mortality rate was 89 (95% CI: 75, 104) per 1,000 live-births. The greatest contributors to infant mortality were acute respiratory infections, ARI, (52% including pneumonia), central nervous system infections (13%) followed by diarrhoea and low birth weight (11% each). Importantly, mortality due to vaccine preventable diseases (such as polio, diphtheria, pertussis, tetanus, tuberculosis, and measles) only accounted for 3% of deaths. The results indicated that current efforts to reduce childhood mortality should focus on reducing ARI and meningitis.

5.1.2 Maternal Mortality Data on maternal mortality remains poor. Estimates were only reported for the national level in the latest IDHS 2007 report, which puts the a maternal mortality ratio (MMR) at 228 per 100 000 live births in 2007 [1]. WHO estimated the MMR at 420/100 000 live births (95% CI: 240-600) in 2005 based on IDHS 20020-03 data [2]. Reliance upon IDHS data, however, may result in an underestimate of maternal mortality due to survivorship bias. Different methods of adjustment for this may therefore result in wide ranging estimates. One of the most comprehensive analyses of maternal mortality investigated specific cause of death based on a district-level audit of the causes and circumstances of 130 maternal deaths in South Kalimantan [38]. Through the collection of hospital and health service data as well as the use of verbal autopsies and other in depth interview techniques, the study also investigated access, transport and usage issues associated with each death. The most frequent cause of death was haemorrhage (41%) followed by hypertension (32%). Delays in decision-making (77%) and poor quality of care (60%) were the most common factors involved in the deaths. Despite the small sample size, this study was very comprehensive and the findings of birth attendant use and access to health care are consistent with wider population estimates. Maternal health policy in Indonesia has relied on strategies to increase the proportion of births attended by a health professional. A recent study assessed maternal mortality in relation to these programs in two districts (Serang and Pandeglang) in West Java [7] using informant-based capture-recapture methods, which also gathered information on birth attendant choices. The MMR in the two districts (435 per 100 000) was higher than the Indonesian average (307/100 000) with mortality peaking among the lowest wealth quartile. Even in the groups with a higher proportion of assisted births, the MMR rate was still much higher than expected. This is possibly due to confounding: the increased prevalence of complications in assisted births as a result of a preference for assistance in high-risk births. One of the key conclusions was that more than just the provision of midwives was necessary to improve


maternal health in Indonesia. The same authors also estimated the population-based incidence of pregnancy-related illness and mortality in the same two districts [39]. Life-threatening hospital maternal morbidity was examined in relation to population maternal mortality and whether hospital records of these events could be used to create estimates of maternal mortality outside of hospital admissions. This study assumed that the conditions defined as life threatening would be fatal if untreated (i.e. out of hospital), which the authors themselves feel may have introduced error in the calculations. Thus, while its use as an estimation tool still needs to be proven, the cause specific morbidity events may be helpful in examining potential causes of death. The largest direct contributors to mortality and near miss were found to be haemorrhage and hypertension, however non-obstetric complications such as TB and hepatitis also added significantly to the burden. The frequency and causes of near miss and maternal deaths in four public and private hospitals in West Java were investigated [40]. Although there were differences between private and hospital systems it appeared that this was most likely due to differing case mixes, with wealthier (and presumably healthier) women more likely to use private services and the most serious cases being referred to the larger public hospital. In addition, most of the near misses occurred on or just after arrival at the hospital, suggesting considerable delays in the transfer process. Another notable finding was the proportion of near misses following abortion. The authors reported that a large proportion of these cases may have been due to unsafe rather than spontaneous abortions and that measurement of these near miss events could lead to more accurate estimates of the burden of unsafe abortion. Despite the increasing uptake of maternity cases by private hospitals, obstetric emergencies were still the domain of public hospitals. Regional variations in exposure to risk factors may influence the burden of mortality and morbidity due to each cause, e.g. the impact of multi-drug resistant malaria on maternal health in West Papua [41]. In the population studied, 17% of women were infected at the time of delivery and 22% of preterm births were associated with such infections. The influence of malaria induced fever throughout pregnancy on low birth weights was not quantified; however the authors believed that it may be a significant contributor to adverse neonatal outcomes. More comprehensive, high quality data on maternal mortality is required, particularly at a sub-national level. This work, however, remains outside the scope of the current study.

5.1.3 Information Availability and Gaps Estimates of Indonesia’s MNCH mortality burden are most comprehensively available at national level and by province using IDHS. Systematic estimates at sub-province level are lacking. Data collected from the population censuses have been used to estimate provincial level infant, child and adult mortality rates. Demographic models have been used to estimate projections of district mortality rates. Sources of data There are several sources of data on cause-specific mortality, including maternal, newborn and child mortality:

a) Mortality Study of Survei Khusus Tabungan Dan Investasi Rumahtangga (SKTIR) /Susenas (2001) and NHSNHS 2001. The SKTIR is a special survey on savings and household investments, latest available for 1997;


b) Baseline Health Research/Susenas (Riskesdas 2007); c) IMRSSP (Indonesia Mortality Registration System Strengthening Project – SPH UQ +

AusAID + WHO 2006 – 2008); and d) Tuberculosis Mortality Surveillance System (2006 – 2008; WHO assisted).

Sub-national (province, district, city) level mortality analysis depends on:

a) Mortality registration (local area monitoring); b) Maternal-Perinatal Hospital Reporting Recording System (see IMRSSP); and c) MNCH Surveillance Audit.

The sub-national data are periodic and of fair quality. They could be used as a complement to indirect estimation of community-based survey results. The information gap is that coverage at national and provincial level is still low. The minimum demographic information that should be captured in the census are: age of women; children ever born; and the survival status of those children. These have been suggested and will be implemented in the 2010 Population Census.

Projects that are Addressing Causes of Mortality There are some projects that are noting causes of MNCH mortality:

a) The IMRSSPcurrently covers two districts/cities in each of six provinces: Jakarta, Central Java, Lampung, West Kalimantan, Gorontalo and Papua. Similar activities are being started in Bali and East Nusa Tenggara. There are some preliminary analyses but the results are not likely to be representative at either the national or provincial level;

b) Mortality Registration based on Law No. 23/2006 on Population Administration (Ministry of Home Affairs); and

c) Improvement of Mortality Recording-Reporting System of Hospitals that include Multiple Causes of Death based on WHO ICD-10 (MoHoH).


Table 5.1: Summary of information Related to MNCH Mortality

MORTALITY ANALYSIS

NATIONAL SUB-NATIONAL NAME OF STUDY DATA DETAILS INFORMATION GAP

Levels and trends - Maternal mortality

Yes: trends over time, age.

No DHS DHS 1994, 1997, 2002-2003, 2007 Refer to three years before the survey; Indirect Estimation Method No data at sub-provincial level

Levels and trends - Infant, child, under-5, neonatal mortality

Yes: trends over time, gender, urban/rural, mother’s education, wealth, birth order, birth interval, woman’s status

Yes (Province) DHS, Susenas DHS 1994, 1997, 2002-2003, 2007; Annual Survey of Susenas (Core Instrument)

Refer to three years before the Survey; Indirect Estimation Method; under-reporting of Susenas data (35-40%) No data at sub-provincial level

Cause-specific mortality

Causes of hospital deaths by top 15 disease conditions and frequencies. Case fatality rates for selected diseases (Diarrhoea, Malaria, Meningitis, Pneumonia, Tuberculosis Community based survey, data on underlying causes of deaths for various age groups, including neonates, infants, under fives and mothers and by city/district

Only for big islands/ regions

Annual Mortality data from hospital reporting system; Susenas, Household Health Survey, National Health Survey Riskesdas, IMRSSP

SKRT/SurKesNas, RisKesDas 1992, 1995, 2001, 2007 IMRSSP from 2006 – 2008; major national underlying causes of deaths by age group and sex; e.g. for 2007 major causes include: Early neonates (respiratory disorder, prematurity, sepsis, hypothermia, congenital malformation); late neonates (Sepsis, pneumonia, RDS, prematurity, birth trauma, tetanus, SIDS); Maternal Factors in perinatal deaths (hypertension, haemorrhage, maternal trauma, multiple pregnancy, infection); under-5 (diarrhoea, pneumonia, dengue, measles, TB., malaria, drowning, malnutrition); maternal deaths aged 15-44 years (liver diseases, tuberculosis, obstetric complications)

Pilot mortality registration (IMRSSP) only covers 6 provinces (15 districts/cities)


MORTALITY ANALYSIS


Specific child mortality studies

Yes Regional Houweling, T.A.J., et al., Mortality inequalities in times of economic growth: time trends in socioeconomic and regional inequalities in under 5 mortality in Indonesia, 1982-1997. Journal of Epidemiology & Community Health, 2006. 60(1): p. 62-68.

DHS 1987, 1991, 1994, and 1997

Regional Titaley, C.R., et al., Determinants of neonatal mortality in Indonesia. BMC Public Health, 2008. 8(232): p. 1-15.

DHS 2002-03

Rural West Java Alisjahbana et al. Perinatal mortality and morbidity in rural West-Java, Indonesia Part I: Vital statistics based on cross-sectional surveys. Part II: The results of a longitudinal survey on pregnant women. Paediatr Indones 1990; Part 1: 30(1-2) 1-11. Part 2. 30(7-8) 179-90.

Pt 1. Cross sectional survey of 7964 houses in 3 villages Part 2. TBA visited each pregnant woman in Ujung-Berung area (rural West Java) 1978-80

South Sumatra Nazir, M., N. Pardede, and R. Ismail, The incidence of diarrhoeal diseases and diarrhoeal diseases related mortality in rural swampy low-land area of south Sumatra, Indonesia. J Trop Pediatr, 1985. 31(5): p. 268-72.

Cross sectional survey and a one year surveillance 1983-84 in five villages

Lombok Nelson, C.M., et al., Age- and cause-specific childhood mortality in Lombok, Indonesia, as a factor for

Cross-sectional data, hamlet-level mortality survey in 40 of 305 villages.


MORTALITY ANALYSIS


determining the appropriateness of introducing Haemophilus influenzae type b and pneumococcal vaccines. J Health Popul Nutr, 2000. 18(3): p. 131-8

Specific maternal mortality studies

Serang and Pandeglang districts

Ronsmans, C., et al., Estimation of population-based incidence of pregnancy-related illness and mortality (PRIAM) in two districts in West Java, Indonesia. Bjog-An International Journal of Obstetrics & Gynaecology, 2009. 116(1): p. 82-90.

All women residing in 2 districts - Serang and Pandeglang. 4 sources: hospital case notes, community based data of maternal deaths, National Statistical Office for population size; a population-based survey of births2004-06 (30006 admisssions)

Two districts in Banten Province

Adisasmita, A., et al., Obstetric near miss and deaths in public and private hospitals in Indonesia. BMC Pregnancy & Childbirth, 2008. 8: p. 10.

Cross sectional study in four hospitals in two districts in Banten province review of registers and case notes 2003-04


5.2 Priority MNCH interventions Below is a review of the key studies identified in Indonesia regarding the effectiveness of the ‘Best-buy range of interventions’ for MNCH. In addition, some MNCH programmes implemented in Indonesia and that incorporate many of these interventions have recently been evaluated and are reviewed below.

5.2.1 Maternal Health PREVENTATIVE CARE Antenatal Care (ANC) In Indonesia, routine ANC is offered to all pregnant women as a national policy, included in the MSS. Nuraini [42] conducted a field trial in central Java to assess whether a new approach to ANC would improve women’s knowledge of its benefits in pregnant women. In addition to routine ANC, the new approach provided counselling on the need of ANC and gathered information about the involvement of the pregnant women’s families particularly in the management of pregnancy complications and referral. This small scale study found significant improvement in the knowledge of the intervention group with regard to healthy pregnancy, pregnancy complications, safe birth and taking care of the newborn. However, this improvement was significantly influenced by educational background and socio-economic status. On the other hand, it should be noted that to maximise participation and retention in the study, several measures addressing barriers to scale-up ANC were undertaken. They included pro-active involvement of the head of the health centre who personally invited participants and removal of financial and access barriers. Both treatment and control groups were picked up by health centre vehicles, accompanied by midwives from the villages and waived the corresponding user charges. RISK CARD/BIRTHING CENTRE IN VILLAGE/RADIO FOR REFERRAL Two studies describe methods to both improve the attendance of SBA and the referral system for dealing with obstetric emergencies. A study by Pusat Safe motherhood [43] evaluated the use of an antenatal card introduced into the community to detect pregnancies at risk and refer those at high risk for SBA or delivery in hospital. The introduction of the card resulted in a significant decline in both MMR and IMR in the districts of Nganjuk, Probolinggo and Trenggalek. It was noted that a good referral system was needed to be able to make effective use of the card [43]. This was in contrast to a previous study by Kwast [44] in the Probolinggo district that found risk cards did not encourage women at risk to seek SBA and that failed to identify many women who subsequently had difficult deliveries. In a related study into community based maternity programmes through The MotherCare Project, found that the village birthing centres (polindes) were an effective way of promoting SBA where physical and economic constraints in accessing health centres were present and where access to midwives is regular. Radios to support referral of emergencies were provided as well as community activities to promote the use of polindes. The study found that the efficiency of a birthing home depends on a complex set of factors. Fundamental to the success of birthing homes is the desire of village residents to participate in their development and clear guidelines for their management.


Iron and Micronutrient Supplementation In a randomised control trial (RCT) community based study in Indonesia, Muslimatun et al (2000) [45] found that in the study setting, weekly supplementation was as effective as daily supplementation, provided compliance could be ensured and addition of Vitamin A improved haemoglobin concentrations. However, in a study in eight developing countries, including districts in South Kalimantan and West Java in Indonesia, Galloway, R et al [46] suggested that factors other than negative side-effects of iron supplements are the main reason for women’s non-compliance. The researchers recommend addressing these other factors for non-compliance, in particular inadequate supply of supplements and behavioural aspects, such as lack of knowledge of the causes and importance of anaemia. Kurniawan et al [47] recommend expanding the current iron-folate supplement programme to adolescent girls, since almost a quarter of girls tested in a rural coastal area of Indonesia were found to suffer from iron deficiency anaemia. In a double-blind randomised trial in Lombok, Indonesia, the SUMMIT Study Group [48] found that supplementation with multiple micronutrients (MMN) as compared to Iron, Folic Acid supplementation (IFA) was effective at reducing infant mortality particularly in undernourished or anaemic women and might play an important part in improving prenatal-care programmes in Indonesia. Shankar [49] suggests that community facilitators play an important role in changing women’s health behaviour. Access to health facilities was also found to have an impact on child health. Block et al [50] found that those mothers with access to health centres/posyandu and who were provided with knowledge on nutrition spent more money on micro-nutrient rich food than those mothers who did not have access to these health centres. Family Planning Promoting a national family planning programme in a country as geographically and culturally diverse as Indonesia is not straight-forward. In a study using 1997, IDHS data and a qualitative study carried out in July 2000 to evaluate the acceptance of Indonesia’s family planning programme, Cammack [51] found that regional variations were hard to predict. Whilst media exposure and education appeared to offer the best means of promoting family planning and contraceptive use, cultural and historical local factors also played a part. Utomo et al (2006) [52] reported on the study in 1997–98 of the role of village family planning volunteers and the cadres who worked under them in West Java, Central Java and DI Yogyakarta, in implementing the national family planning programme in Indonesia. The study found that volunteers did much to promote family planning activities. However, since women were often identified for these roles and their services were directed mainly towards women, it reinforced the gender gap in responsibility for family planning. In an evaluation of the promotion and service of the family planning programme in primary health care and district hospitals following decentralisation, Tjipto et al [53] recommended that family planning and contraceptive delivery should be conducted by the primary health provider under the regulation of the district health office and with the coordination of the district BKKB [53]. In addition, the 2008 family planning programme evaluation [54] found that up to the end of the middle-term development plan (2004-2009) the family planning programme goals were yet to be fulfilled. The main results from this evaluation were: 1) new users of family planning increased for the last three years; 2) male family planning use tended to increase but remains far from the target; and 3) the fulfilment of unmet needs has not yet been reached. System constraints, such as lack of political will, fragmentation of roles between different institutions and limitations of human resources in the field have been suggested as reasons for the failure


to reach targets. Further recommendations include increasing equitable access to the family planning service, introducing the idea of health reproductive service and family planning as a human right, improving communication, information and education for couples of reproductive age, protecting the users of family planning to the possible negative effects of contraceptive devices and improving the quality and equitable service for effective and efficient contraceptive methods [55]. Hotchkiss et al [56] examined the relationship between service utilisation and contraceptive use in five countries including Indonesia. Data from IDHS on women of reproductive age was linked with service availability surveys and analysis was carried out at the level of individual woman. In Indonesia, the analysis showed a positive association with intensity of health service use and subsequent contraceptive use among women, even after controlling for observed and unobserved individual and community level factors. This study suggests that health services play an important role in the promotion and subsequent use of contraception by women who use these services.

HIV/AIDS PREVENTION AND CARE: PMTCT Stigmatisation and association of HIV/AIDS with injecting drug use and sex work in Indonesia hampers efforts in the prevention of mother to child transmission (PMTCT) of HIV. In their qualitative study in a community-based PMTCT programme run by an NGO in Indonesia, Hardon et al [57] investigated the local context of care and found that women value the provision of HIV tests in ANC but found counselling and follow-up services poor. Tailoring globally designed PMTCT programmes to local settings as well as employing strategies to reduce the negative consequences, such as the discrimination of those found to be HIV positive, is recommended.

PRIMARY CLINICAL CARE - SKILLED DELIVERY AT BIRTH There have been a number of studies evaluating the use of different training methods for midwives to improve their clinical skills at the time of birth. Budijanto et al [58] report the results of a training programme aimed at improving midwives knowledge, attitude and skills in APN (Asuhan Persalinan Normal/Normal birth care), KIP/K (Komunikasi Interpersonal dan Konseling/IECC) and PWS-KIA (Pemantauan Wilayah Setempat Kesehatan Ibu-Anak/MCH surveillance). The training was not successful in increasing knowledge in these areas since more than 60% of midwives still had low knowledge of APN, KIP/K and PWS-KIA. However the psychomotoric skill was improved for newborn care and postpartum care [58].

Sulistomo (1999) evaluated the Life Saving Skills (LSS) training undertaken by midwives in Central and East Java. The training was conducted in recognition that midwives often work in isolation in villages or remote areas. The study found a significant difference in infection prevention between LSS and non-LSS trained respondents in antenatal care in Central Java but not in East Java. In management of labour there was a significant difference between LSS and non-LSS trained respondents in both Central and East Java. Orientation before midwife placement was found to be an important factor to improve performance [59]. Fahdhy [60] evaluated the use of WHO partograph by midwives for labour in a maternity home, by comparing outcomes after birth using a cluster randomised control trial. The study found that introducing the partograph significantly increased referral rate and reduced the number of vaginal examinations, oxytocin use and obstructed labour, whilst caesarean sections and prolonged labour were not significantly reduced. It was recommended that a


training programme with follow-up supervision and monitoring could be introduced in other similar settings and endorsed the use of WHO partograph for use by midwives practising in maternity homes. Maternal death audits are a useful tool to evaluate the cause of death and to provide information on what should be improved. Supratiko et al [61] evaluated a district audit in three provinces of South Kalimantan on the causes and circumstances of maternal deaths between 1995 and 1999. Of the 130 maternal deaths included in the audit, delays in decision making and poor quality of health care contributed to 77% and 60% of maternal death during the three year period. 37% of deaths were believed to be due to economic constraints. Supratiko suggests that the success of these audits is due to the collaboration of policy-makers, health care providers at different levels and the community in the process. The audit system needs to be evaluated continuously to ensure confidentiality and evidence based practices in managing the cause of maternal death to optimise changes needed in the health care system. Analen [62] describes a scheme in Ngawi district in East Java that has been implemented to try to ensure that a midwife or other TBA assists deliveries. Since 2006, dukun (traditional birth attendant), have been given incentives of up to US$ 12 by the local government budget for referring pregnant women to SBAs or community-based midwives. The scheme has proved successful, with a dramatic drop in deliveries aided by dukun (from 86% in 1984 compared to fewer than 1% today). Maternal deaths also have decreased; while 15 mothers died during delivery in 2002, this number dropped to nine in 2006.

5.2.2 Child Health According to a report by BAPPENAS, the main causes of child death are: acute respiratory infection; prenatal complications; and diarrhoea. The combination of these three factors contributes to 75% of infant mortality [4]. Factors for the death in children Under-5 are almost identical, i.e. acute respiratory infection, diarrhoea and neurological illnesses—including meningitis and encephalitis—and typhus. Related to MGD4, some best-buy interventions have been identified and are reported under their different delivery methods. FAMILY ORIENTED COMMUNITY BASED SERVICES Among family oriented community based services, four interventions that have been studied in Indonesia were identified, including hand washing, clean delivery and cord care, kangaroo mother care and exclusive breast feeding. Hand-Washing No recent evaluation studies of hand-washing were found during this mapping exercise. Although slightly outdated, the studies reviewed here provide some useful guidance on interventions addressing behavioural constraints. Wilson et al [63] evaluated the impact of hand washing on the incidence of diarrhoea in community based study conducted in Central Lombok, Indonesia. The study involved two villages as intervention and control respectively. Mothers from the treatment village received soap and explanation regarding the transmission route of diarrhoea, i.e. oral-faecal. That message was repeated and reinforced fortnightly. The study showed that the intervention resulted in the reduction of diarrhoea episode in the intervention village by as high as 89%, whereas there was no reduction in the control village. In a follow-up study Wilson [64] found the intervention was sustainable in the two years


following. This study suggests a simple health education message delivered face-to-face is effective at changing behaviour with regard to hand hygiene. Clean Delivery and Cord Care In a hospital-based RCT, Rasyidah et al [65] compared the efficacy of 10% povidone iodine versus 70% alcohol in umbilical cord care of newborn infants in Medan Indonesia. The study indicated both treatments are equally effective. Furthermore, no omphalitis was observed in either group. Kangaroo Mother Care Three RCT hospital based studies on ‘Kangaroo Mother Care’ (KMC) to regulate babies’ temperatures and to promote exclusive breastfeeding have been identified in Indonesia. Cattaneo et al [66] conducted a multi-country study in Addis Ababa (Ethiopia), Yogyakarta (Indonesia) and Merida (Mexico), while Haksari [67] and Suradi [68] conducted their studies in teaching hospitals in Yogyakarta and Jakarta respectively. All studies compared KMC and Conventional Mother Care (CMC) with incubator. All studies showed that KMC was at least as effective and safe as CMC, and less expensive. In addition, KMC may increase the prevalence and duration of breastfeeding practice, which is usually under-practiced in low birth weight infants. Exclusive Breastfeeding Four studies on exclusive breastfeeding in several districts in Indonesia have been identified. They showed the benefit of breastfeeding in preventing under nutrition, ARI and diarrhoea. In a cross-sectional study carried out in Bandung’s urban slum area, evaluating the effect of exclusive breastfeeding on the linear growth of children aged 24-36 months, it was found exclusive breastfeeding had a significant positive effect on the linear growth [69]. Julia [70] compared the effect of breastfeeding on the nutrition status of under-two children between a poor and non-poor area and found breastfed children have lower risk for under nutrition. Furthermore, it was shown that the protective effect of breast milk is more significant in poor area with a lower intake of protein[70]. In a case-control study, assessing the effect of exclusive breastfeeding toward acute respiratory infection among infants 7-12 months of age, [71], Kurniawan [72] investigated the association of 4-months exclusive breastfeeding and diarrhoea, and found that the incidence of diarrhoea in breastfeed baby was significantly lower than the non-breastfeed baby (8,1% vs 24%, p 0.037) [72]. Even though studies proved the positive effect of breastfeeding in promoting the growth, preventing malnutrition and infectious disease especially ARI and diarrhoea, the prevalence of exclusive breastfeeding is still low 4-12% in urban and 4-24% in rural area (nutrition and health surveillance, 2002). Socio-economic and culture factors influence this behaviour, and a strong commitment and leadership from local government to implement breastfeeding practice policy should be a priority. POPULATION ORIENTED SCHEDULE SERVICES: PREVENTIVE INFANT & CHILD CARE Two interventions have been studied in Indonesia in relation to preventive infant and child care, including measles vaccination (association with pneumonia) and zinc supplementation (association with nutritional status and cognitive development). Measles Vaccination In a case control study in Sumatera Selatan, Hatta [73] assessed the correlation between measles vaccination with incidence of pneumonia. The study showed that the risk for Under-5


children aged 9-59 months, that are not measles-vaccinated, to acquire pneumonia is 2,3-fold higher compared to those Under-5 children that were measles-vaccinated. Other influences on the occurrences of pneumonia were: mother’s education (OR=2.037; p=0.013); mother’s knowledge (OR=2,364; p=0,005); kitchen smoke pollution (OR=2.99; p=0.002); house crowdedness (OR=3.247; p=0,0005); and distance to health care centre (OR=0.431; p=0.007 [73]. A survey conducted by Pusat Penelitian dan Pengembangan Pemberantasan Penyakit (Centre for Research and Development of Disease Control) evaluated the effectiveness of measles immunisation. The study showed that immunisation led to a reduction in the incidence of measles in Bali and West Java [74]. However, there was wide variation in measles immunisation coverage amongst provinces, so these results are not representative. Zinc Supplementation In a RCT study, Retno [75] evaluated the effects of zinc supplementation on nutritional status and cognition in children. The study showed a significant difference in weight for age between the zinc group and placebo [0.28 (SD 0.18) vs 0.09 (SD 0.14); P=0.0001]. Height increments were also greater in the zinc group [0.34 (SD 0.15) vs 0.02 (SD 0.12); P=0.0001). There was no significant difference between weight and height. Intelligence quotient (IQ) measured by the Stanford-Binnet test was slightly higher in the zinc group [2.26 (SD 3.11) vs 2.00 (SD 2.81], but the difference was not significant according to sex. The study concluded that zinc supplementation produced highly positive responses in weight for age and height for age increments in children with zinc deficiency compared with placebo. There was no effect of zinc supplementation on weight for height index and none on cognition measured by IQ [75]. Vitamin A Supplementation In a randomised, double-blind, placebo-controlled clinical trial to evaluate the impact of linking vitamin A supplementation with the Expanded Programme on Immunisation on morbidity and child growth, Semba (2001) [76] found vitamin A had no impact on growth or infectious disease morbidity in the first 15 months of age. A study by Berger et al (2008) [77] found that those children not reached by a vitamin A supplementation programme in urban slum areas had poorer health outcomes and importantly were less likely to have received other outreach services such as vaccinations.

5.2.3 Individual Clinical Services Among individual clinical services, interventions that have been studied in Indonesia include steroid for preterm labour, zinc and ORS for diarrhoea management, and antibiotic and vitamin A for pneumonia. Steroid for Pre-term Labour Sumiartini et al [78] conducted a RCT assessing the efficacy of dexamethasone for lung maturity in preterm delivery in a teaching hospital in Denpasar (Bali). This study showed that administration of dexamethasone in pregnant women during preterm delivery significantly improves lung maturity. Taking into consideration that prematurity is an important cause of neonatal mortality, this study suggests the scaling-up of this intervention should be explored. Zinc for Diarrhoea Management Three studies have been identified on the role of oral zinc supplementation for diarrhoea management in Indonesia. All studies were RCTs, hospital-based and conducted in Surabaya [79]; [80]. Pulveres form of zinc was used in two studies while one study used oral solution. All


studies consistently showed oral zinc supplementation shortened the duration of diarrhoea. However, none of the studies evaluated its impact on the recurrence of diarrhoea. One of the studies [79] also investigated the role of zinc supplementation in relation to the serum level of zinc. The result revealed that supplementation was beneficial regardless to the level of serum zinc of the patients. No study so far in Indonesia has assessed the compliance of taking zinc supplementation, and whether the form of zinc preparation affects compliance. Currently, there is one ongoing study in Yogyakarta led by Prof Yati Soenarto evaluating both the efficacy and compliance of zinc supplementation as a part of study concerned with the use of standard WHO recommendations for diarrhoea management in children. To date there is no study in Indonesia assessing the cost-effectiveness of this intervention. Oral Rehydration Solution (ORS) for Diarrhoea Risnelly et al [81] evaluated the comparison of low osmolarity ORS (new formula of ORS) and standard ORS in a hospital-based RCT carried out in Medan. The study showed that using the low osmolarity ORS was significantly associated with shorter duration of diarrhoea. There is no effort to evaluate the compliance that may affect the efficacy of both types of ORS. The issue of compliance will be more important in a community setting where there is no health worker to advise the patients and family. It should also be noted that a problem remains in implementing the usage of this new ORS formula since it has not been available widely in community or in health facilities. In addition, in a cross-sectional study based in Waru Jaya village of West Java, Indonesia, Macdonald et al [82] found low levels of maternal knowledge on the signs of dehydration. The study also found a significant relationship between maternal knowledge and use of ORS in home treatment. The authors recommend health education for mothers of young children. Antibiotics and Vitamin A for Pneumonia Rumbajan et al [83] evaluated the efficacy of ampicillin-chloramphenicol combination and cefuroxime for treatment of pneumonia in an RCT hospital-based study conducted in Manado. The study found both treatments were effective but cefuroxime had a better efficacy. However, no cost-effectiveness analysis was done. A RCT study assessed the effect of vitamin A supplementation on severe pneumonia. The result found vitamin A supplementation associated with faster disappearance of fine crackles but not with other clinical indicator [84]. SELECTED MNCH PROGRAMMES RECENTLY EVALUATED District Team Problem Solving – Making Pregnancy Safer A programme was implemented in 2007 by UNESCO and the Indonesia Health Department in Wonosobo district to deliver DTPS-MPS (District Team Problem Solving – Making Pregnancy Safer). The aim of the programme was to accelerate the decrease of maternal and infant mortality. Data were collected from district health offices and medical records of Wonosobo General Hospital to monitor the effects of the programme. Suhadi & Hakimi [85] found that during 2007 the proportion of births attended by trained health personnel rose to 70.4% in 2007 from 67% in 2006. There was no significant difference in the causes of death or mortality rate which requires coordinated and long term efforts.


PONEK and PONED Rachmawati, et al. [86] report the results of a study by the Indonesian Centre of Health Policy Research and Development to evaluate the basic obstetrics and neonatal emergency service (PONED) and comprehensive obstetrics and neonatal emergency service (PONEK) programmes in Indonesia. The study areas were in East Java, West Java, Bali and North Sulawesi provinces. The aim was to analyse the availability, utilisation, sustainability, community acceptance and constraints towards delivering PONED and PONEK. The study found there was lack of human resources, facilities, and coordination in delivering PONED and PONEK. The data were not sufficient to conduct impact evaluation of the programmes on maternal and neonatal death rates [86]. “SUAMI SIAGA” ALERT HUSBAND CAMPAIGN The Indonesia Health Department launched a national campaign between 1998 and 2001 to promote the decrease of maternal mortality with “Suami Siaga” (Alert Husband) campaign1. The goal of the campaign was to improve knowledge of the three delays contributing to maternal mortality and promote attitude and behaviour change to overcome these delays. The programme used mass media including television, radio, promotional posters and stickers, leaflets, promotion by health staff and at community meetings to get the message across to the Indonesian population. More than 80% of husbands, wives, and bidan and community leaders were exposed to the campaign. The mass media campaign can improve intended behaviour (the successful scale-up of the programme depends on good coordination at field level; availability of health service of good quality; and a good relationship between midwives and TBA). Village Midwife Programme Using the IFLS, Frankenberg [87] found that regardless of a women’s educational status, the placement of village midwives increase women’s use of SBA and receipt of iron tablets. Improving ANC during the first trimester for women with low levels of education was also observed. Achadi et al [88] studied two districts in West Java and found those with a higher density of midwives (6 vs 2 per 10,000 population) had a three-fold increased odds of delivering with a health professional. Other benefits to the Village Midwife Programme have also been observed. Shrestha’s analysis of the IFLS found an association between Village Midwife Programmes and lower neonatal mortality rates (but not post-neonatal mortality), suggesting that the programme may have contributed to a reduction in infection related to the birth process. Frankenberg [89] used IFLS data and found the Village Midwife Programme was associated with higher body mass index in women of reproductive age and higher birth weight, a result that was robust to the inclusion of community-fixed effects. However, this policy has failed to improve maternal health outcomes in Indonesia (see review of analytical work on health system constraints and strategies below). The Integrated Management of Childhood Illness (IMCI) IMCI is a strategy to reduce childhood mortality and morbidity. It has three components: improving health worker skills; strengthening the health system; and improving family and community practices. This program was adopted and launched by Indonesian MoH in 1997.

1 Monitoring and evaluation of suami siaga (husband alert) is conducted by joint collaboration of ministry for Women’s empowerment. UNFPA and CCP the Johns Hopkins University (2003). The program is introduced nationally through mass campaign. http://www.jhuccp.org/research/researchDB/search.php?do=results&primaryTopic%5B%5D=Maternal%20Health

http://www.jhuccp.org/research/researchDB/search.php?do=results&primaryTopic%5B%5D=Maternal%20Health

http://www.jhuccp.org/research/researchDB/search.php?do=results&primaryTopic%5B%5D=Maternal%20Health


However, there is only limited studies reported evaluation in implementation of this program and none assess this program on infant and Under-5 children morbidity and mortality. An evaluation study of IMCI on pneumonia recovery among Under-5 children was conducted in Puskesmas Kabupaten Bungo Propinsi Jambi. This study showed that the standard IMCI services have a greater change toward the recovery of Under-5 pneumonia compared to non-standard IMCI [26] OTHER NUTRITION PROGRAMS Friedman et al [19] undertook preliminary cost-effectiveness analysis of nutrition programs in five districts. The districts were purposively selected to reflect a variety of geographical and economic characteristics. Program unit costs varied greatly across five districts, which is not surprising considerING the differences in local cost drivers, such as local price levels; size of the population served and density of the catchment area. For example the cost of therapeutic feeding varies by 2.1 fold between the lowest and highest cost districts. A similar variation of 1.5 fold is also observed in growth monitoring costs for children U5 years. The opportunity costs of volunteer services, not included in the budget, were significant in all cases, but also varied widely across districts. Disability Adjusted Life Years (DALYs) were used to measure the effectiveness of three nutrition interventions: (i) vitamin A supplementation for children 6-59 months; (ii) prenatal iron supplementation and (iii) growth monitoring and complementary feeding for children 6-12 months. Preliminary results suggest that the relative cost-effectiveness for each intervention is quite different, with iron supplementation being the most-cost effective, followed by Vitamin A supplementation. The least cost effective is growth monitoring and complementary feeding. However, as expected the cost per DALY averted varied greatly across districts for each intervention. As noted by the authors, further analysis is required to assess the sensitivity of the estimates to the various assumptions and to include discounting rates. However, this study suggests that the cost-effectiveness of individual interventions is likely to differ greatly across different local settings, reflecting the heterogeneity of provinces and districts in Indonesia.

5.2.4 Available Information and Gaps A systematic analysis of the ‘Best buy range of interventions’ for MNCH identified in the Lancet Series has not been undertaken in Indonesia. Due to small sample sizes and the rarity of maternal death, there is scarce evidence on the impact of a particular intervention on maternal mortality. In addition, only one study has attempted to incorporate cost-effectiveness into the evaluation of MNCH interventions. This study suggests regional heterogeneity needs to be considered when assessing the cost-effectiveness of health interventions as they are likely to vary greatly among districts and provinces. The apparent contradiction of some studies shows that there is a complex set of factors that influence the effectiveness of interventions in a particular setting. In some cases, it is also difficult to disentangle the ‘behavioural’ aspects of implementation from the effectiveness of the intervention itself, for instance compliance issues around the taking of micronutrients. Behavioural barriers and enablers to the success of interventions have been explored but are culturally and locally specific. For a country as diverse as Indonesia, ‘representativeness’ is not necessarily helpful in identifying which interventions would work best at a local level. To some extent such research does supplement the global evidence of ‘best buy range of interventions’ for MNCH for use in


the local context. However they need to be viewed with some caution. In conjunction with an analysis of health systems constraints provided later in this section, these studies and the methods that have been employed to implement them, can be used to inform strategies for scaling-up, particularly to disadvantaged populations.


Table 5.2: Summary of Information Related to Priority MNCH Interventions

STUDY/REPORT TYPE OF

INTERVENTION DESCRIBED

NAME OF INTERVENTION

LEVEL OF STUDY COMMENTS ON

STUDY POTENTIAL USE IN

THIS STUDY

INFORMATION GAP IN

REPORTS/STUDIES

MATERNAL HEALTH

Muslimatun, S., et al., Weekly Supplementation with Iron and Vitamin A during Pregnancy Increases Hemoglobin Concentration but Decreases Serum Ferritin Concentration in Indonesian Pregnant Women. Journal of Nutrition, 2001. 131(1): p. 85-90.

ANC/Preventive Care Iron and micronutrient supplementation

Small-scale community based (Bogor district, West Java)

RCT study Delivery of weekly supplementation of iron may be as effective as delivery of daily supplementation and the addition of Vitamin A increased haemoglobin concentration.

No cost-effectiveness analysis.

The Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT) Study Group, Effect of maternal multiple micronutrient supplementation on fetal loss and infant death in Indonesia: a double-blind cluster-randomised trial. The Lancet, 2008. 371(9608): p. 215-227.

ANC/Preventive care Multiple micro-nutrient (MMN) supplementation

Lombok Double-blind randomised control trial

MMN compared to IFA is effective at reducing infant mortality particularly in under-nourished and anaemic women.

No cost-effectiveness analysis

Analen, C., Saving mother's lives in rural Indonesia. Bulletin of the World Health Organization,, 2007. 85(10): p. 740-1.

ANC/Preventive care Incentives for TBA to refer pregnant women for SBA

Ngawi district (East Java)

One district. Descriptive.

Incentives to TBA to refer pregnant women may increase use of SBA in some settings.







THIS STUDY

INFORMATION GAP IN

REPORTS/STUDIES

Kwast, B.E., Building a community-based maternity program. International Journal of Gynecology & Obstetrics, 1995. 48(Supplement 1): p. S67-S82

ANC/Preventive care Use of birthing homes (polindes) to improve SBA and referral

27 villages in Tanjungsari district, West Java. 10 intervention villages and 17 control villages

Small-scale study Success of birthing homes to improve SBA and referral depends on a complex set of factors that are highly localised. Difficult to extrapolate results to other areas

Hotchkiss, D.R., et al., Is Maternal and Child Health Service Use a Causal Gateway to Subsequent Contraceptive Use?: A Multi-country Study. Population Research & Policy Review, 2005. 24(6): p. 543-571.

ANC/Preventive care Health services utilisation to promote family planning/ future contraceptive use

National (using DHS data)

Cross-sectional analysis using DHS data linked to service availability surveys. Controlled for individual and community level factors.

Importance of health services utilisation in subsequent contraceptive use. Relies on good health services infrastructure/health personnel.

Hardon, A.P., et al., Preventing mother-to-child transmission of HIV in Vietnam and Indonesia: Diverging care dynamics. Social Science & Medicine, 2009. 69(6): p. 838-845.

ANC/Preventive care PMCTC – HIV testing for pregnant women

Community based study (Jakarta and Karawang)

Qualitative community based study

Acceptability of PMCTC in ANC services but need for improved counselling and follow-up

Information on impact of the programme on PMTCT of HIV.

Nuraini, E. and E. Parker, Improving knowledge of antenatal care (ANC) among pregnant women: a field trial in central Java, Indonesia. Asia-Pacific Journal of Public Health, 2005. 17(1): p. 3-8.

ANC/Preventive care Increasing knowledge of safe pregnancy and pregnancy complications in pregnant women

Small-scale field trial Other measures to improve ANC take-up in both intervention village and control village were employed such as transport and waiving of fees.

New method of ANC that includes counselling and gathering information on family involvement in birthing plans can increase knowledge of healthy pregnancy and pregnancy complications compared to routine ANC







THIS STUDY

INFORMATION GAP IN

REPORTS/STUDIES

Fahdhy, M. and V. Chongsuvivatwong, Evaluation of World Health Organization partograph implementation by midwives for maternity home birth in Medan, Indonesia. Midwifery, 2005. 21(4): p. 301-310

Primary clinical care Training and use of WHO partograph during labour

20 midwives working in maternity homes

RCT study Training on the use of partograph during labour may increase referrals of at risk women

Impact on use of partograph on perinatal and neonatal deaths.

Tsu, V.D., et al., Oxytocin in prefilled Uniject(TM) injection devices for managing third-stage labour in Indonesia. International Journal of Gynecology & Obstetrics, 2003. 83(1): p. 103-111

Active management of third stage labour

Oxytocin to prevent postpartum haemorrhage (PPH)

Three rural districts and one municipality in Lombok

Small scale qualitative study: 140 midwives and 2220 mothers interviewed

Oxytocin in prefilled Uniject-injection devices are feasible for use by midwives in home-based active management of third stage labour and may reduce PPH.

Information on the impact of Oxytocin in prefilled Uniject-injection devices on PPH.






THIS STUDY

INFORMATION GAP IN

REPORTS/STUDIES

CHILD HEALTH

Wilson, J.M. and G.N. Chandler, Sustained improvements in hygiene behaviour amongst village women in Lombok, Indonesia. Transactions of the Royal Society of Tropical Medicine and

Family orientated community based services

Hand washing to reduce diarrhoea

Central Lombok Follow-up study on an intervention to improve hand washing that included provision of soap and counselling on transmission route for diarrhoea.

Simple health education messages on the importance of hand washing can improve compliance and are sustainable 2 years after the intervention.







THIS STUDY

INFORMATION GAP IN

REPORTS/STUDIES

Hygiene, 1993. 87(6): p. 615-616.

Suradi et al (2002) Early kangaroo mother care vs conventional method in stabilizing low birth weight infant: physiologic parameters (preliminary report); Paediatr Indones 2002;42:273-279


Kangaroo mothercare (KMC) to stabilise temperature in low birth weight infants

Teaching hospital in Jakarta

RCT The intervention was carried out in a teaching hospital setting.

KMC is as effective as conventional care and is less expensive.

Information on KMC vs conventional care in a district hospital setting.

Ismawaty N et al 2008) The effect of exclusive breast-feeding on the linear growth of children aged 24-36 months in Bandung’s urban slum area. Paedtr Indones,2008;48:120-124


Exclusive breastfeeding Bangdung urban slum Cross-sectional study.

Exclusive breastfeeding is an effective and inexpensive way to promote growth in infants.

Information on the reasons for the low prevalence of breast-feeding including the local level/cultural factors.

Julia M. Breastfeeding protects the children in poor area from malnutrition: a comparative study of nutrition status of under-two children in Belu District, East Nusa Tenggara and in Purworejo District, Central java, Indonesia. Thesis Faculty of Medicine, Gadjah Mada University


Breastfeeding Poor and non-poor area Belu District, East Nusa Tenggara and in Purworejo District, Central java

Breast-feeding can reduce the risk of under nutrition of infant and this effect is more significant in poorer populations.








THIS STUDY

INFORMATION GAP IN

REPORTS/STUDIES

Kurniawan A. The effect of 4-months exclusive breastfeeding on the incidence of diarrhoea. Annual Scientific Meeting of Indonesian Society of Pediatrics, 2007


Exclusive breast-feeding

Exclusive breast-feeding may reduce the incidence of diarrhoea in infants


Hatta M (2000) Correlation between measles vaccination with incidence of pneumonia in Kabupaten Ogan Komering Ulu Sumatera Selatan Tahun 2000. Program Pascasarjana Ilmu Kesehatan Masyarakat Universitas Indonesia

Population orientated scheduled services

Measles vaccination Sumatera Selatan Case control study. Other differences between cases and controls may have confounded results. Other factors such as mother’s education and knowledge, kitchen smoke pollution and house-crowdedness also found to be associated with risk of pneumonia.

Measles vaccination may decrease incidence of pneumonia

Impact of measles immunisation on infant and child mortality

Retno Asih S et al Effects of zinc supplementation on nutritional status and cognition in children. Paediatr Indones 2006; 46:64-70.


Zinc supplementation Randomised, double-blind, placebo-controlled trial

Evidence for the effects of zinc supplementation on weight age and height for age increments in children who are zinc deficient. No effect of weight for height index or on cognition.

Cost-effectiveness analysis of this intervention compared to others that improve child nutritional status.

Semba, R., et al., Integration of vitamin A supplementation with the Expanded Programme on Immunization: Lack of impact on morbidity or


Vitamin A supplementation for infants

West Java Randomised, double-blind, placebo-controlled clinical trial 467 six-week old babies.

It is not clear whether there are any benefits of Vitamin A supplementation on child growth or morbidity.







THIS STUDY

INFORMATION GAP IN

REPORTS/STUDIES

infant growth. Acta Paediatrica, International Journal of Paediatrics, 2001. 90(10): p. 1107-1111.

Sumiartini NM, et al (2007) Efficacy of dexamethasone for lung maturity in preterm delivery in association with lamellar bodies count Paediatr Indones 2007;47:115-119

Individual clinical services

Steroid for pre-term labour

Teaching hospital in ?? Quasi-experimental study Non-random element complicates analysis

Administration of dexamethasone in pregnant women during preterm delivery improves lung maturity in infants.

Information on the impact of dexamethazone on infant mortality and morbidity.

Risnelly S, et al Comparison low osmolarity ORS and standard ORS for acute diarrhoea in children). 3

rd

Annual Scientific Meeting of Indonesian Society of Pediatrics, 2007

Individual clinical services

Oral Rehydration Solution in treatment of diarrhoea

Hospital-based study Medan

Hospital-based RCT Low osmology ORS can reduce duration of diarrhoea compared to standard ORS.

Information on compliance issues of both types of ORS and community level studies to assess effectiveness of this intervention outside a hospital setting.


5.3 Equitable Progress towards MDGs 4 and 5 The objective of this section is to review recent analyses undertaken on the equitable distribution of MNCH outcomes, interventions and inputs. A review of the datasets that have been used in these studies or that are available for further equity analysis is provided in Section 4. Maternal Health National Maternal Mortality ratios are subject to high sampling errors. Even in a high maternal mortality setting like Indonesia the absolute number of maternal deaths is low. Analyses of distribution of maternal mortality are thus scarce and Indonesia is no exception. Most maternal health studies focus on the analysis of distribution of health interventions and inputs such as health workers and facilities. A recent study [7] highlights the inequities in maternal health. The authors examine the determinants of maternal mortality and the effect of programmes aimed at increasing the number of births attended by health professionals in two districts in West Java. This study found that only 33% of women gave birth with assistance from a health professional and even amongst these women, maternal mortality ratios remain excessively high. The authors note that this may reflect the limitations of home based-care, since a large proportion of births take place at home. For women in the lowest quartiles that had access to SBA, mortality ratios were substantially higher, at 2,303 per 100,000, which might be the result of them seeking help only once a serious complication has arisen. Mortality rates remained very high for those in the lower middle and upper middle quartile ranges (1218 and 778 per 100,000, respectively). The authors suggest that phased introduction of fee exemption and financial incentives to cover transport costs will enable all women to access skilled delivery care in health centres and emergency care in hospitals, which would contribute to reduce Indonesia's MMR. The importance of fee exemptions to enable poor women to have access to SBA has been stressed by Ensor et al (2009) [90]. They note that the dependence of midwives on private income and the corresponding user charges have resulted on low access to SBA by the poor. Constraints to implementation of fee exemptions should be carefully considered. Makowiecka et al (2008) study on midwifery provision in Banten province shows that three quarters of midwives did not make regular use of the fee exemption scheme [91]. The above observations are supported by the IDHS 2007 survey. While 86% of women in the highest wealth quintile were assisted at delivery by SBA, only 65% of those in the lowest quintile were assisted. Furthermore, the distribution of births delivered in a health facility is highly inequitable with 83% of women in the highest wealth quintile and only 14% of women in the lowest quintile giving birth at a health facility. A similar inequitable distribution is observed in regard to access to specialists. While 34% of women in the highest wealth quintile were assisted by an OB/GYN, only 1% in the poorest quintile were assisted by medical specialists [1]. Overall, the findings of the IDHS 2007 survey show a highly inequitable distribution in relation to MNCH variables, with national figures masking ssubstantial geographical disparities. The percentage of births assisted by SBA stands at 79% in the country. Whereas 97% of births are assisted by a skilled health professional in DKI Jakarta and 93% in Bali, the proportion of births assisted by SBA in Maluku and West Sulawesi were 33% and 44%, respectively. Similarly, although nationally 46% of births take place at a health facility, sub-nationally, this ranges from 91% in Bali to 8% in South Sulawesi.


BAPPENAS reports the provincial disparity of medically trained birth attendants [4]. In some provinces (NTB and South Sulawesi), coverage increased during the period 2004- 2007 compared to 2000 -2004 [4]. However, in other provinces, such as NTT, Maluku, and Gorontalo, coverage declined. The disparity is wide, ranging from around 38% in North Maluku to almost 100% in DK Jakarta. In regard to maternal mortality, the AusAID annual program performance report for Indonesia 2007 noted regional disparities, quoting a MMR of 1116 in the Papua region and 554 in Nusa Tenggara Timur [92].

A recent study by the IMMPACT project estimated the cost of health care for management of obstetric complications and the effect on household expenditure. For these purposes both quantitative and qualitative analyses were conducted in two district hospitals (Serang and Pandeglang) in 2007 [93]. A total of 640 women were interviewed two weeks after being discharged. This study found the average cost per case was around US$172-US$272, with drugs and medical supplies being the largest item (48%). Government subsidies finance only about 39% of health care costs, while the rest, 61% is financed by household’s out-of-pocket payments. Such large out-pocket payments represent catastrophic expenditure for the vast majority (74%) of the poorest quintile households who were able to afford these services. The study also found Jamkesmas covered almost 67% of the catastrophe poor household, for maternal care spending.

Child Health and Nutrition The World Bank 2008 [13] and BAPPENAS [4] note that, notwithstanding improvements in child mortality outcomes during the last decades, substantial geographical disparities remain. The IMR in the best performing provinces is four times lower than the IMR in the lowest performing provinces, for example the IMR in East Nusa Tenggara is 80, versus 20 in Bali. The BAPPENAS report also highlights similar disparities in nutrition outcomes. The percentage of children U-5 suffering from severe malnutrition stood at 28% in the year 2005, ranging from 15% in DK Yogyakarta to 41.5% in Gorontalo. The heterogeneous conditions among the regions partly explain the different outcomes. Malnutrition is usually associated with poverty. In 2005 seven provinces with above average prevalence of under-nourishment also showed high percentage of poor populations. There are, however a number of provinces with high poverty rates and under-nourishment prevalence lower than the national average [19]. Friedman et al (2006) [19] have examined inequalities in nutrition outcomes and program utilisation using three major data sources, SUSENAS 2001 and 2003, IFLS 2000 and IDHS 2002/2003. The authors stress that understanding disparities is essential for developing effective strategies to achieve equitable improvement in nutrition outcomes. This study found that women and children in rural areas exhibit poorer nutritional outcomes and lower program utilisation than those in urban areas, although exclusive breastfeeding was slightly higher in rural areas. Clusters of districts showing poor nutritional outcomes are found in NTT, with pockets in NTB, South Sulawesi and East and Central Java [19]. Prevalence of underweight children 0-4 years ranged from 3% in Tabanan (Nusa Tenggara Barat) to 81% in Barito Selatan (Kalimantan Tengah). Similarly the authors report that women and children in the highest economic welfare quintile measured by wealth and expenditure, show better nutritional outcomes and higher utilisation rates.


Children from poor households are also more likely to die than those in wealthier households. For example, in 2007 child mortality in the poorest quintile was 27% versus 17% in the richest quintile. Poerwanto’s analysis of 1997 IDHS data also shows that there are differences in infant mortality according to the family welfare index and mother’s educational status as well as variation in access to health services between provinces [94]. Although a causal relationship cannot be established, Poerwanto’s analysis confirms that, as expected, there is a negative association between household welfare and infant mortality. Inequality in the distribution of child health outcome and interventions has also been documented in the IDHS 2007 survey (see section 2). Inequities in maternal and child health are in line with documented inequities in life expectancy between provinces. The national average life expectancy is 69 years, ranging from 72 in Yogyakarta to 59 in West Nusa Tenggara [13]. Geographical disparities have also been documented in regard to the availability of human resources. The problem is particularly acute in remote locations. The Ministry of Health [95] has estimated that 30% of the 7,500 community health centres (Puskesmas) in remote regions did not have doctors. A survey by Pusrengun (Ministry of Health Centre for Human Resources Empowerment) in 78 regencies in 17 provinces confirmed this finding. Approximately 50% of the community health centres in the remote areas surveyed did not have doctors. This is in sharp contrast with the situation in non-remote areas, where only 5% of the Puskesmas did not have doctors [95]. The geographical imbalance of specialists has been discussed by Maryam [96]. According to KKI data (2007), DKI Jakarta had 2,890 specialists (23.92%). East Java, 1,980 (16.39%) and West Java 1,881 (15.57%). On the other hand only 167 (1.38%) specialists were located in West Sumatra. In regions where doctors are rare, poor communities had difficulties in accessing medical services. In contrast, in regions where there are many doctors, poor communities have easier access to health services. Maryam author notes that several factors, including those related to doctors’ behaviour and health policy are at play. Available Information and Gaps The inequitable distribution of maternal and child health has been extensively documented in Indonesia. Reports of various government agencies and development partners highlight geographical disparities in the distribution of mortality, intervention coverage and health resources. Inequitable distribution across socio-economic strata has also been documented. Although to a lesser extent, the academic literature has also examined inequities in MNCH. In regard to Maternal Mortality, it should be noted that very limited analyses of the equitable distribution of maternal mortality are possible. The most important source of information for the equity analysis has been the IDHS, although other datasets and some small-scale studies have also been analysed. To the best of our knowledge, at the time of writing this report there was no comprehensive study of equity in MNCH mortality and intervention coverage that includes analysis of recent trends; estimation of equity indicators and multivariate analysis. Therefore although sufficient evidence exists to identify the most vulnerable groups in the population, more detailed analysis is required to measure the degree of inequality and trends over time.


Table 5.3: Summary of Information Related to Equitable Progress towards MDGs 4

ANALYSIS ACCORDING TO

EQUITY MARKERS

WHAT ANALYSIS HAS

BEEN COMPLETED AT

NATIONAL LEVEL?

WHAT ANALYSIS HAS

BEEN COMPLETED AT SUB-NATIONAL

LEVEL?

NAME OF REPORT/STUDY

DATA SOURCE/S

AND REFERENCE

YEAR

COMMENTS ON ANALYSIS

INFORMATION GAP

Wealth No Maternal mortality and SBA (Two districts in West Java)

Ronsmans, C., et al., Professional assistance during birth and maternal mortality in two Indonesian districts. Bulletin of the World Health Organisation, 2009. 87(6): p. 416-23.

Authors’ survey data

Small-scale - two districts Uses capture–recapture method which is likely to be less biased than the crude death count

No national analysis of maternal death by equity markers.

Wealth/ Geography Residence/ Education

Maternal health interventions and inputs

Maternal health interventions and inputs (Provincial level)

IDHS 2007 IDHS 2007 Women who gave birth in the 5 years preceding the survey.

No information at district level

Wealth/ Geography Residence/ Education

Contraception use Contraception use (Provincial level)

IDHS 2007 IDHS 2007 No information at district level

Wealth/Geography/ Residence/ Education

Infant and child mortality, U5 morbidity, nutrition, interventions and inputs

Infant and child mortality, nutrition, interventions and inputs and U5 morbidity (Provincial level)

IDHS 2007 IDHS 2007 Mortality rates for the 10 year period preceding the survey.

No information at district level

Wealth/Geography/ Residence

Child health and nutrition, interventions

Child health and nutrition, interventions (Province/district)

Friedman, J., et al., Health sector decentralisation and Indonesia nutrition programs: Opportunities and challenges. 2006

SUSENAS 2001 and 2003 IFLS 2000 IDHS 2002/2003

Family welfare index/Mother’s education

Infant mortality Poerwanto, S., M. Stevenson, and N. de Klerk, Infant mortality and family welfare: policy

DHS 1997 Causal relationship cannot be established.


ANALYSIS ACCORDING TO

EQUITY MARKERS

WHAT ANALYSIS HAS

BEEN COMPLETED AT

NATIONAL LEVEL?

WHAT ANALYSIS HAS

BEEN COMPLETED AT SUB-NATIONAL

LEVEL?

NAME OF REPORT/STUDY

DATA SOURCE/S

AND REFERENCE

YEAR

COMMENTS ON ANALYSIS

INFORMATION GAP

implications for Indonesia. Journal of Epidemiology & Community Health, 2003. 57(7): p. 493-498

Geography Medical specialists Indonesian Medical council (KKI) data 2007

Indonesian Medical council (KKI) data 2007

Datasets – for use in additional analyses

DATA SOURCE TYPE OF DATA QUALITY OF

DATA

POTENTIAL USE IN STUDY DATA GAP

NATIONAL SUB-NATIONAL

DHS (1994/1997/2002-3/2007)

Population-based survey

Equity by residence (Urban/Rural) and assets

Maternal mortality (2000) and infant/child mortality by Province

Sampling restricts analysis to provincial level (no district level analysis possible)

Population census (2000)

Equity by residence Infant mortality by Province/District

SUSENAS Large-scale multi-purpose socioeconomic survey

Equity by residence, assets and expenditure

No

Baseline Health Research/RisKesDas 2007

Individual and household survey

Equity by place of residence, sex, level of education, level of expenditures

Equity by place of residence, sex, level of education, level of expenditures (Province, district and city)

Health outcome data (mortality) is not available


DATA SOURCE TYPE OF DATA QUALITY OF

DATA

POTENTIAL USE IN STUDY DATA GAP

NATIONAL SUB-NATIONAL

Micro-data IFLS4, survey on individual, household and community aspects, Book 4: info about child; Book 5: info about ever married woman

Individuals, households and community level data

13,995 households was target contacted for IFLS4. Sample included 13 provinces containing 83% of the population

Aggregate data for 13 provinces

IFLS4, 13 provinces, 321 enumeration area (urban and rural)

Community data is not available yet


5.4 Health Systems Constraints and Strategies Several reviews of the various constraints affecting the delivery of health services have been undertaken during the last years. Some of them have been requested by the Government of Indonesia with the objective of supporting a comprehensive assessment of the health system performance that would guide the development of the Medium Term Development Plan 2009-2014. This section presents a summary review of the key studies on health system constraints in Indonesia. Due to the general scope of most of the studies reviewing constraints and strategies, there is no attempt to summarise these studies in the corresponding tables.

5.4.1 Decentralisation There have been many studies and reports on the issue of decentralisation in Indonesia and its impact on health service provision, including MNCH. Lieberman et al 2005 [97] describe how decentralisation should provide the opportunity for local ownership of the planning, financing and delivery of health services in Indonesia but highlight problems with poor implementation and the intergovernmental fiscal transfer system. The problem of late disbursement of central funds and unspent resources at local government level. In addition, ownership of planning and budgeting at local level has been questioned. A recent study [18] examined the public expenditure on health services in 15 districts in Java, and found districts had discretion for managing less than one third of this expenditure, with major decisions still made at central government level. Even after decentralisation 90% of funds for regional budgets, including health still, come from the central government. As previously observed, the capacity of local governments to deliver health services has been seriously impaired after decentralisation. On the health financing side, limited opportunities for local governments exist to allocate resources according to the population needs; weaknesses in the Public Financial Management, including perverse incentives to hire additional; and a complex and unreliable flow of funds from the centre to local governments have been highlighted [13, 15]. Indeed, one of the major problems with decentralisation in Indonesia is that of implementing policy, including MNCH. This is illustrated by Friedman et al [19] in their analysis of decentralisation and nutrition [19]. Opaque, fragmented and overlapping responsibilities within districts and between districts and provinces have created confusion and paralysis. Provinces have 11 roles and responsibilities but only two are implemented as programs and receive budgetary support at provincial level. The remaining nine relate to standards setting and monitoring and receive no funding support. Policy implementation is entirely left to the districts. However, the skills set of local district staff is not in line with the new responsibilities under decentralisation. Notwithstanding the challenges of decentralisation, Friedman et al noted that given the heterogeneity observed in Indonesia, locally-driven solutions are required. High variation in health system performance across provinces and districts illustrates the geographical disparities that are hampering equitable progress on MDGs 4 & 5. On one hand, they reflect the diversity of the country that could be well served by an effective decentralisation policy [18, 20]. Different districts face different problems and the most cost-effective strategies will also vary. On the other hand, high variation is also observed among districts with similar socio-economic and geographical characteristics and similar health expenditure levels.


The reasons for the disparity in performance are poorly understood [13]. The positive deviants in Indonesia provide useful lessons on what strategies can be effective on the ground and what contextual factors affect district performance. The lessons from the best-performing districts are yet to be understood. They should provide useful guidance for improving performance in districts lagging behind.

5.4.2 Health Workforce After decentralisation human resources management was transferred to the districts. However, the centre retained control over salaries, working conditions, deployment and sanctions. As observed by a recent review on decentralisation and human resources [20], decentralisation has: (a) reduced the scope of districts to make decisions on health staff, which account for as much as 40% of district expenditure on health; (b) led to overlapping and conflicting goals for human resource management at various levels; (c) created the need for local governments to have command over their skill mix and allocation of human resources, while the central government regained control over human resources; and (d) deteriorated the Health Human Resources Information system, which makes it difficult to conduct strategic workforce planning based on evidence. Heywood and Harahap [20] also highlight that analysis of health workforce is difficult due to lack of data. Data on registered doctors available from the Indonesian Medical Council (IMC) has found to be more reliable since 2007 as collecting this information is now a legal requirement. The Indonesian Health Profile compiled by the MoH is less reliable. Prior to decentralisation lists on government employees and permanent civil servants in the district by sector, including health, were available at district level. Private practitioners should be licensed by district government, so this information can supplement that provided by the lists. However, since decentralisation, districts and provinces are not legally required to provide the information and so do not keep these lists up to date. Information about private practitioners has found to be patchy and unreliable [20]. The World Bank review on health workforce in Indonesia [14] suggests that some of the main constraints related to human resources are the shortage and inequitable distribution of doctors and specialists; the poor quality of tertiary education and the lack of strategic policy development and planning for the workforce. The shortage and inequitable distribution of human resources has been extensively documented. Using PODES 2006, the World Bank [14] estimates that Indonesia has 18 doctors per 100,000 population. This ratio improves to 25 doctors per 100,000 if medical doctor registration data is used. By any measure, these ratios are low when compared to those in Asia. Furthermore, substantial geographical inequities are also observed in the distribution of doctors. For example, while urban areas in Java and Bali have 18.5 doctors per 100,000 population; this ratio stands at 6.6 in remote areas. Indonesia has relatively more nurses than other countries in Asia. The village midwife program has succeeded in increasing the number of midwives in the country, with almost 50 midwives per 100,000 people. One World Bank study observes a more equitable distribution than that of doctors, with rural areas showing higher ratios than urban areas [14]. Ratios are also higher in provinces outside Java and Bali. However, the World Bank report on Maternal Health [6] suggests that Indonesia is far from the goal of placing a midwife in every village. Data from the MoH suggests only 40 percent of the 68,816 villages in Indonesia had midwives in place and in some places, such as North Sumatra, less than 10 percent of the 5,360 villages had a midwife. In addition, shortages in remote locations are still a problem. For example, in a study in the Serang and Pandeglang districts in Banten Province on Java, Makowiecka et al [91] found a


higher density of midwives work in urban areas compare to remote areas and that those assigned to remote areas were less experienced and managed fewer births, compromising their capacity to maintain professional skills. Heywood and Harahap [20] collected data on human resources in 15 districts in Java. They found that the ratio of health care providers (doctors, nurses and midwives) in all the surveyed districts is substantially lower than the recommended WHO standard of 2.5 providers per 1000 population. A ratio below 1 is observed in 11 of the districts. The authors note that the observed ratios might increase when taking into consideration the effects of dual practice. However, even then, it is highly unlikely that the WHO standard will be reached. Furthermore, absenteeism would most probably lower the provider density ratio and remote locations are highly disadvantaged. As discussed below, a recent study has found that notwithstanding financial incentives for midwives to work in remote locations, they are unwilling to do so for non-financial reasons [90]. The financial reward required to compensate for transferring to a remote location was substantially higher than could realistically be afforded by the system. The findings of this study suggest current policies such as dual practice; the PTT doctor scheme and financial incentives for doctors in remote areas have not had the expected impact. It should be noted that further analysis using rigorous econometric techniques to examine the impact of human resource policies on utilisation and availability of quality of health care is currently being undertaken by the World Bank team. Results were not available at the time of writing this review. However, preliminary evidence suggests that quality of care is rather poor [14]. Using IFLS data for 1997, Barber et al [98] found that ambulatory health providers show little knowledge of basic pre-natal care criteria, with private providers being less knowledgeable than those in the public sector [98]. Although, analysis of the latest round of IFLS will bring more light into the issue, quality of care does not seem to have improved in the last decade. D’Ambruso et al [99] conducted a confidential enquiry to assess the quality of care provided by Indonesian village midwives. This study found that although emergency diagnostic skills were accurate, clinical management was poor. Contraindicated and unnecessary examinations were performed, basic assessments of vital signs and contractions were missed and continuity of care thorough pregnancy was not optimal. In a study using a modified instrument to assess the training needs of midwives, Hennessy also found occupational roles for midwives differed significantly between provinces, with the need for training in a wide variety of tasks [100]. Failure to improve the quality of care during the last decade could be partly explained by the human resource problem previously discussed and the shortcomings of the training and accreditation system for health workers. It has been noted that addressing the human resource challenges would require substantial changes in the way health workforce planning is conducted [14]. Prior to decentralisation, central-driven, linear and straightforward estimation of health workers required per facility was sufficient. Local diversity did not need to be accounted for and the role of the private sector could be ignored. Locally driven solutions that respond to the diversity of the country are required. For this, better information on human resources and upgraded skills on human resource planning at various government levels are a must [20].


5.4.3 Village Midwife Programme The mainstay of the maternal and child health programme in Indonesia has been the Village Midwife Programme, introduced in 1989; it aimed to place a midwife in every village in Indonesia. As described earlier, studies suggest that this programme has been successful in improving the chances of SBA, but might have been less successful in improving MNCH outcomes. Problems with inequitable distribution of midwives and variations in quality of care are described above. These and other health systems constraints prevent this programme having a real impact on maternal and perinatal mortality. In a 2008 Lancet article, Shankar et al [101] suggest the progress in reducing maternal mortality has been slower than it might have been due to the quality of midwife training, inadequate supervision and mentoring, limited access and financial support for referral of obstetric emergencies, declines in health care expenditure and the reduction of the influence of the MoH associated with decentralisation. The limitations of home-based delivery and the continued constraints in referral in cases of obstetric emergency also highlight the inadequacy of relying solely on village midwives [7]. Hatt et al (2007) [102] use pooled IDHS data from 1986–2002 to evaluate trends in SBA and rates of caesarean section and suggest that whilst inequity in SBA has decreased, the village midwives programme has actually increased inequity in access to emergency obstetric care (EOC). Studies by Ronsman) [103] advises that increasing access to midwives and SBA is not enough where costs for EOC are prohibitive. Since most maternal deaths occur during an obstetric emergency, physical and financial access to these services is vital to reducing maternal mortality. In a recent study, Ronsman [7] proposes the phased introduction of fee exemption and transport incentives to allow women to access skilled delivery in healthcare centres might be one of the required strategies to reduce MMR [7].

5.4.4 Access to Health Services As discussed in section 2, after the Asian financial crisis of 1997, Indonesia underwent a major social health protection reform. By 2004, only 20.6% of Indonesians were covered by health insurance. In 2005, Askeskin program was implemented with a view of increasing access to health services for the poor and vulnerable populations. The program covers primary health care and hospital services prior referral from the health centre or in case of emergency. Benefits include ANC and health check-ups for U5 children and it is expected to help in reducing infant and child mortality rates, particularly among the poor. A review of the health insurance program for the poor has been undertaken by Setiana [10]. Targeting the program benefits was identified as one of the key challenges. Formal identification of the poor was problematic. An ambitious project of attaching photographs to the health cards was abandoned due to administrative difficulties. Local governments were responsible for identifying the poor, a responsibility that has been delegated to village heads. And sometimes, the hospitals themselves had to supervise whether the card holder was entitled to the benefits or not. Although there is evidence of leakages and exclusion of some poor people, overall the program has been successful in extending access to health services to poor and vulnerable populations [10]. Mukti [11] found that during the period 2005-2007 the use of health services increased dramatically Health System Strengthening using Primary Health Care Approach Panel C: Health Financing and Poverty Alleviation The number of people using health services went from 1.4 million in 2005 to 6.5 million in 2007, which represents an increase of 392%. Hospital inpatient care also rose from 562,167 to 2,431,139 during the same period.


Notwithstanding the success of the health insurance for the poor program, Jamkesmas, significant constraints remain to scale-up quality health care and improve health outcomes, particularly of vulnerable groups. On the demand side, financial barriers to access health care still exist. Transport costs, especially in remote locations, and other non-medical costs prevent the sick from receiving health care [10]. In recognition of the financial barriers to scale-up priority MNCH interventions, conditional cash transfers were adopted as a strategy to promote the demand of MNCH services, including ANC and SBA. The impact of the program is still to be assessed, but concerns have been raised about mistargeting. By removing the financial constraints to access health services by the poor, Jamkesmas and the conditional cash transfers programmes are expected to lead to an overall increase in the demand of health services in Indonesia. The increased demand needs to be met by higher supply of quality health services [13]. A pilot program in ten districts in East and Central Java addressed both the supply and demand constraints. Performance-based contracting was used to stabilise the incomes of the midwives, while coupon books were used to estimate the demand for their services. The program was found to have positive results. Mukherjee [25] undertook a study on what constraints the poor face to access health services and what the rationale is for the choices they make regarding basic health services, including health. This study is highly relevant for the IC, since it addresses in detail the constraints and potential strategies to scale-up health and water and sanitation services for the poor. The study focuses on eight services, out of which six relate to MNCH: ANC, childbirth assistance, curative services for 0-2 month old infants; curative services for 2 months to 5 year old children; clean water services and sanitation facilities. The author uses qualitative methodologies to represent the point of view of the poor in eight locations in Indonesia. The key messages in regard to constraints to scale-up MNCH services to the poor are as follow: Perceptions on service quality are not always in line with those of health professionals.

For example, the poor perceive TBAs provide better quality service for childbirth assistance than trained midwives;

Notwithstanding availability of midwife services, the poor do not demand them. They are not aware of the benefits of SBA; when aware of the benefits, they do not seem to compensate for the extra-cost; TBA are older and respected member of the communities, while the midwives are usually young and “outsiders”; and TBA are more readily available than midwives;

Programs to extend social health coverage to the poor are highly regarded, but information is not available to the poor;

Low quality services also affect demand of health services by the poor. Quality seems to be worse for providers serving the rural poor than those serving urban slums;

Absenteeism is also linked to bad working conditions in health facilities serving the poor, e.g. lack of water supply and sanitation facilities at health outposts;

The poor are not aware of low-cost and affordable quality water and sanitation services;

Water vendors have a monopoly of clean water in islands and urban slums affecting the access by poor households; and

When there is no secondary school in the village, girls are married off and get pregnant at very young ages.

Several direct recommendations are made to address these constraints. As previously noted they are highly relevant for the IC since they aim to remove both the demand and supply


barriers hampering the use of MNCH health services and better access to water and sanitation by the poor. These recommendations include: Increase the number and quality of drug supplies at the health center and health post; Establish practical performance indicators for health workers that can be easily

understood and verified by them and their clients; Adopt performance incentives similar to those in the private sector, including

deducting salaries from health workers when they are absent; Publicise the rights of the poor to health services through mass media, including

measures available for the poor to make village midwife services more affordable; Make benefits clear, including the right to free treatment. Sometimes the poor do not

use health services because they are afraid of the potential expenses; Provide better information on pregnancy danger signs that require immediate referral

to health centers; Provide information on the ANC services that can be provided by TBAs and SBAs; Provide better information about availability of affordable water and sanitation

services and promote their use; Promote better sanitation and hygiene practices; Address the policy and strategy vacuum in regard to sanitation services; and Ensure competition among water providers where it is feasible.

5.4.5 Availability of Information and Gaps Similar to other countries, evaluations of health system constraints in Indonesia have faced challenges of data availability, especially at district level. The “statistical” gold standard of randomised control trials is rarely available when evaluating health policy. Therefore, various methodological issues make it difficult to disentangle the effects of various policy initiatives and measuring their impact on health outcomes. Some of the studies available in Indonesia exploit panel data from the various rounds of the IFLS to measure the effect of individual policy initiatives. Other studies have combined quantitative and qualitative methodologies and discuss the contextual factors affecting policy implementation. The econometric analysis of the impact of human resource policies on utilisation and availability of quality of health care, currently being undertaken by the World Bank, will provide more rigorous evidence in this regard. Notwithstanding the above, it would be fair to conclude that existing analyses provide a comprehensive diagnosis of the system constraints, although more detailed analysis at district and provincial level will be required. Vast ground has been covered by the recent assessments of the health system performance requested by the Government of Indonesia for the development of the Medium Term Plan 2009-2014. The constraints to scale-up health services imposed by the poorly designed and implemented decentralisation reform have been extensively documented. The limitations of the village midwife program, the backbone of the Government maternal health policy have also been diagnosed. Key barriers to increase access to MNCH services by the poor have been examined, including those related to the newly implemented Askeskin program. In the same light broad strategic lines of policy have been suggested. However, there is insufficient evidence on implementation. The evidence on what works and does not work on the ground is rather scarce. The well performing districts, so called positive deviants, provide useful lessons on what strategies can be effective and what contextual factors affect district performance. These lessons are yet to be teased out.


This review shows that there is consensus on how imperative it is for a diverse country like Indonesia to make decentralisation to work. However, the country lacks a strategy that improves fiscal space at district level and outlines the steps required to help districts to develop evidence-based plans linked to priorities and budgets.


5.5 Allocation of Financial Resources to MNCH and Resource Requirements for Scale-up of Interventions

Very few studies have examined the allocation of resources to MDGs 4 and 5 and the resource requirements to scale-up priority interventions. This section aims at providing an overview of the key studies in this area. The lack of evidence-based budgets has been highlighted by Marhaeni et al [104]. This research applied an explorative mixed-method to analyse the maternal and child health allocations at central and local government. Data come from the MoH, MoF, BAPPENAS, the House of Legislatives, and selected provinces (East Kalimantan and D.I. Yogyakarta). The focus was on the health-deconcentrated fund, health-assisting fund and MoH sectoral fund. The study found that budget allocation was not related to the fiscal capacity of local government, suggesting that central government budget is not distributed to compensate for the low fiscal space of poor provinces. The study also found that political interests, rather than local needs, were the drivers behind the budgeting process and the corresponding allocation of resources.


Table 5.4: Summary of Information Related to Allocation of Financial Resources

STUDY/REPORT BREAKDOWN OF

FUNDING FOR MNCH?

LEVEL OF BREAKDOWN

TYPE OF FUNDING

QUALITY OF REPORT

POTENTIAL USE IN THIS STUDY

INFORMATION GAP

Indonesia NHA 2002-2004

Breakdown by source by financial agents and by programme/activities

National (and provincial/ district to some extent)

All sources of funding for which data was available

Limited No breakdown by MNCH categories.

National/Provincial /District and Municipality Budget (APBN) Report

Breakdown by programmes and activities/line items

National, Provincial, District/ Municipality

Public funding The data form is from government accounting standard

Estimates of public available funding

Marhaeni D.H et al, Development of Budget Formulation in Ministry of Health (2008) Pasca Sarjana FK – UGM, Jogjakarta

Data from the Ministry of Health, Ministry of Finance, national Planning Body (Bappenas), House of Legislatives and selected provinces (East Kalimantan and D.I. Yogyakarta

National/Provincial Public funding Assessing funding flows from central to local level in relation to local fiscal capacity.

Data collected for two provinces only. No analysis at district level.


Tandon [12] (2009) analyses fiscal health space in Indonesia. The paper discusses several policy options for Indonesia to raise resources allocated to the health sector. They include reprioritising health within the government budget; cross-subsidisation within a universal health insurance system and increasing health-specific foreign development assistance funding. Although the author acknowledges that there is wide variation at district level in health spending as a share of the district budget, the option of increasing local government funding for health is not explored. However, the study notes that an effective way of improving the effective fiscal space in a decentralised country like Indonesia would be the implementation of interfiscal transfers that have built-in incentives for attainment of health outputs and/or outcomes.

A recent study by BAPPENAS [31], estimated the financing gaps limiting to achieve the MDGs in the country. The study uses a needs assessment approach as follows: (i) a literature review on the various estimation methods and a review of the main data sources was undertaken; (ii) a list of priority MNCH interventions was chosen, along with the corresponding list of inputs; and (iii) coverage targets for the selected interventions were set. They were based on the targets included in the national medium term planning document, MSS, strategic planning on health sector and other national policy documents. For those interventions for which no target was included in policy or planning documents, a realistic target was set: (iv) detailed costings were estimated for each intervention; (v) the financing requirements to achieve the intervention coverage targets were estimated on the basis of the costings of intervention; and (vii) available financing resources were calculated.

BAPPENAS calculated that to achieve the coverage targets for MNCH in 2008 around Rp 15trillion (U$1.5billion) would be required. However, the available resources from government funding (excluding Jamkesmas) amount to approximately 6 trillion rupiah (U$ 600million), that is 35% from total needs, which leaves a financing gap of 65% gap. In a scenario of budget-effectiveness, available resources will be raised up to 55%. An on-going study by Jamkesmas2 has preliminary estimates showing that available government resources will increase up to 70-75% when the social health insurance funding is included. Therefore, according to this study, the annual financing gap to achieve MDGs 4 & 5 would be around 25-30%, that is Rp 6trillion (U$ 600million), assuming government budget effectiveness. (see Figure 5.1). Figure 5.1: Financial Gaps and Financial Space

Source: BAPPENAS, 2008

2 GTZ-Indonesia, Evaluation of the Jamkesmas performance, GTZ-Indonesia, 2009 (on going project).

0%10%20%30%40%50%60%70%80%90%

100%

Fiscal Gap (2008) Potensial Fiscal Space* (2008)

Gap (need-available)

Donor (non APBN)*

APBD

APBN (Peningkatan Gizi)

APBN (Imunisasi)

APBN (JAMKESMAS)


Costings of Achieving Universal Coverage for Reproductive Health In the year 2007, UNFPA Indonesia undertook a costing of Reproductive Health, including Family Planning at the national, provincial and district level. The study used the RH Costing model version 1.1, released by UNFPA [105] and is based on WHO standard treatment guidelines for Reproductive Health Interventions. The data were collected from National level, six provinces (Aceh, South Sumatera, West Java, West Kalimantan, West Nusa Tenggara, and East Nusa Tenggara) and 22 districts level. For reproductive health services, this study estimates that at current coverage levels the annual cost per Woman of Reproductive Age (WRA) stands at U$2 – U$3. The annual cost per WRA is increased to U$4 if universal coverage is to be achieved. Evidence-based Budgeting Available information and Gaps The recent analysis of fiscal space for health provides valuable information on projections of available government funding for health under various scenarios. More directly related to the investment case, BAPPENAS report the required funding to achieve MDGs, provide national estimates of available resources and the financing gap to achieve MDGs 4 & 5. More detailed costing and financial envelope analysis for reproductive health has been undertaken by UNFPA. The strength of this high-level evidence is contrasted with the poor use of data and evidence at district level for planning and budgeting. One of the key information gaps highlighted during this mapping exercise has been the lack of detailed analysis of district and provincial fiscal capacity and the extent to which local funding may be mobilised to finance MNCH priority interventions. Available evidence suggests that fiscal space for health, including MNCH, will not be translated into higher outputs and outcomes if absorptive capacity constraints at the level of local government are not addressed. The extent to which funding from local level governments, particularly in rich provinces and districts, can be used to leverage the scaling-up of the best-buy MNCH interventions has not been sufficiently explored. In a diverse and decentralised country like Indonesia, strengthening local budgeting and planning processes and mobilising local government funding are required if equitable progress to achieve MDGs 4 & 5 is to be achieved.


Table 5.5: Summary of Information Related to Resource Requirements for Scale-up of Interventions

REPORT/STUDY TYPE OF COSTING

DATA/FISCAL SPACE

LEVEL OF ANALYSIS

QUALITY OF STUDY/ANALYSIS

POTENTIAL USE IN THE STUDY

INFORMATION GAP

Tandon, A., Giving more weight to health: assessing fiscal space for health in Indonesia 2009: Washington D.C.

Policy options to raise fiscal space for health

National Analysis of drivers of fiscal space for health

No examination of local level fiscal space

Bappenas, GoI Financial Scheme for Achieving MDG targets in Indonesia Report 2008

Costings for interventions and financing requirements to meet intervention coverage targets

National Available financial resources and financing gap for MDGs calculated.

Estimates for financial resources needed to achieve MDGs 4 & 5 at national level.

No sub-national estimates available. An analysis of fiscal capacity at provincial and district level will be necessary to improve MNCH financing.

Moertiningsih, S. Reproductive Health Costing Indonesia 2005-2015 Study and Analysis UNPF, Jakarta

Costing of reproductive health including family planning

National, provincial and district level

Estimates for reproductive health services at the current coverage and for universal coverage


6. RECOMMENDATIONS One of the key challenges for policymakers on the ground is to develop plans and budgets that set implementation and funding priorities based on evidence. This mapping exercise has found that there are gaps in data analysis and availability. There is no report available on national infant and mortality data at district level and rates are extrapolated. There is no systematic analysis of the cost-effectiveness of MNCH interventions in the Indonesian setting. Although there is limited research on family oriented, population oriented and individual clinical services, this information is not used for MNCH budgeting at the central, provincial or district government level. Recent reports have examined system constraints to scale-up health services delivery and highlighted the challenges imposed by decentralisation. However, there is limited analysis of the impact of policy interventions on health services coverage and quality. Moreover, there are no costing data that can be readily used by local governments to prepare their plans and budgets. These gaps reflect the problem for estimating the additional funding required to effectively address the constraints and bottlenecks and to scale-up the “best-buy range of interventions” to achieve such equitable progress on MDGs 4 and 5. Available studies on the funding gap for MDGs 4 and 5 have been undertaken at national level. However, in such a diverse and decentralised country, a bottom up approach is required. Based on the decentralisation policy and MSS, the decision making for prioritising effective interventions and investment for MNCH should be initiated at the district level. The decision making for resources allocation should use Musrenbang (local government development plan process) from district to provincial level. This is the main reason why we recommend a district level focus for the IC in Indonesia. One intermediate outcome of the IC could be the increase in the budget for MNCH from various sources, particularly at local level. Increasing the fiscal space for MNCH in Indonesia requires mobilisation of local government funding. The implementation of the Askeskin and Jamkesmas programmes have led to substantial increases in central government funding in order to extend the coverage of priority health services, including MNCH to the poor population. Such investment, which is mostly focused on curative services, would need to be complemented by increasing funding from local governments. Financing from local governments is required to scale-up the delivery of preventative and primary health care interventions. The local government engagement is required to effectively address the social determinants of health in the local communities. Innovative approaches that involve the active participation of the private sector should also be explored by local governments. The geographical disparities provide good examples of positive deviants from which useful, innovative and pragmatic lessons can be learned to implement strategies to scale-up priority interventions in the poor performing districts.


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63. Wilson, J.M., Handwashing reduces diarrhoea episodes: A study in Lombok, Indonesia. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1991. 85: p. 819-821.

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77. Berger, S.G., et al., Malnutrition and morbidity among children not reached by the national vitamin A capsule programme in urban slum areas of Indonesia. Public Health, 2008. 122(4): p. 371-378.

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related dehydration and its influence on ORS use in Indonesia. Asia Pacific Journal Public Health 2007. 19(1): p. 34-9.

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86. Rachmawati, T., et al. , Efforts to Improve Basic and Comprehensive Emergency Obstetrics and Neonatal Service for accelerating Maternal and Neonetal Death Rate Reduction,, Center for Research and Development of Health Policy, Editor. 2006.

87. Frankenberg, E., et al., Do women increase their use of reproductive health care when It becomes more available? Evidence from Indonesia. Studies in Family Planning, 2009. 40(1): p. 27-38.

88. Achadi, E., et al., Midwifery provision and uptake of maternity care in Indonesia. Tropical Medicine & International Health, 2007. 12(12): p. 1490-7.

89. Frankenberg, E. and D. Thomas, Women's health and pregnancy outcomes: Do services make a difference? Demography, 2001. 38(2): p. 253-265.

90. Ensor, T., et al., Level and determinants of incentives for village midwives in Indonesia. Health Policy & Planning, 2009. 24(1): p. 26-35.

91. Makowiecka, K., et al., Midwifery provision in two districts in Indonesia: how well are rural areas served. Health Policy & Planning, 2008. 23(1): p. 67-75.

92. AusAID, Annual program performance report for Indonesia 2007. 2008: Canberra. 93. Nadjib, M., IMMPACT Study, Initiative for Maternal Mortality Programe Assessment

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Annotated Bibliography - Country Mapping Report – Indonesia 78

APPENDIX 1 – ANNOTATED BIBLIOGRAPHY

Author, Title, Source, Year Description/Results Key Words

Achadi E, Scott S, Pambudi ES, Makowiecka K, Marshall T, Adisasmita A, et al. Midwifery provision and uptake of maternity care in Indonesia. Tropical Medicine & International Health. 2007.

This research examines the association between midwife density, other characteristics of midwifery provision and village contextual factors, and the percentage of births attended by a health professional and deliveries via caesarean section in two districts in West Java, Indonesia. Analyses: (i) a census of midwives; (ii) a population-based survey of women delivering over a 2-year period; (iii) a census of all caesareans in the 4 hospitals serving the two districts; and (iv) data from National Statistical Office. Results/Conclusions: At an average density of 2.2 midwives per 10 000 population, 33% of births are with a health professional, and 1% by caesarean section. Having at least six midwives per 10 000 population was associated with a fourfold increase in caesareans and a threefold increase in the odds of having a health professional attend the delivery [adjusted odds ratio. The assigned midwife's professional status and the duration of her service in the village were also associated with higher rates of health professionals' attendance of delivery and caesareans. Regardless of the provision of services, women's education and wealth were strong predictors of delivery with a health professional. Promoting a stable workforce of midwives, better financial access for the poor and expanding female education are important for the achievement of the MDG-5.

MNCH interventions

Adisasmita A, Deviany PE, Nandiaty F, Stanton C, Ronsmans C, Adisasmita A, et al. Obstetric near miss and deaths in public and private hospitals in Indonesia. BMC Pregnancy & Childbirth. 2008.

Falling numbers of maternal deaths have stimulated an interest in investigating cases of life threatening obstetric morbidity or near miss. The purpose of this study was to document the frequency and causes of near miss and maternal deaths in four hospitals in West Java, Indonesia. This cross sectional study was conducted in four hospitals in two districts in Banten province, Indonesia. Registers and case notes were reviewed to identify the numbers and causes of near miss and death between November 2003 and October 2004. Near miss cases were defined based on organ dysfunction, clinical and management criteria. Near miss was categorised by whether or not the woman was at a critical state at admission by reviewing the final signs at admission. Results/Conclusions: The prevalence of near miss was much greater in public than in private hospitals (17.3% versus 4.2%, p = 0.000). Haemorrhage and hypertensive diseases were the most common diagnoses associated with near miss, and vascular dysfunction was the most common criterion of organ dysfunction. The occurrence of maternal deaths was 1.6%, with non-obstetric complications as the leading cause. The majority (70.7%) of near miss in public hospitals were in a critical state at admission but this proportion was much lower in private hospitals (31.9%). This is the first study to document near miss in public and private hospitals in Indonesia. Close to a fifth of admissions in public hospitals were associated with near miss; and the critical state in which the women arrived suggest important delays in reaching the hospitals. Even though the private sector takes an increasingly larger share of facility-based births in Indonesia, managing obstetric emergencies remains the domain of the public sector.

Maternal Mortality Constraints/Strategies



Agha S, Do M. Does an expansion in private sector contraceptive supply increase inequality in modern contraceptive use? Health Policy & Planning, 2008.

This study analyse whether an expansion in private sector contraceptive supply is associated with increased socio-economic inequality in the modern contraceptive prevalence rate (MCPR inequality). Multiple rounds of Demographic and Health Surveys data were analysed for five countries that experienced an increase in the private sector supply of contraceptives: Morocco, Indonesia, Kenya, Ghana and Bangladesh. Information on household assets and amenities was used to construct wealth quintiles. A concentration index, which calculates the degree of inequality in contraceptive use by wealth, was calculated for each survey round. Results/Conclusions: Socio-economic inequality in the MCPR (MCPR inequality) declined in Morocco and Indonesia, where substantial expansion in private sector contraceptive supply occurred. In both countries, poor women continued to rely heavily on contraceptives supplied by the public sector even as they increased use of contraceptives obtained from the private sector. The study found no support for the hypothesis that an increase in private sector contraceptive supply leads to higher MCPR inequality. The findings suggest that continued public sector supply of contraceptives to the poorest women protects against increased MCPR inequality. The study highlights the role of the public sector in building contraceptive markets for the private sector to exploit.

Equity MNCH Interventions Constraints/Strategies

Analen C. Saving mother's lives in rural Indonesia. Bulletin of the World Health Organization. 2007.

This article is a descriptive report of a health care initiative in the Ngawi district in East Java that has been initiated to try to ensure that a midwife or other trained birth attendant assists deliveries. Since 2006, dukun are given incentives of up to IDR 100 000 (US$ 12) for referring pregnant women to skilled birth attendants or community-based midwives. Funding comes from the local government budget. This report emphasises that the traditional healer, or dukun, may not be able to deal with complications during labour, and by the time the mother gets to a local clinic it may be too late. As a result, maternal mortality in Indonesia is high compared to most South-East Asian countries. The chief cause of maternal death in Indonesia is bleeding, followed by eclampsia, infection, and the complications of abortion and prolonged labour. Most of these deaths occur with births handled by traditional birth attendants rather than by medically trained health-care professionals. Results/Conclusions: The scheme is proving successful. In 1984, a total of 86% of deliveries in Ngawi were aided by dukun, compared with fewer than 1% of deliveries today. Maternal deaths also have decreased: while 15 mothers died during delivery in 2002, this number dropped to 9 in 2006. Awareness of the risks of delaying transfer of pregnant women to health centres also has grown as a result of the Program Gerakan Sayang Ibu (To Love Mother Programme in Bahasa). This information programme prompted many villages to provide transportation to transfer pregnant women either to community health centres or midwife delivery huts.

Maternal Mortality MNCH interventions

Andajani-Sutjahjo S, L. M. Stillbirth, neonatal death and

The main purpose of this study was to find out the extent to which reproductive rights of women are being fulfilled by maternal and child health clinics in Indonesia. The data in this paper derive from a longitudinal study

Constraints/Strategies



reproductive rights in Indonesia. Reproductive Health Matters. 2004.

of motherhood and emotional well-being of women in Indonesia; 488 women were interviewed in late pregnancy, and 290 at six weeks post-partum. This paper reports on in-depth interviews with four women who reported a stillbirth and six who reported a neonatal or infant death. They were asked about their understanding of why their baby had died and the information, care and support given to them. Results/Conclusions: The study suggest that Maternal and child health services do not provide health care in a respectful and consensual manner, information to mothers on how they should care for themselves and their infants and support to those who experience stillbirths or neonatal deaths including home visits. This needs to be incorporated into health professional training. Women need to be educated on what to expect from clinics and health services. Health professionals and policymakers need to be trained on what services they should provide and to ensure that these are available for women.

Andajani-Sutjahjo S, Manderson L, J. A. Complex emotions, complex problems: understanding the experiences of perinatal depression among new mothers in urban Indonesia. Culture, Medicine & Psychiatry. 2007.

This study explore how Javanese women identify and speak of symptoms of depression in late pregnancy and early postpartum and describe their subjective accounts of mood disorders. The study, conducted in the East Java region of Indonesia in 2000, involved in-depth interviews with a subgroup of women (N=41) who scored above the cut-off score of 12/13 on the Edinburgh Postnatal Depression Scale (EPDS) during pregnancy, at six weeks postpartum, or on both occasions. This sample was taken from a larger cohort study (N cohort = 488) researching the sociocultural factors that contribute to women’s emotional wellbeing in early motherhood. Results/Conclusions: Women attributed their mood variations to multiple causes including: premarital pregnancy, chronic illness in the family, marital problems, lack of support from partners or family networks, their husbands’ unemployment, and insufficient family income due to giving up their own paid work. The researchers argue for the importance of understanding the context of childbearing in order to interpret the meaning of depression within complex social, cultural, and economic contexts.

MNCH Interventions

AusAID. Annual program performance report for Indonesia 2007. Australian Agency for International Development. 2008. (http://www.ausaid.gov.au/publications/pdf/appr_indonesia_0708.pdf)

This report gives an overview of the Indonesia’s performance in the year 2007 and assesses the progress made under the AusAID cooperation. Results/Conclusions: Indonesia is on track to meet the Millennium Development Goals (MDGs) for alleviating poverty, achieving universal primary education and literacy, eliminating gender disparity in primary education, and improving sanitation. However, there is still a high degree of regional disparity; some provinces have high incidences of extreme poverty, maternal and infant mortality and a high disease burden. For example, the estimated national maternal mortality rate is 307 deaths per 100 000 live births; yet estimates for the Papua region are 1116 deaths and Nusa Tenggara Timur 554. Close relationships with the government at all levels are contributing to greater government ownership and leadership and aiding sustainability. However, limited capacity in some ministries is hampering progress, making implementation complex and resource-intensive.


http://www.ausaid.gov.au/publications/pdf/appr_indonesia_0708.pdf





The withdrawal of donors engaged in the health sector is a worrying trend and could impact on the agency’s capacity to scale up activities focused on HIV and maternal and neonatal health.

AusAID. Australia Indonesia Partnership for Decentralisation Concept Note. Australian Agency for International Development. 2009. (http://www.indo.ausaid.gov.au/docs/AIPD-ConceptNote.pdf)

This is the concept note of the Australia Indonesia Partnership for Decentralisation (AIPD) which aims to strengthen the capacity of sub-national governments in NTT, NTB, Papua and West Papua, with the overall aim of contributing to poverty reduction in the region through improved sub-national governance and economic growth. This concept note outlines AIPD’s purpose, its key features and the changes it is anticipated to achieve. Results/Conclusions: AIPD will effectively be the successor to AusAID’s main program of support for economic and financial governance at the sub-national level in eastern Indonesia - Australia Nusa Tengara Assistance for Regional Autonomy (ANTARA1). AIPD will deliver a direct program of capacity building support, including technical assistance (TA) as appropriate. This support will focus on strengthening the quality of public financial management at the provincial and district levels, including the ability for civil society to actively engage in monitoring the use of public resources. Focus will also be given to supporting the development of a business environment that will encourage business development and, ultimately, economic growth. Approaches will be tailored to the needs of each participating province. In addition to implementing these activities, AIPD will provide a platform for, and drive the increased integration of, AusAID’s broader package of support for governance and service delivery in the region. Through these approaches, it is hoped that AIPD will significantly strengthen country systems and support the more effective delivery of services to the poor in Indonesia’s highest poverty incidence provinces.


BAPPENAS. Report on the Achievement of Millennium Development Goals Indonesia. 2007

This report aims at providing information on progress made towards the achievement of the MDGs. Examines the relevant indicators and evaluates the current situation, trends and challenges, including constraints to scaling-up priority interventions. The Report also provides broad suggestions to address those constraints. Results/Conclusions: The challenges posed by decentralization are highlighted. Recommends clear guidelines on the roles and responsibilities of the different levels of government in regard to MNCH. The report stresses the importance of interventions aimed at improving water and sanitation and nutrition for the reduction of child mortality. In regard to MDG 5, the report highlights various accessibility and financial barriers to the use of health services.

Maternal Mortality Under-5 Mortality Constraints/Strategies

Barber SL, Gertler PJ. Strategies that promote high quality care in Indonesia. Health Policy. 2008.

The main objective of this study was to assess which factors determine quality of care in Indonesia. The study combined two surveys in 13 provinces: a household survey of 2451 women who delivered a live birth in 1992-1998, and a facility survey that measured quality available from outpatient providers. Multivariate regressions were used for analysis. Results/Conclusions: High facility quality predicts an increase in quality received. Although poor households

Equity Funding/Costing

http://www.indo.ausaid.gov.au/docs/AIPD-ConceptNote.pdf

http://www.indo.ausaid.gov.au/docs/AIPD-ConceptNote.pdf



have access to the same or higher quality care compared with the least poor, the poor receive lower levels of quality. In remote regions, quality received rises with increasing levels of maternal education and household wealth. Improving health provider knowledge, and increasing household financial resources and information could redress inequalities in quality received among the poor and least educated. Increased information regarding services at the health facility could improve quality among the poor. Another factor is increasing financial resources so that households can access health facilities. This can be done by providing subsidies and health insurance for the poor.

Barber SL, Gertler PJ. Health workers, quality of care, and child health: Simulating the relationships between increases in health staffing and child length. Health Policy. 2009.

One in three children globally is stunted in growth. Many of the conditions that promote child stunting are amenable to quality care provided by skilled health workers. The study uses household and facility data from the Indonesian Family Life Surveys in 1993 and 1997. The first set of multivariate regression models evaluate whether the number of medical doctors, nurses, and midwives predict quality of care as measured by adherence to clinical guidelines. The second set explains the relationships between quality and length among children less than 36 months. Using the information generated from these two sets of regressions, the authors simulate the effect of increasing the number of medical doctors, nurses, and midwives on child length and stunting. Results/Conclusions: Increases in the number of medical doctors and nurses predict increases in the quality of care. Higher quality care is associated with child length in centimetres and stunting. Simulations suggest that large health gains among children under 24 months of age result by placing medical doctors where none are available. Improvements in child health could be made by increasing the number of qualified health staff. The returns to investing in improvements in human resources for health are high.

MNCH Interventions Constraints/Strategies

Beegle K, Frankenberg E, Thomas D. Bargaining power within couples and use of prenatal and delivery care in Indonesia. Studies in Family Planning. 2001.

Using data from the second round of the Indonesian Family Life Survey (IFLS) this study analyses couples' bargaining power and its influences on women's use of prenatal and delivery care in Indonesia. The population studied were married women (15- 49 years old). Results/Conclusions: Holding household resources constant, a woman's control over economic resources affects the couple's decision-making. Compared with a woman with no assets that she perceives as being her own, a woman with some share of household assets influences reproductive health decisions. This evidence suggests that her influence on service use also varies if a woman is better educated than her husband, comes from a background of higher social status than her husband's, or if her father is better educated than her father-in-law. Therefore, both economic and social dimensions of the distribution of power between spouses influence use of services, and conceptualising power as multi-dimensional is useful for understanding couples' behaviour.

Equity



Bender K, Knöss J. Social Protection Reform in Indonesia – In Search of Universal Coverage. In: Social and Ecological Market Economy. GTZ; 2008.

This is a review of the Social Protection Reform in Indonesia and details of the GTZ assistance. Results/Conclusions: The current form of publicly provided social protection in Indonesia is based on two kinds of public interventions, namely (a) contributory social insurance or mandatory savings for civil servants (covered by PT TASPEN and PT ASKES), the armed forces (covered by PT ASABRI), and formal-sector employees (covered by PT JAMSOSTEK) and (b) targeted efforts to provide economic or social support for poor or vulnerable groups of society. By passing Law No. 40 in 2004, the Government of Indonesia initiated a comprehensive process of reforming the existing system towards universal coverage, aiming to improve access as well as enhance quality of service delivery. The reform process implies a multitude of policy decisions and legal and regulatory adjustments that are currently being addressed by the various stakeholders to the process. Reviewing the current situation and analysing the options for the various social protection schemes for citizens also reveals that the efficacy of ongoing and future reforms depends greatly on developments and progress in other sectors. Most prominently, it will depend on private sector development and the expansion of the formal sector and attendant reduction of the informal sector, tax system reforms, and sustained efforts in decentralisation reforms.

Equity

Berger SG, de Pee S, Bloem MW, Halati S, Semba RD. Malnutrition and morbidity among children not reached by the national vitamin A capsule programme in urban slum areas of Indonesia. Public Health. 2008.

This study assesses whether children not reached by the vitamin A capsule programme in Indonesia's urban slums are at higher risk of malnutrition and morbidity. As part of a national surveillance system, nutritional status and other factors were compared in 138,956 children, aged 12-59 months, who had and had not received vitamin A supplementation in urban slum areas in Indonesia. Results/Conclusions: In total, 63.1% of children had received a vitamin A capsule within the previous 6 months. In families where a child had or had not received vitamin A supplementation, the proportion with a history of infant death < 12 months was 5.2% vs 7.2% (P<0.0001) and child death < 5 years was 6.7% vs 9.2%, respectively (P<0.0001). Children who had not received vitamin A supplementation were also significantly more likely to be anaemic and have diarrhoea or fever on the survey day compared with children who had received supplementation. In the urban slums of Indonesia, children who do not receive vitamin A supplementation tend to be slightly more malnourished and ill, and are more likely to come from families with higher child mortality than children who receive vitamin A. Higher rates of child mortality in non-participating households suggest that reaching preschoolers could yield a disproportionate survival benefit. Importantly, children who are not reached by the vitamin A programme are also unlikely to be reached by vaccination and other services, emphasising the need to identify and extend efforts to reach non-participants.

MNCH Interventions Equity



Block S. Maternal nutrition knowledge and the demand for micronutrient-rich foods: Evidence from Indonesia. Journal of Development Studies. 2004.

The purpose of this study was to assess to what extent maternal nutrition knowledge influences on child nutritional status in rural Indonesia. This study applies both parametric and non-parametric techniques to a new household data set from rural Indonesia to explain previous findings of a reduced-form relationship between nutrition knowledge and child micronutrient status. Seven household data surveys conducted between December 1998- January 2001 looking households (n=7,200) in 30 villages within Central Java where the population was 30 million. Results/Conclusions: Households of mothers with and without nutrition knowledge allocate identical budget shares to food; yet, within the food budget, 'knowledge' households allocate substantially larger shares to micronutrient-rich foods and smaller shares to rice than do 'non-knowledge' households. These differences are partially attributable to differences in maternal schooling, but nutrition knowledge has additional sources (in particular, access to the village health centre/posyandu) and independent explanatory power in conditioning the demand for micronutrient-rich foods. Access to the local health centre means that it has a greater influence on maternal knowledge regarding nutrition and consequently the child's nutritional status. Block reports that although the budget allocated to food was the same within both "knowledge" and "non-knowledge" households, where mothers had knowledge they allocated a greater share of the budget to foods rich in micronutrients and a smaller share to the starch staple (rice). Where women have knowledge regarding nutrition their children are more likely to have a better nutritional status. The health system can therefore influence child health by increasing nutrition knowledge among mothers.

MNCH interventions Constraints/Strategies

Block SA, Kiess L, Webb P, Kosen S, Moench-Pfanner R, Bloem MW, et al. Macro shocks and micro outcomes: child nutrition during Indonesia's crisis. Economics & Human Biology. 2004.

A survey of households in rural Java is used to assess the nutritional impact of Indonesia’s drought and financial crisis of 1997/1998. Results/Conclusions: A time-age-cohort decomposition reveals significant nutritional impacts. However, child weight-for-age (WAZ) remained constant throughout the crisis, despite rapid increases in food prices and the consequent household consumption shock. Evidence is consistent with the hypothesis that within households, mothers buffered children’s caloric intake, resulting in increased maternal wasting. However, reductions in the consumption of high-quality foods further resulted in increased prevalence of anaemia for both mothers and children. The combined effects were particularly severe for cohorts conceived and weaned during the crisis. In the short-term financial crisis have a bigger effect on mothers than children as the latter go without in order to provide for their children. Food supplements for children and mothers in the long term would be beneficial during a financial crisis.

Equity

BPS-Statistics Indonesia, BAPPENAS, UNDP. The

Indonesia has made critical human development gains in recent years. These include the steady reduction of extreme poverty, improved access to basic services, and the creation of a more equitable society. Central to all




Economics of Democracy: Financing Human Development in Indonesia. 2004. (http://www.undp.or.id/pubs/ihdr2004/index.asp)

these gains has been the development of Indonesia's democracy, where improved public participation in the political process will put more pressure on the public sector to deliver services to all. This report examines the cost of guaranteeing these rights for every citizen. Results/Conclusions: In the economics of democracy, public expenditure is the critical driver in delivering basic standards and rights. Understanding these costs, and their benefits, is especially vital to a country that is consolidating its democracy. Many districts cannot meet the cost of basic social needs, while others are disproportionately compensated for their requirements. Such inequality in social spending exacerbates the country's wide regional variations in resources and human development achievements. Authors argue that national consensus on sharing the collective responsibility of meeting human development needs and propose an Indonesian Social Summit to achieve this.

Cammack M, Heaton TB. Regional variation in acceptance of Indonesia's family planning program. Population Research and Policy Review. 2001.

Indonesia's family planning program is regarded as a major success. Survey data from 1997 reveal that rates of contraceptive use vary dramatically among Indonesia's 27 provinces, from a high of 67 percent of ever married women currently using contraceptives in the province of North Sulawesi, to a low of 19 percent current users in East Timor and 28 percent in Aceh. This study uses both a quantitative analysis of the 1997 Indonesia Demographic and Health Survey, and a qualitative study carried out in July of 2000 to understand regional variation. Results/Conclusion: The study identified a small number of factors that show a clear relation with levels of contraceptive use. Media exposure and education are the strongest and most consistent predictors of levels of contraceptive use, and appear to be the surest strategies for promoting family change. But the study also showed that the process of social change is subject to culturally and historically specific local factors whose presence and importance is difficult to predict. Our study of regional variation in contraceptive use illustrates the range and complexity of obstacles faced by Indonesia's leaders in attempting to forge a single nation from such a diverse and far-flung population. Although the creation of Indonesia in the space of just half a century is a monumental achievement, the project is clearly not yet complete.


Creati M, Saleh A, Ruff TA, Stewart T, Otto B, Sutanto A, et al. Implementing the birth dose of hepatitis B vaccine in rural Indonesia. Vaccine . 2007.

This paper synthesises the practical experience gained through a number of demonstration projects in Indonesia which have supported the administration of HepB vaccine to newborns. The paper identifies and discusses operational issues key to the successful delivery of a timely birth dose of HepB vaccine, such as birth notification, early postnatal contact between mothers and their newborn and health workers, optimal vaccine presentation, cold chain requirements, vaccine wastage, safe injection practices and recording of doses. It also explores the synergies between administration of this birth dose and the provision of other home-based MCH services.


http://www.undp.or.id/pubs/ihdr2004/index.asp

http://www.undp.or.id/pubs/ihdr2004/index.asp



Results/Conclusions: Barriers to the timely administration of the birth dose of HepB vaccine include weakness in policy development and implementation, difficulties in reliably supplying potent vaccine to community level, limited transport, poor communication, limited cold chain capacity, lack of effective training, and lack of a clear delineation of responsibility between health care professionals. Demonstration projects, such as those in Indonesia, suggest that there are significant opportunities to improve the timely delivery of HepB vaccine birth dose in existing maternal and child health programmes where health workers are trained to provide home delivery care.

D'Ambruoso L, Achadi E, Adisasmita A, Izati Y, Makowiecka K, Hussein J. Assessing quality of care provided by Indonesian village midwives with a confidential enquiry. Midwifery. 2009.

The objective of this study was to conduct a confidential enquiry to assess the quality of care provided by Indonesian village midwives and to identify opportunities for improvement. The local health-care practitioners assessed village-based care in obstetric emergencies in 13 cases of maternal death and near-miss from rural villages in West Java. The study focused on clinical quality of care, but also investigated the influence of the health system and social factors. The reviews were based on transcripts of interviews with health-care providers, family and community members involved in the cases. At the end of a series of case reviews, recommendations for practice were generated and disseminated. Results/Conclusions: In the cases reviewed, midwives facilitated referral effectively, reducing delays in reaching health facilities. Midwives' emergency diagnostic skills were accurate but they were less capable in the clinical management of complications. Coverage was poor; in some locations, midwives were responsible for up to five villages. Village midwives were also perceived as unacceptable to women and their families. Families and communities did not prepare for emergencies with finances or transport, partly due to a poorly understood health insurance system. The village midwives should: receive appropriate support for the management of obstetric emergencies; engage with communities to promote birth preparedness; and work in partnership with formal and informal providers in the community. Practitioners had a unique insight into factors that contribute to quality care and how feasible interventions might be made.


Davidson R. Gwatkin, Shea Rustein, Kiersten Johnson, Rohini P. Pande, Wagstaff A. Socio-economic differences In health, nutrition, and population in Indonesia. World Bank. 2000. (http://siteresources.worldbank.org/INTINDONESIA/Resources/H

The publication is one of a series covering forty-four countries, commissioned by the World Bank’s HNP (health, nutrition, population) and poverty thematic group. The figures presented in the series have been tabulated from data collected through the multi-country Demographic and Health Survey (DHS) program. Results/Conclusions: These figures describe the health, nutrition, and population (hnp) status and service use among individuals belonging to different socio-economic classes. The figures are intended to provide World Bank operational staff, the government officials with whom they work, and others with basic information for use in preparing country analyses and in developing hnp activities for the disadvantaged.

Equity

http://siteresources.worldbank.org/INTINDONESIA/Resources/Human/socio-economic.pdf

http://siteresources.worldbank.org/INTINDONESIA/Resources/Human/socio-economic.pdf



uman/socio-economic.pdf)

Ensor T, Nadjib M, Quayyum Z, Megraini A. Public Funding for Community-Based Skilled Delivery Care in Indonesia: To What Extent Are the Poor Benefiting? European Journal of Health Economics. 2008.

This research paper uses a funding flow analysis and population-based survey in two districts, and investigates to what extent funding allocated for maternal services enables access to skilled services by rich and poor households. Results/Conclusions: Although resources reach remote poor areas, the poor obtain unequal access to skilled delivery services. Because rural midwives must earn a significant fraction of their income from private fees this acts to deter women from seeking their help. A new system of targeting poor women utilising the existing state insurance company (ASKES) is an important step in helping to reduce these barriers, but may not be sufficiently generous to protect all those that are considered vulnerable.


Ensor T, Quayyum Z, Nadjib M, Sucahya P. Level and determinants of incentives for village midwives in Indonesia. Health Policy & Planning. 2009.

This research article assesses the effect of financial incentives on the distribution of skilled rural midwives and the use of their services. This study employs multivariate analysis to use the survey of the rural midwife programme in Banten Province. Results/Conclusions: The midwives are well able to earn a substantial private income even in remote areas. However, there is a high level of unwillingness to move posts to a more remote area for a variety of non-financial reasons. The results suggest that the access to skilled attendance of those unable to afford fees may be impaired by the dependence on fee income, a result supported by companion household studies. In addition, ensuring that staff live and work in remote areas is only likely to be financially sustainable if midwives can be attracted to live in these areas early in their careers. Financial incentives alone are insufficient for midwives to work in remote areas. A different strategy is needed perhaps where rural midwives end up working in their own villages. The private sector is maintaining inequality in access to skilled birth attendants through user fees. For this to change the public sector needs provide salaries as well as attractive career opportunities in rural and remote areas. Finally, the overall strategy of basing skilled attendance mainly on village services throughout the country may need to be re-visited, with alternative models offered in areas where it continues to be impractical even with a change in the incentive framework.


Fahdhy M, Chongsuvivatwong V. Evaluation of World Health Organization partograph implementation by midwives for maternity home birth in Medan, Indonesia. Midwifery. 2005.

This cluster randomised-control trial study was conducted among 20 midwives in Medan city, North Sumatera Province, Indonesia with the objective to assess the effectiveness of promoting the use of the World Health Organisation (WHO) partograph by midwives for labour in a maternity home by comparing outcomes after birth. Intervention was under supervision from a team of obstetricians; midwives in the intervention group were introduced to the WHO partograph, trained in its use and instructed to use it in subsequent labours. There were 304 eligible women with vertex presentations among 358 labouring women in the intervention group and 322 among 363 in the control group.




Results/Conclusions: Among the intervention group, 304 (92.4%) partographs were correctly completed. From 71 women with the graph beyond the alert line, 42 (65%) were referred to hospital. Introducing the partograph significantly increased referral rate, and reduced the number of vaginal examinations, oxytocin use and obstructed labour. The proportions of caesarean sections and prolonged labour were not significantly reduced. Apgar scores of less than 7 at 1 min was reduced significantly, whereas Apgar scores at 5 mins and requirement for neonatal resuscitation were not significantly different. Foetal death and early neonatal death rates were too low to compare. A training programme with follow-up supervision and monitoring may be of use when introducing the WHO partograph in other similar settings, and the findings of this study suggest that the appropriate time of referral needs more emphasis in continuing education. The WHO partograph should be promoted for use by midwives who care for labouring women in a maternity home.

Frankenberg E, Buttenheim A, Sikoki B, Suriastini W. Do women increase their use of reproductive health care when It becomes more available? Evidence from Indonesia. Studies in Family Planning. 2009.

Between 1991 and 1998, Indonesia trained some 50,000 midwives, placing them in poor communities that were distant from health-care centres. This study uses data from the Indonesia Family Life Survey are used to investigate the impact of a major expansion in access to midwifery services on women's use of antenatal care and delivery assistance. Pregnancy histories information was analysed to relate changes in the choices that individual women make across pregnancies to the arrival of a trained midwife in the village. Results/Conclusions: The results show that regardless of a woman's educational level, the placement of village midwives in communities is associated with significant increases in women's receipt of iron tablets and in their choices about care during delivery - changes that reflect their moving away from reliance on traditional birth attendants. For women with relatively low levels of education, the presence of village midwives has the additional benefit of increasing use of antenatal care during the first trimester of pregnancy. Indonesia’s national effort to improve access to reproductive health care has increased women’s use of skilled assistance during pregnancy and delivery.

MNCH Interventions

Frankenberg E, Suriastini W, Thomas D. Can expanding access to basic health care improve children's health status? Lessons from Indonesia's "midwife in the village" program. University of California. 2004. (http://repositories.cdlib.org/cc

In the 1990s, the Indonesian government placed over 50,000 midwives in communities throughout the country. This report assesses the effects the introduction of a midwife has on the nutritional status of children using the "Midwife in the Village Programme". Data are drawn from the Indonesia Family Life Survey (IFLS), a panel survey of individuals, households, communities, and facilities. Results/Conclusions: The nutritional status of children fully exposed to a midwife during early childhood is significantly better than that of their peers of the same age and cohort in communities without a midwife. These children are also better off than children measured at the same age from the same communities, but who were born before the midwife arrived. Within communities, the improvement in nutritional status across cohorts is greater where midwives were introduced than where they were not. As access to midwives in rural


http://repositories.cdlib.org/ccpr/olwp/ccpr-018-04/



pr/olwp/ccpr-018-04/) areas improves the health of children, efforts should be made to ensure that distribution is equitable.

Frankenberg E, Thomas D. Women's health and pregnancy outcomes: Do services make a difference? Demography. 2001.

Between 1990 and 1998 Indonesia trained some 50,000 midwives. Between 1993 and 1997 these midwives tended to be placed in relatively poor communities that were relatively distant from health centres. This study investigates the impact of a major expansion in access to midwifery services on health and pregnancy outcomes for women of reproductive age. The data sources included data from two rounds of the IFLS, an ongoing panel survey of individuals, households, communities, and facilities. Results/Conclusions: The additions of village midwives to communities between 1993 and 1997 are associated with a significant increase in body mass index in 1997 relative to 1993 for women of reproductive age, but not for men or for older women. The presence of a village midwife during pregnancy is also associated with increased birth weight. Both results are robust to the inclusion of community-level fixed effects, a strategy that addresses many of the concerns about biases because of non-random program placement.

MNCH interventions

Friedman J, Heywood Peter, Marks Geoff, Saadah Fadia, Choi. Y. Health sector decentralisation and indonesia nutrition programs: Opportunities and challenges. World Bank. 2006. (http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2007/07/09/000020439_20070709143246/Rendered/PDF/396900IND0Heal101OFFICIAL0USE0ONLY1.pdf)

The paper analyses Indonesia's nutritional programs in the context of decentralisation and intended to assist the centre navigate the tension between opportunities and challenges as activities are adapted to the decentralised national nutrition policy, and to help guide districts and provinces in the conduct of locally appropriate nutrition programs. This paper synthesises the findings of an extensive study undertaken by the World Bank and provides extensive data and analysis to shed light on the opportunities and challenges in the new institutional environment. Results/Conclusions: It highlights cost-effective nutrition programs that can be delivered. The government now needs to (1) reform government structures and processes so that they are suited to tackling nutrition in a large and diverse country, (2) augment human resources so that there is a close match between the required skills and those available, (3) strengthen planning and implementation of nutrition programs, (4) ensure adequate financial resources for nutrition programs, especially in the worst affected areas, and (5) promote collaboration at all levels.

Constraints/Strategies Funding/Costing

Galloway R, Dusch E, Elder L, Achadi E, Grajeda R, Hurtado E, et al. Women's perceptions of iron deficiency and anemia prevention and control in eight developing countries. Social

This paper investigates factors that influence women’s decisions to take iron supplements and to suggest ways to improve existing programs. During the period 1991-98, the MotherCare Project supported formative research, using qualitative methods, on this subject in eight countries (Bolivia, Burkina Faso, Guatemala, Honduras, India, Indonesia, Malawi and Pakistan). Both pregnant and no pregnant women participated in the studies. the other ‘‘key informants’’ included husbands/men, mothers and mothers-in-laws, both public health and traditional health providers, and community leaders.


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Science & Medicine. 2002. Results/Conclusions: The way women view anaemia and react to taking iron tablets was found similar across the regions. Contrary to the belief that women stop taking iron tablets mainly due to negative side effects, only about one-third of women reported that they experienced negative side effects in these studies. The major barrier to effective supplementation programs is inadequate supply. Additional barriers include inadequate counselling and distribution of iron tablets, difficult access and poor utilisation of prenatal health care services, beliefs against consuming medications during pregnancy, and in most countries, fears that taking too much iron may cause too much blood or a big baby, making delivery more difficult. Facilitators include women's recognition of improved physical well being with the alleviation of symptoms of anaemia, particularly fatigue, a better appetite, increased appreciation of benefits for the foetus, and subsequent increased demand for prevention and treatment of iron deficiency and anaemia.

Hardon AP, Oosterhoff P, Imelda JD, Anh NT, Hidayana I. Preventing mother-to-child transmission of HIV in Vietnam and Indonesia: Diverging care dynamics. Social Science & Medicine. 2009.

How do women and frontline health workers engage in preventing mother-to-child HIV transmission (PMTCT) in urban areas of Vietnam and Indonesia, where HIV is highly stigmatised and is associated with injecting drug use and sex work? This qualitative study explores local dynamics of care, using a mix of observations, focus group discussions, and interviews. In Indonesia the study was conducted in a community-based PMTCT program run by an NGO. Results/Conclusion: In both of these PMTCT arrangements (the routine provider initiated approach in Vietnam and a more client-oriented system in Indonesia); pregnant women value the provision of HIV tests in antenatal care (ANC). Concerns are raised, however, by the unhappy few who test positive. These women are unsatisfied with the quality of counselling, and the failure to provide antiretroviral treatments. Acceptability of HIV testing in ANC is high, but the key policy issue from the perspective of pregnant women is whether the PMTCT services can provide good quality counselling and the necessary follow-up care. The local level providers of PMTCT are pleased with the PMTCT program. In Indonesia, community cadres are pleased with the financial incentives gained by mobilising clients for the program. Achieving the global aims of reducing HIV infections in children by 50% requires a tailoring of globally designed public health programs to context-specific gendered transmission pathways of HIV, as well as local opportunities for follow-up care and social support.

MNCH Interventions

Hatt L, Stanton C, Makowiecka K, Adisasmita A, Achadi E, Ronsmans C. Did the strategy of skilled attendance at birth reach the poor in Indonesia? Bulletin of the World Health

The objective of this paper is to assess whether the strategy of “a midwife in every village" in Indonesia, improved access to care for the poor in Indonesia. Pooled Demographic and Health Surveys (DHS) data from 1986-2002 was used and logistic regression was employed to examine trends in the percentage of births attended by a health professional and deliveries via caesarean section. Results/Conclusions: There was no change in rates of professional attendance or caesarean section before the programme's full implementation (1986-1991). After 199 1, the greatest increases in professional attendance




Organization. 2007. occurred among the poorest two quintiles. In contrast, most of the increase in rates of caesarean section occurred among women in the wealthiest quintile. Rates of caesarean deliveries remained at less than 1% for the poorest two-fifths of the population, but rose to 10% for the wealthiest fifth. The Indonesian village midwife programme dramatically reduced socioeconomic inequalities in professional attendance at birth, but the gap in access to potentially life-saving emergency obstetric care widened. This underscores the importance of understanding the barriers to accessing emergency obstetric care and of the ways to overcome them, especially among the poor.

Health Metrics Network. Indonesia Health Information System Review and Assessment. Centre for Data and Information MoH, Indonesia. 2007. (http://www.who.int/healthmetrics/library/countries/HMN_IDN_Assess_Draft_2007_08_en.pdf)

This review aims to ascertain the Country Health Information Systems (CHIS) in support of evidence based decision making by: establishing baseline information of currently applied HIS; obtaining stakeholders awareness and understanding their role in HIS; and, implementing the HIS assessment result in building up stakeholder commitment and participation in HIS strategic planning development. Data collection was done over a two month period (March to April 2007) in all stakeholders i.e. MOH, BPS, Depdagri, and BKKBN. In addition, sub-national assessments were also conducted in 7 provinces. Results/Conclusions: Health infrastructures are relatively adequate at national and regional level. Health infrastructures and human resources are available down through to sub-district and village level. There has been a high demand for HIS to support evidence-based decision by health managers, policy makers, donors, and NGOs. Fragmentation of HIS was found within MOH units. Changing government policy from centralise to decentralise has affected flow of information. Policy on centralisation of networking in CHDI, MOH, has increased the role of CHDI significantly. Government budget allocated for HIS and donors fund contributions are increasing. The perceived threats include feeling that ICT facilities can be damaged by computer virus or hacker attacks, which can erase information in databank. The frequent changes in government policy have affected HIS policy and implementation. Data collection systems at regional level are frequently uncoordinated, therefore integration is difficult.


Hennessy D, Hicks C, Hilan A, Y. K. The training and development needs of nurses in Indonesia: paper 3 of 3. Human Resources for Health. 2006.

This study aimed to establish the occupational profiles of each grade of nurse identify their training and development needs and ascertain whether any differences existed between nurses working in different regions or within hospital or community settings. An established and psychometrically valid questionnaire was administered to 524 nurses, covering three grades and coming from five provinces. Results/Conclusions: Significant differences in job profile were found in nurses from different provinces, suggesting that the nature of the role is determined to some degree by the geographical location of practice. The roles of hospital and community nurses, and the different grades of nurse, were fairly similar. All nurses reported significant training needs for all 40 tasks, although these did not vary greatly between grades of


http://www.who.int/healthmetrics/library/countries/HMN_IDN_Assess_Draft_2007_08_en.pdf





nurse. The training needs of nurses from each of the provinces were quite distinct, while those of hospital nurses were greater than those of community nurses. The results suggest that the role of the nurse is not as diverse as might be expected, given the different levels of preparation and training and the diversity of their work environments. This may reflect the lack of a central registration system and quality framework, which would normally regulate clinical activities according to qualifications. The differences in training needs between subsections of the sample highlight the importance of identifying skills deficits and using this information to develop customised post-registration education programmes. Together, these results provide a rigorous and reliable approach to defining the occupational roles and continuing education needs of Indonesian nurses.

Hennessy D, Hicks C, Hilan A, Y. K. A methodology for assessing the professional development needs of nurses and midwives in Indonesia: paper 1 of 3. Human Resources for Health. 2006.

Despite recent developments, health care provision in Indonesia remains suboptimal. Difficult terrain, economic crises, endemic diseases and high population numbers, coupled with limited availability of qualified health care professionals, all contribute to poor health status. In line with government initiatives, this series of studies was undertaken to establish the training and development needs of nurses and midwives working within a variety of contexts in Indonesia, with the ultimate aim of enhancing care provision within these domains. An established, psychometrically valid and reliable training needs instrument was modified for use within the Indonesian context. While this technique has had widespread international use in the developed world, its application for developing countries has not yet been established. The standard form consists of a biographical cover sheet and a core set of 30 items (all health-related tasks), which have to be rated along two seven-point scales. The first of these scales asks respondents to assess how important the task is to their job and the second scale is a self assessment of respondents' current performance level of the task. By comparing the importance rating with the performance rating, an index of training need can be obtained (high importance and low performance indicating a significant training need). The modifications incorporated for use in this series of studies were a further 10 items, which were constructed following expert group and focus group discussions and a review of the relevant literature. Pilot trials with 109 respondents confirmed its feasibility and acceptability. The instrument was then administered to 524 nurses and 332 midwives across Indonesia. The data were subjected to a retrospective factor analysis, using a Varimax rotation and Cronbach's α to check the instrument's validity and reliability following modification. Results/Conclusions: The results yielded six factors, which accounted for >53% of the variance, each of which had a Cronbach's α score of between 0.8644 and 0.7068. The results suggest that the modified instrument remained valid and reliable for use in the Indonesian nursing and midwifery context.


Hennessy D HC, Koesno H. The training and development needs

The current study was part of a review of the existing complex system of midwifery training in Indonesia and the development of a coherent programme of continuing professional development, tighter accreditation




of midwives in Indonesia: paper 2 of 3. Human Resources for Health. 2006.

regulations and clearer professional roles. Its aims were to identify the occupational profiles and development needs of the participating midwives, and to establish whether any differences existed between grades, geographical location and hospital/community midwives. A psychometrically valid training-needs instrument was administered to 332 midwives from three provinces, covering both hospital and community staff and a range of midwifery grades. Results/Conclusions: The occupational roles of the midwives varied significantly by province, indicating regional service delivery distinctions, but very little difference in the roles of hospital and community midwives. The most-educated midwives recorded training needs for 24 tasks, while the less-educated had training requirements for all tasks, which suggests that new training programmes are effective. The results from this survey suggest important regional differences in how the midwife's role is discharged and underline the importance of this sort of research, in order to ensure the suitability of basic and post basic educational provision. The study also highlights the need for further development and training of midwives in a wide range of tasks.

Heywood P, Harahap N. P. Human resources for health at the district level in Indonesia: the smoke and mirrors of decentralization. Human Resources for Health. 2009

The objective of the study is to examine the stock of human resources for health in 15 districts in Java and assess their service status and primary place of work. The study also evaluates the effects of decentralization on human resources management. The authors collected information on all health care providers (doctors, nurses and midwives) in each of the districts. Results/Conclusions: In 11 districts there was less than 1 doctor/nurse/midwife per 1000 population. Approximately half of the health providers were permanent public servants, although private sector as the primary source of employment for 37% of doctors. Decision space at the district level is very limited, so the central government remains in command of human resources management. Substantial challenges remain, particularly regarding the increasing role of the private sector and the lack of local control over human resources.


Heywood P, Harahap N. Public funding of health at the district level in Indonesia after decentralization - sources, flows and contradictions. Health Research Policy & Systems. 2009.

Indonesia experienced radical political, administrative and fiscal decentralisation with delivery of services becoming the responsibility of district governments. In addition, public funding for health services more than doubled between 2001 and 2006. It was widely expected that services would improve as district governments now had both more adequate funds and the responsibility for services. To date there has been little improvement in services. Therefore this paper looks at public funds available at the district level for health and the way in which they are used – this is important for assessment of the effects of decentralisation and if we are to improve the allocation and utilisation of public funds for health by districts. Information was collected on public expenditure on health services for the fiscal year 2006 in 15 districts in Java, Indonesia from the district health offices and district hospitals. Information on district government revenues were obtained from district

Constraints/Strategies Funding/Costing



public expenditure databases maintained by the World Bank using data from the Ministry of Finance. Results/Conclusions: The district governments are reliant on the central government for as much as 90% of their revenue; that approximately half public expenditure on health is at the district level; that at least 40% of district level public expenditure on health is for personnel, almost all of them permanent civil servants; and that districts may have discretion over less than one-third of district public expenditure on health; the extent of discretion over spending is much higher in district hospitals than in the district health office and health centres. There is considerable variation between districts. The study concludes that in contrast to the promise of decentralisation there has been little increase in the potential for discretion at the district level in managing public funds for health - this is likely to be an important reason for the lack of improvement in publicly funded health services. Key decisions about money are still made by the central government, and no one is held accountable for the performance of the sector - the district blames the centre and the central ministries (and their ministers) are not accountable to district populations.

Hotchkiss DR, Rous JJ, Seiber EE, Berruti AA. Is Maternal and Child Health Service Use a Causal Gateway to Subsequent Contraceptive Use?: A Multi-country Study. Population Research & Policy Review. 2005.

The purpose of this study is to examine the relationship between MNCH service utilisation and contraceptive use in five countries: Bolivia, Guatemala, Indonesia, Morocco, and Tanzania. The analysis is carried out at the level of the individual woman, with contraceptive-use status modelled as a function of: (1) the availability, quality, and packaging of MCH and family planning services; (2) community- and individual-level determinants of health service and contraceptive use; and (3) intensity of prior MCH service use. Data for the analysis comes from DHS data on women of reproductive age linked with data from service-availability surveys. The study uses full-information, maximum-likelihood regression techniques to control for the effects of unobserved heterogeneity that might otherwise bias the study estimates. Results/Conclusions: In three of the five countries (Morocco, Guatemala, and Indonesia) the results of the analysis suggest that the intensity of MCH service use is positively associated with subsequent contraceptive use among women, even after controlling for observed and unobserved individual- and community-level factors. This result lends support to the proposition that, at least in the context of these three countries, the intensity of MNCH service per se use does have a "causal" impact on subsequent contraceptive use, even after controlling for factors that "predispose" sample women to use health care services.

MNCH Interventions

Houweling TAJ, Kunst AE, Borsboom G, Mackenbach JP. Mortality inequalities in times of economic growth: time trends in socioeconomic and regional

This study examines the time trends in socioeconomic and regional inequalities in under 5 mortality in Indonesia during almost two decades of economic growth (1982 - 1997). Under 5 mortality was calculated for the total population and for subgroups by maternal education, household wealth, rural/urban residence, and island group, using the 1987, 1991, 1994, and 1997 Indonesian Demographic and Health Surveys. Inequalities were calculated using Cox proportional hazards analysis.

Equity Under-5 Mortality



inequalities in under 5 mortality in Indonesia, 1982-1997. Journal of Epidemiology & Community Health. 2006.

Results/Conclusions: Under 5 mortality declined substantially during the 1980s and 1990s. Educational inequalities in under 5 mortality decreased, although not statistically significantly, from a hazard ratio of 2.00 (95% CI 1.60, 2.50) to 1.52 (95% CI 1.27, 1.82). Inequalities between urban and not electrified rural areas increased, from 1.84 (95% CI 1.48, 2.28) to 2.18 (95% CI 1.70, 2.80). Inequalities between the Outer Islands and the central islands of Java/Bali increased from 1.16 (95% CI 0.92, 1.46) to 1.43 (95% CI 1.17, 1.74). Irregular time trends were seen for inequalities by household wealth. Trends in health care use were fairly similar for the low and high educated. These results for education show that socioeconomic inequalities in under 5 mortality do not inevitably rise in times of rapid economic growth. Widening or narrowing of health inequalities in times of economic growth might depend on how equally this growth is distributed.

Hussein J, D'Ambruoso L, Armar-Klemesu M, Achadi E, Arhinful D, Izati Y, et al. Confidential inquiries into maternal deaths: modifications and adaptations in Ghana and Indonesia. International Journal of Gynaecology & Obstetrics. 2009.

Factors contributing to the limited use of confidential inquiries into maternal deaths include the negative focus and demotivating effect of such inquiries, perceptions of unavailability of sufficient documentation of events, and lack of time and resources. To ascertain whether these problems can be overcome, variations to confidential inquiries into maternal deaths were introduced in Ghana and Indonesia. Clinical review panels were set up as part of the usual process of confidential inquiries, and modifications to the confidential inquiries were introduced. In Ghana, the traditional confidential inquiry process focusing on health facility care was modified to introduce the assessment of positive factors. In addition to the assessment of positive factors, adaptations in Indonesia consisted of including cases of obstetric complications, as well as deaths, and the use of interview testimonials as data sources. Information about resource and time needs for conducting confidential inquiries was collected. Results/Conclusions: The introduction of positive aspects to the process provided a balanced and more motivating setting for the inquiry. The data obtained from case notes in district hospitals and interview testimonials provided sufficient information to assess why maternal deaths and severe complications occurred. The costs of conducting the inquiries ranged from US $4000 to US $11000 (per study), and the estimated time required for a panel member to review each case was more than 3 hours. This study introduced practical ways to encourage the implementation of maternal death reviews, inquiries, and audits that are context specific and, therefore, acceptable to local practitioners.

Maternal Mortality

Johar M. Impact of Indonesian health card programme: A matching estimator approach. University of New South Wales. 2007.

This study evaluates the effectiveness of a pro-poor nation-wide health card program in Indonesia which provides free basic health care at public health facilities. To quantify the effect of the program, it departs from the traditional regression-based approach in the literature to employ propensity score matching to reduce the selection bias due to non-random health card distribution. The setting of the program and the richness of the data set support this strategy in providing accurate estimates of the program’s effect on its recipients.

Equity



(http://wwwdocs.fce.unsw.edu.au/economics/Research/WorkingPapers/2007_30.pdf)

Results/Conclusions: The result finds that in general the health card program only has limited impact on the consumption of primary health care by its recipients. In addition, the role of informal health care, such as traditional healers and home-grown remedies is prevalent, and households consider them as acceptable substitutes for formal health care. In most cases they are cheap and highly accessible.

Julia M, van Weissenbruch MM, de Waal HA, Surjono A, de Waal HAD-v. Influence of socioeconomic status on the prevalence of stunted growth and obesity in prepubertal Indonesian children. Food & Nutrition Bulletin. 2004.

This cross-sectional study, performed in two adjacent areas in Central Java, assesses the prevalence of stunting, overweight, and obesity in prepubertal children from different socioeconomic groups in Indonesia. Children from rural, poor urban, and non poor urban communities were studied (n = 3,010). Results/Conclusions: The prevalences of stunting, wasting, overweight, and obesity were 19.3%, 5.0%, 2.7%, and 0.8%, respectively. The odds ratios (OR) for stunting, as compared with non poor urban children, were higher among rural children (2.92; 95% confidence interval [CI], 2.37-3.59) than among poor urban children (1.58; 95% CI, 1.18-2.13). The prevalence of wasting was not influenced by socioeconomic status. Both rural and poor urban children were significantly less likely to be overweight than were non poor urban children: in comparison with non poor urban children, the OR values were 0.19 (95% CI, 0.10-0.36) for rural and 0.13 (95% CI, 0.04-0.43) for poor urban children. Boys were more likely to be stunted or obese than girls: OR for stunting, 1.75 (95% CI, 1.44-2.12); OR for obesity, 4.07 (95% CI, 1.40-11.8). Stunted children were less likely than non-stunted children to be overweight: OR, 0.10 (95% CI, 0.03-0.43). In Indonesia, under nutrition is still related to poverty, whereas obesity is more related to prosperity.

Equity

Jus'at I, Achadi EL, Galloway R, Dyanto A, Zazri A, Supratikto G, et al. Reaching young Indonesian women through marriage registries: an innovative approach for anemia control. The Journal of Nutrition. 2000.

This paper evaluates an anaemia control program for newlywed women implemented by the Indonesian Ministry of Health and the MotherCare project. As part of an existing program to counsel couples about marriage and require them to obtain tetanus toxoid immunisation before obtaining a marriage certificate, women also were counselled to buy and take 30-60 iron-folate (IFA) tablets. Women (n = 344) were enrolled from one of three participating districts in South Kalimantan, Indonesia. Results/Conclusions: This study found that reaching Indonesian women with an educational intervention before pregnancy through the marriage registration system and making low cost IFA tablets available in the community were effective ways in which to decrease anaemia and improve their iron status. There was a 40% decrease in anaemia prevalence between baseline and the first monitoring (1 mo after the baseline). Among women anaemic at baseline, the increase in haemoglobin was significant.

MNCH interventions

Koblinsky M. Indonesia, 1990 -1999. In: Reducing Maternal Mortality: Learning from Bolivia, China, Egypt, Honduras,

This book section discusses case studies in Indonesia with a view of addressing the issue of how maternal mortality can be reduced significantly over the course of a single decade. These case studies also inform the current debate on whether it is wiser to invest first in skilled birth attendants or in the care of obstetric emergencies, or both at once.

Maternal mortality Strategies/Constraints

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Indonesia, Jamaica, and Zimbabwe. World Bank. 2003.

Results/Conclusions: The strategy of a midwife in each village has clearly resulted in a dramatic increase in skilled birth attendance, but not as yet in any increase in specialised obstetric care for the women needing it. Although midwives may have treated more complications at home, it is unlikely they could have prevented or treated most of the severe complications that require a hospital intervention to save the woman's life. Despite government's efforts to overcome financial constraints for the poor during the economic crisis, high costs of emergency interventions may well have remained the most important obstacle to use of hospital care.

Levin CE, Nelson CM, Widjaya A, Moniaga V, Anwar C. The costs of home delivery of a birth dose of hepatitis B vaccine in a prefilled syringe in Indonesia. Bulletin of the World Health Organization. 2005.

This paper aims at providing the global policy-makers with decision-making information for developing strategies for immunisation of infants with a birth dose of hepatitis B vaccine. This paper presents a retrospective cost analysis, conducted in Indonesia, of delivering this vaccine at birth using the Uniject prefill injection device. The incremental costs or cost savings associated with changes in the hepatitis B immunisation programme were calculated using sensitivity analysis to vary the estimates of vaccine wastage rates and prices for vaccines and injection devices, for the birth dose of hepatitis B vaccine. Results/Conclusions: The introduction of hepatitis B vaccine prefilled in single-dose injection devices (Uniject - a trademark of BD, Franklin Lakes, NJ, USA) for use by midwives for delivering the birth dose is cost-saving when the wastage rate for multidose vials is greater than 33%. The introduction of HB-Uniject for birth-dose delivery is economically worthwhile and can increase coverage of the critical birth dose, improve resource utilisation, reduce transmission of hepatitis B and promote injection safety.

MNCH Interventions

Lieberman S, Marzoeki P. Indonesia health strategy in a post-crisis, decentralizing Indonesia. World Bank. 2000. (http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2001/03/30/000094946_01011305321862/Rendered/PDF/multi0page.pdf)

The focus of the paper is on the anticipated impacts of the 2001 decentralisation reform on the health system. The paper also gives an overview of the health system in 2000 including disparities between the wealthiest and poorest quintiles in infant mortality and nutrition. The report describes the health system performance, and costs in the country. Results/Conclusions: The potential health system benefits, associated with decentralisation, will enable citizens to become involved systematically in decisions regarding health policy, design, and financing, as well as influencing service provision. However, mixed results proved great imbalances, for low income families lagged behind other quintiles in terms of infant mortality rates, prevalence of specific diseases, and nutrition problems, while households in the top expenditure distribution, proved high uses of public facilities, compared to the bottom expenditure distribution. The pre-crisis policy is examined, i.e., the impacts on the provider-client equation; and, policy options offer opportunities through decentralisation, reform related issues, and effective partnerships with non-governmental organisations.


Lieberman SS, Capuno JJ, Minh HV. Chapter 8 - Decentralizing

This chapter examines the decentralisation experience of three East Asian countries from the perspective of how well they have addressed the special features and requirements of the health sector. This chapter outlines


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Health: Lessons from Indonesia, the Philippines, and Vietnam. In: East Asia Decentralizes: Making Local Government Work. World Bank. 2005.

the decentralisation health policies and programs of Indonesia, the Philippines, and Vietnam, focusing on the period 1985-2003, spanning the years before and after significant decentralisation began in these countries. Results/Conclusions: Decentralisation in Indonesia, the Philippines, and Vietnam may help sustain overall improvements in health that have occurred during the last two decades. Decentralisation has appeared to spur local initiative in planning, delivering, and financing services. However, weakness in decentralisation policy also contributed to lower-than-expected health payoffs. These include ambiguities in goals, lack of detailed design, inconsistency with other policies, and poorly thought-out implementation strategy. Inconsistent priorities have translated into inconsistencies in policies and poor design of policy instruments, especially the inter-governmental fiscal transfer system.

MacDonald S, Moralejo M, Mathews M. Maternal understanding of diarrhoea-related dehydration and its influence on ORS use in Indonesia. Asia Pacific Journal Public Health. 2007.

This study aimed at assessing whether mothers' understanding of diarrhoea-related dehydration influenced their use of ORS in home treatment. The study utilised a cross-sectional design to survey a sample of mothers of children under the age of five years, with data collection taking place in the village of Waru Jaya in the West Java, a district in Indonesia, between August and October 2001. One hundred mothers of children under the age of five years in rural Indonesia were surveyed using a structured questionnaire, administered in an interview format in their homes. Results/Conclusions: Only 38 (38%) of the mothers surveyed could identify two or more correct signs of dehydration. Significant relationship was found between maternal knowledge of correct signs of dehydration and the use of ORS in home treatment (OR 3.36, 95% CI 1.24, 10.63). Resulting recommendations include improved health education programming for mothers of young children, as well as future programme evaluation and intervention studies.

MNCH Interventions

Madi BC, Hussein J, Hounton S, D'Ambruoso L, Achadi E, Arhinful DK. Setting priorities for safe motherhood programme evaluation: a participatory process in three developing countries. Health Policy. 2007.

This paper reports author’s experiences and lessons learnt in implementing a participatory process of setting a research and evaluation agenda. Its main thrust is on country focused priority setting for safe motherhood programme evaluation, which is related to the 5th Millennium goal of improving maternal health. It describes a process involving key stakeholders to elicit and prioritise evaluation needs for safe motherhood in three developing countries (Burkina Faso, Ghana and Indonesia). A series of reiterative consultations with safe motherhood stakeholders from each country was conducted over a period of 36 months. In each country, the consultation process consisted of a series of participatory workshops; firstly, stakeholder's views on evaluation were elicited with parallel descriptive work on the contexts. Secondly, priorities for evaluation were identified from stakeholders; thirdly, the evaluation-priorities were refined; and finally, the evaluation research questions, reflecting the identified priorities, were agreed and finalised. Results/Conclusions: Three evaluation-questions were identified in each country, and one selected, on which a

MNCH Interventions



full scale evaluation was undertaken. While there is a great deal written about the importance of transparent and participatory priority setting in evaluation; few examples of how such processes could be implemented exist, particularly for maternal health programmes. Our experience demonstrates that the investment in a participatory priority-setting effort is high but the process undertaken resulted in both globally and contextually-relevant priorities for evaluation. This experience provides useful lessons for public health practitioners committed to bridging the research-policy interface.

Makowiecka K, Achadi E, Izati Y, Ronsmans C. Midwifery provision in two districts in Indonesia: how well are rural areas served. Health Policy & Planning. 2008.

This study examines the village-based midwife programme by describing the provision of midwifery services in two districts, Serang and Pandeglang, in Banten Province on Java, Indonesia. This paper examines the midwives’ professional characteristics and their place of work relative to the population and area that they serve, and discuss the place of workforce density in a strategy to reduce maternal mortality. The data sources were: (1) a questionnaire for all the listed midwives and nurses on their professional characteristics, (2) a questionnaire on their clinical work in the villages, (3) data from the National Statistical Office for the size and population of each village, and (4) field staff generated data on distances from a village to the nearest public hospital within the study area using Geographic Positioning Systems. Results/Conclusions: 10% of villages do not have a midwife but a nurse as a midwifery provider; there is a deficit in midwife density in remote villages compared with urban areas; those assigned to remote areas are less experienced; midwives manage few births and this may compromise their capacity to maintain professional skills; over 90% of non-hospital deliveries take place in the woman’s (64%) or the midwifes (28%) home; three-quarters of midwives did not make regular use of the fee exemption scheme; midwives who live in their assigned village spend more days per month on clinical work there. Changing the policy from home births to births in facilities within the community would improve the quality of care received by mothers, provide an environment where midwives get more experience and improve access to emergency obstetric care during complications.

Equity MNCH interventions Constraints/Strategies

Marzolf J. Indonesia's private health sector: Opportunities for reform: An analysis of the obstacles and constraints to growth. World Bank. 2002. (http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/I

The paper analyses the private health care as an alternative to the inadequate services being provided by public sector. In doing so it provides an overview of the health system in Indonesia looking at expenditure, personnel, infrastructure, finance, tax reform and the capacity of the Ministry of Health among other topics covered. This report describes the public and private provision of health care, discusses expenditures, hospital assets, the availability of health care personnel, health care infrastructure, health care training facilities, health care financing and taxation, foreign investment in the health sector, health care reform efforts, medical services demand, Ministry of Health capacity, and government subsidisation in the health sector. Results/Conclusions: The Indonesian health care system is inadequate to meet the needs of the country's

Constraints/Strategies Funding/costing

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B/2005/11/10/000160016_20051110165704/Rendered/PDF/342300IND0Private1Health1Sector01PUBLIC1.pdf)

population. Unless major changes can be effected and more emphasis is given to private healthcare, the adequacy of the system will continue to decline and the hard won gains in health status of the last three decades will be jeopardised. There is a need for new strategies and approaches to meet the healthcare needs of the Indonesian people in which private health care will play a larger role. The report offers near term and long terms recommendations.

McDermott J, Beck D, Buffington ST, Annas J, Supratikto G, Prenggono D, et al. Two models of in-service training to improve midwifery skills: how well do they work? Journal of Midwifery & Women's Health. 2001.

This study evaluated the Safe Motherhood Initiative launched in Indonesia in 1989. Three evaluation tools were created to measure changes in the village midwives’ knowledge, confidence, and skills. The five key skills compared were prevention of infection, use of the partograph, manual removal of placenta, bimanual uterine compression, and neonatal resuscitation. For qualitative data collection, an interview guide was used for interviewing midwives. Results/Conclusions: Midwives from the intensive in-service that combined competency-based skill training with peer review and continuing education scored higher on the knowledge test and demonstration of the five key skills and reported managing complications better than midwives who attended no training program. Midwives from the internship program scored intermediate between the intensively trained and the untrained midwives. Overall, skill scores were 71% for midwives in the intensive program, 62% for the interns, and 51% for midwives with no in-service training. Village midwives from the intensive program scored significantly higher in the practical demonstration of manual removal of placenta, bimanual compression, and neonatal resuscitation than the interns, but the scores on infection prevention and use of the partograph were not different between the two groups. Differences in the volume of training opportunities between the two programs could be responsible for the different outcomes.

MNCH Interventions

Ministry for National Development Planning, UNDP. Report on the Achievement of Millennium Development Goals Indonesia. Ministry for National Development Planning/National Development Planning Agency. 2007. (http://www.undp.or.id/pubs/docs/MDG%20Report%202007.pdf)

The aim of this report is to review the progress made on MGDs since 1990 to 2007. The report briefly explains the challenges being faced and the efforts needed to achieve the various targets under the MDGs The regional challenges are highlighted. Results/Conclusions: Considering the present trend, reaching the maternal mortality target will be indeed quite difficult. Projections show that a MMR of 163 deaths per 100,000 live births may be reached by 2015 against the MDGs target of 102. To achieve this target, health policies should improve the number, network, and quality of community health care centres, accompanied by improving the number and capacity of health workers. Improving the safety of mothers during childbirth remains a major challenge. The Government has announced it will launch the Health Indonesia 2010: Making Pregnancy Safer (MPS) program which focuses on a systematic and integrated planning approach in medical interventions, as well as placing emphasis on partnerships. In order to improve access for poor communities, efforts need to focus on developing the health

Maternal Mortality Under-5 Mortality Equity Constraints/Strategies

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insurance system. Regional governments have limited knowledge about the MDGs. This also true for most of the members of DPRD, civil society organisations, and the general public. There is ignorance of the region of their obligation to adopt the MDGs - an international commitment - as the commitment of the region. This requires serious attention of the Central Government.

Ministry of Health, World Health Organization. Indonesia's reproductive health profile. Ministry of Health. 2003. (http://www.searo.who.int/LinkFiles/Reporductive_Health_Profile_RHP-Indonesia.pdf)

This report provides the reproductive health information in Indonesia until 2003. It includes the reproductive health status of the population, their access to services, current programmes, the policy environment and financing schemes. In addition, it outlines the challenges regarding reproductive health services within the health system. The data sources include Demographic Health Surveys (1997 and 2002/3) and other surveys on welfare. Results/Conclusions: The health system is not adequately prepared to deal with birth related complications. A delay in referrals and handling of cases causes 92% of maternal deaths in emergency cases. Furthermore, availability of obstetricians and surgical emergencies interventions in rural districts affected the quality and access of emergency obstetric care. Although midwives are more accessible they face challenges such as lack of supervision, insufficient coverage and transportation. Funding for reproductive health services from the government continues to be inadequate. Coverage of emergency obstetric services has to extend to rural areas for maternal deaths to decrease. Quality and access to obstetric care has improved very little mainly because of insufficient doctors.

MNCH Interventions Maternal Mortality Constraints/Strategies

Moench-Pfanner R, de Pee S, Bloem MW, Foote D, Kosen S, Webb P, et al. Food-for-work programs in Indonesia had a limited effect on anemia. Journal of Nutrition. 2005.

This independent evaluation assessed the effect of the Food for Work (FFW) programs on nutrition outcomes, particularly anaemia. A quasi-experimental design was used in which 1500 beneficiary and 1500 control households were randomly selected and followed in each of 3 urban and 2 rural sites. Baseline data were collected before program implementation and subsequently at approximately 6-months intervals for 2.5 years. Results/Conclusions: The poor were found to be appropriately targeted, and program participation ranged from 4 to 18 months. The proportion of households with debts ranged from 32 to 70%; although it was higher among beneficiaries than controls, it increased among controls, but not beneficiaries. However, only among urban poor mothers in Surabaya were the odds of anaemia at end line lower when participating in the FFW program (0.60, 95%CI [0.40-0.89]). Other risk factors for anaemia in mothers and children included nutritional status (anaemia at baseline, low BMI, receipt of vitamin A capsule, child age) and socioeconomic status (maternal education, having official residency in the area, income level). Thus, post crisis FFW programs had limited effect on anaemia, the main identified nutritional problem. Closer attention is required to the potential for affecting nutritional outcomes through FFW, including food aid quality and quantity and complementary non-food interventions. Micronutrient deficiencies should be addressed directly via supplements and fortified


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foods.

Mukherjee N. Voices of the poor: Making services work for the poor in Indonesia. World Bank. 2006. (http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2007/02/20/000020953_20070220102819/Rendered/PDF/386390IND0Voice0of0the0poor01PUBLIC1.pdf)

This report aims to provide analytical support for the Indonesian Government's efforts to improve access to and quality of basic services for the poor in the wake of the decentralisation. The purpose is to summarise the status of basic service delivery for the rural and urban poor from their perspective. Includes a look at health, water and sanitation services which influence progress of MDGs 4&5. This study focused on eight types of key services: antenatal services, childbirth assistance, curative services for 0 to 2 month old infants, curative services for >2 months to 5 year old children, primary schooling, transition to secondary schooling, clean water services, sanitation facilities (excreta disposal). Results/Conclusions: High malnutrition, maternal and infant mortality, and low education can be directly traced back to failings in these services. The charging of fees by trained midwives resulted in the poor preferring services from traditional birth attendants (TBAs). Low demand for trained midwives was the main reason births were not assisted by skilled attendants instead of lack of access to these services. This was due in part to insufficient information regarding additional benefits of midwives over TBAs. Indonesia adopted a policy of subsidised public services aimed at the poor including the health card. However, insufficient information regarding this service among the poor meant that it was underutilised.

Constraints/Strategies Equity

Muslimatun S, Schmidt MK, Schultink W, West CE, Hautvast JGAJ, Gross R, et al. Weekly Supplementation with Iron and Vitamin A during Pregnancy Increases Hemoglobin Concentration but Decreases Serum Ferritin Concentration in Indonesian Pregnant Women. Journal of Nutrition. 2001.

This study investigated whether weekly iron supplementation was as effective as the national daily iron supplementation program in Indonesia in improving iron status at near term in pregnancy. In addition, authors examined whether weekly vitamin A and iron supplementation was more efficacious than weekly supplementation with iron alone. One group of pregnant women (n = 122) was supplemented weekly with iron (120 mg Fe as FeSO4) and folic acid (500 {micro} g); another group (n = 121) received the same amount of iron and folic acid plus vitamin A [4800 retinol equivalents (RE)]. A third ("daily") group (n = 123), participating in the national iron plus folic acid supplementation program, was also recruited. Data on subjects with complete biochemical data are reported (n = 190). Results/Conclusions: At near term, haemoglobin concentrations increased, whereas serum ferritin concentrations decreased significantly in the weekly vitamin A and iron group, suggesting that vitamin A improved utilisation of iron for haematopoiesis. Iron status in the weekly iron group was not different from that of the "daily" group. However, iron status decreased with daily supplementation if <50 iron tablets were ingested. Serum transferring receptor concentrations increased in all groups (P < 0.01). Serum retinol concentrations were maintained in the weekly vitamin A and iron group, but decreased in the other two groups (P < 0.01). Thus, delivery of iron supplements on a weekly basis can be as effective as on a daily basis if compliance can be ensured. Addition of vitamin A to the supplement improved haemoglobin concentration.

MNCH Interventions

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Nuraini E, Parker E. Improving knowledge of antenatal care (ANC) among pregnant women: a field trial in central Java, Indonesia. Asia-Pacific Journal of Public Health. 2005.

The purpose of this study is to assess whether a new approach to antenatal care (ANC) will improve knowledge of its benefits in pregnant women. An experimental design with 60 pregnant women from 10 cluster villages is used in this study. The intervention group received the new approach to ANC, while the control group received routine ANC. Results/Conclusions: The findings show that the improvement of knowledge in the intervention group is significant particularly in the knowledge about healthy pregnancy (p=0.012), pregnancy complications (p=0.01), safe birth (p=0.01) and taking care of the newborn (p=0.012). The improvement of knowledge was significantly influenced by the respondents' educational back ground (p=0.002) and socio-economic status (p=0.027). This study recommends that the new approach to ANC be considered to educate pregnant women regarding safe birth and it is considered as one of the strategies that may be adopted to reduce maternal mortality.


Poerwanto S. The Inequality in Infant Mortality in Indonesia: Evidence-based Information and its Policy Implications. The University of Western Australia. 2003.

The aims of the study were twofold; firstly, to describe the inequality in infant mortality in Indonesia namely, to look at the extent and magnitude of the problem in terms of the estimated number of infant deaths, the differentials in infant mortality rates, the probability of infant deaths across provinces, urban and rural areas, and across regions of Indonesia. Secondly, to examine the effect of family welfare status and maternal educational levels on the probability of infant deaths. The study design was that of a population-based multistage stratified survey of the 1997 Indonesian Demographic and Health Survey. The study population was a sample of 28,810 reproductive women aged 15 to 49 years who belonged to 34,255 households. The variables of interest were related to socio-economic status, measured by Family Welfare Status Index and maternal educational levels. Results/Conclusions: There are inequalities in infant mortality across administrative divisions of the country, represented by provinces and regions, as well as across residential areas, namely urban and rural areas. There is socio-economic inequality in infant mortality, as indicated by a dose-response effect across strata of family welfare and maternal educational levels, both individually and interactively. Both inequality of family income and lack of maternal education increase the probability of infant death, inferring that infant mortality is significantly associated with family welfare status and maternal education, after adjusting for risk factors. The changes of population health-related policies in Indonesia that are likely to significantly reduce the risk of infant mortality are indicated. There is an urgent need to significantly reduce the burden of excess infant mortality suffered by the poorly educated and low-income populations.

Equity Under-5 Mortality

Poerwanto S, Stevenson M, de Klerk N. Infant mortality and family welfare: policy

This population based multistage stratified clustered survey examines the effect of family welfare index (FWI) and maternal education on the probability of infant death. The study population is women aged 15-49 (n=28,810) in Indonesia between 1983–1997. The data source is the 1997 Indonesian Demographic and Health

Under-5 Mortality



implications for Indonesia. Journal of Epidemiology & Community Health. 2003.

Survey. Results/Conclusions: Main results: Infant mortality was associated with FWI and maternal education. Relative to families of high FWI, the risk of infant death was almost twice among families of low FWI (aOR=1.7, 95%CI=0.9 to 3.3), and three times for families of medium FWI (aOR=3.3, 95%CI=1.7 to 6.5). Also, the risk of infant death was threefold higher (aOR=3.4, 95% CI=1.6 to 7.1) among mothers who had fewer than seven years of formal education compared with mothers with more than seven years of education. Fertility related indicators such as young maternal age, absence from contraception, birth intervals, and prenatal care, seem to exert significant effect on the increased probability of infant death. The increased probability of infant mortality attributable to family income inequality and low maternal education seems to work through pathways of material deprivation and chronic psychological stress that affect a person’s health damaging behaviours. The policies that are likely to significantly reduce the family’s socioeconomic inequality in infant mortality are implicated.

Rokx, C, Schieber, G, Harimurti, P, Tandon, A and Somanathan, A. Health Financing in Indonesia. A Reform Road Map. World Bank 2009

This report provides a comprehensive overview of health financing functions in Indonesia in the context of the main strengths and weaknesses of the current system and the future challenges posed by epidemiological and socio-economic factors. It examines the health financing system under decentralization and assesses its performance with a focus on efficiency and equity. Results/Conclusions: The Report presents the evidence available for future health financing reforms and suggests critical policy issues that need to be addressed in particular for the implementation of universal coverage. They include a stronger health information system that would provide the required data for decision making; addressing supply-side constraints on both human resources and physical infrastructure; examining alternative provider payment mechanism; assessing local schemes of health insurance and clarification of roles of different levels of government under decentralization.


Ronsmans C, Endang A, Gunawan S, Zazri A, McDermott J, Koblinsky M, et al. Evaluation of a comprehensive home-based midwifery programme in South Kalimantan, Indonesia. Tropical Medicine & International Health. 2001.

This study evaluates a midwifery programme in three districts within South Kalimantan, Indonesia. This programme consisted of the training, deployment and supervision of a large number of professional midwives in villages, an information, education and communication (IEC) strategy to increase use of village midwives for birth, and a district-based maternal and perinatal audit (MPA). Data was collected from the results of supervision and audit of midwives (n=510) posted in the districts. Results/Conclusions: Home births which make up 90% of all births experienced an increase in the presence of skilled birth attendants from 37% to 59% between 1997 and 1999. Access to health facilities for emergency obstetric complications did not increase however. The strategy of having a midwife in every village has increased access to skilled attendance at birth. However, emergency obstetric care also needs to be accessible by removing their high cost.




Ronsmans C, Scott S, Adisasmita A, Deviany P, Nandiaty F. Estimation of population-based incidence of pregnancy-related illness and mortality (PRIAM) in two districts in West Java, Indonesia. Bjog-An International Journal of Obstetrics & Gynaecology. 2009.

This cross-sectional study of maternal morbidity and mortality introduces a new and untested approach for the measurement of life-threatening maternal morbidity in populations where not all women give birth in a health facility. All cases of life-threatening obstetric morbidity in hospitals and all maternal deaths in the population were counted to describe the incidence of life-threatening morbidity in the total population, to examine its variation across geographical areas and to investigate its relationship with maternal mortality. this study was conducted in Serang and Pandeglang district in West Java, Indonesia. Results/Conclusions: The incidence of maternal mortality and life-threatening complications at the population level was 421 and 1416 per 100 000 births, respectively, resulting in an overall ratio of Pregnancy-related illness and mortality (PRIAM) of 1837 per 100 000. The overall incidence of PRIAM was much lower in rural than in urban areas (1529 and 2880 per 100 000, respectively, P < 0.001), and it was lowest in rural Serang (1304 per 100 000). The approach tested in this study-relying on conditions that are 'absolutely' life-threatening such that their count in hospitals can be used to represent the incidence in the general population-is promising but needs further testing in populations with varied disease epidemiology and access to care. Continued investments in hospital-based audits of life-threatening morbidity may ultimately improve the quality and reliability of information on obstetric complications and facilitate the development of rigorous and standard criteria for the definition of life-threatening morbidity.

Maternal Mortality MNCH Interventions

Ronsmans C, Scott S, Qomariyah SN, Achadi E, Braunholtz D, Marshall T, et al. Professional assistance during birth and maternal mortality in two Indonesian districts. Bulletin of the World Health Organization. 2009.

This study examines determinants of maternal mortality and assesses the effect of programmes aimed at increasing the number of births attended by health professionals in two districts in West Java, Indonesia. The authors used informant networks to characterise all maternal deaths, and a capture-recapture method to estimate the total number of maternal deaths. All midwives practising in the two study districts were counted through a survey of recent births. The case-control analysis was employed to examine determinants of maternal mortality, and cohort analysis to estimate overall maternal mortality ratios. Results/Conclusions: The overall maternal mortality ratio was 435 per 100,000 live births. Only 33% of women gave birth with assistance from a health professional, and among them, mortality was extremely high for those in the lowest wealth quartile range (2303 per 100,000) and remained very high for those in the lower middle and upper middle quartile ranges (1218 and 778 per 100,000, respectively). This is perhaps because the women, especially poor ones, may have sought help only once a serious complication had arisen. Achieving equitable coverage of all births by health professionals is still a distant goal in Indonesia, but even among women who receive professional care, maternal mortality ratios remain surprisingly high. This may reflect the limitations of home-based care. Phased introduction of fee exemption and transport incentives to enable all women to access skilled delivery care in health centres and emergency care in hospitals may be a feasible, sustainable way to reduce Indonesia's maternal mortality ratio.

Maternal Mortality



Sekiyama M, Ohtsuka R, Sekiyama M, Ohtsuka R. Significant effects of birth-related biological factors on pre-adolescent nutritional status among rural Sundanese in West Java, Indonesia. Journal of Biosocial Science. 2005.

Based on an anthropometric measurement and interview survey, this study was conducted among of 310 children aged 5-12 years in a rural Sudanese village, Sukajadi, located in Bogor district, West Java. This study examined the relative significance of the effects of eight biological, eight socioeconomic status (SES) and four health behavioural factors on their Z scores for height-for-age (HAZ) and weight-for-age (WAZ) in particular. Results/Conclusions: Three biological factors, i.e. birth interval, birth weight and mother's body weight, and one SES factor, i.e. mother's occupation, were selected as the predictors of the two Z scores by regression analysis, indicating more significant effects of the biological factors than the other factors. This pattern is judged to occur in less-developed and high-fertility populations. The birth-related biological factors lasted up to, or were strengthened in, pre-adolescent ages, implying the need for more attention to be paid to the nutritional status or growth pattern of this age group. In order to mitigate this vulnerable situation, of all the determining factors revealed in this study, birth interval is the one that can be changed most easily. Thus, effective family planning programmes are needed to elevate the nutritional status of not only young children but also pre-adolescent children.

MNCH interventions

Semba R, Munasir Z, Akib A, Melikian G, Permaesih D, Marituti S. Integration of vitamin A supplementation with the Expanded Programme on Immunization: Lack of impact on morbidity or infant growth. Acta Paediatrica, International Journal of Paediatrics. 2001.

This randomised, double-blind, placebo-controlled clinical trial aims to evaluate the impact of linking vitamin A supplementation with the Expanded Programme on Immunisation on morbidity and child growth. In West Java, Indonesia, 467 six-week-old infants were randomised to receive 7.5 mg retinol equivalent (RE), 15 mg RE, or placebo with childhood immunisation contacts at 6, 10, and 14 wks and 9 mo of age. Child growth was assessed through anthropometry, and morbidity histories were obtained. Results/Conclusions: Vitamin A supplementation had no apparent impact upon linear or ponderal growth or infectious disease morbidity in the first 15 months of age when integrated with the Expanded Programme on Immunisation. Although improving vitamin A nutriture is of general importance in reducing diarrhoeal and measles morbidity and mortality in developing countries, this clinical trial showed no apparent benefit of vitamin A capsules for infant health when given through childhood immunisation programs.

MNCH interventions

Setiana A. Social Health Insurance Development as an Integral Part of National Policy: Recent Reform in the Indonesian Health Insurance System. In: Extending Social Protection in Health - Developing Countries’

This conference paper (presented in international Conference on Social Health Insurance in Developing Countries in Berlin in December 2005) discusses the existing implementation of Social Health Insurance (SHI) in Indonesia, the expansion of coverage to 60 million poorest Indonesians and the political and economic implications of extending social health insurance coverage to 220 million people. A qualitative analysis, including discussions on the political processes involved, conflicts of interests, opposition to the concept, and the prolonged debates on the expansion of coverage as a National Health Policy, is presented. Results/Conclusions: In accordance with Indonesia’s National Health Policy, the right to health care has been included in the Constitution amended in 2002. Coverage by social health insurance is dominated by formal

Equity Constraints/Strategies



Experiences: Lessons Learnt and Recommendations. GTZ. 2007.

sector employees and beneficiaries of government subsidised contribution (Askeskin). In the formal sector, coverage extends to all civil servants, military personnel, police personnel, veterans, and less than 5 % of private sector employees. In 2005, the government underpinned its strong commitment to increase access to health care by paying social health insurance contributions for the poor as prescribed by the SJSN Law of 2004. This program, known as Askeskin, is the largest expansion of health insurance in Indonesian history. Within two years, the Askeskin program extended coverage to about 60 million low-income people across Indonesia and improved access to health care significantly. The program is expected to accelerate the reduction of maternal and infant mortality, thereby speeding up the attainment of Millennium Development Goals. However, substantial implementation challenges remain.

Shankar A, Sebayang S, Guarenti L, Utomo B, Islam M, Fauveau V, et al. The village-based midwife programme in Indonesia. Lancet. 2008.

The paper reviews the impact of the village-based midwife programme launched in 1989 by Government of Indonesia and explores the factors that progress was made, but why was it not greater? Results/Conclusions: These factor include: 1. compromised candidate selection and quality of training due to the push for rapid deployment, 2. Inadequate supervision and mentoring, 3. limited access and financial support for referral to emergency obstetric-care centres, 4. substantial declines in health expenditures due to severe economic crisis in 1997, and 4. reduced influence of the Ministry of Health and further diminished health spending subsequent decentralisation. For scaling up such initiatives, reduction of maternal and newborn mortality requires a health-systems approach. It should be driven by local evidence, be tailored to conditions within each country and district, and be sustainable. In addition to providing quality care for all births, affordable and accessible high quality emergency obstetric care is essential. Monitoring and assessment are integral to maintenance of quality of care while increasing skilled birth attendance.


Shankar AV, Asrilla Z, Kadha JK, Sebayang S, Apriatni M, Sulastri A, et al. Programmatic effects of a large-scale multiple-micronutrient supplementation trial in Indonesia: Using community facilitators as intermediaries for behavior change. Food & Nutrition Bulletin. 2009.

This analysis documents the programmatic impacts of Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT) on health-seeking and early infant mortality resulting from community facilitators' field activities. The SUMMIT, a randomised, controlled clinical trial in Lombok, Indonesia, found that supplementation during pregnancy with multiple micronutrients reduced 90-day infant mortality by nearly 20% as compared with iron-folic acid. This trial was designed as both a program and research trial and used community facilitators to serve as liaisons between the study and the pregnant women. Data on compliance, human resource practices, health-seeking, and health outcomes from the 31,290 SUMMIT enrolees were analysed. Results/Conclusions: Overall compliance with either iron-folic acid or multiple micronutrients was high in the program, at 85.0%. Early prenatal care visits increased significantly. Sixty-three percent of primiparous women used a skilled birth attendant (SBA); among multiparous women, the rate of use of a SBA rose from 35% for the

Under-5 Mortality MNCH interventions



last birth to 53%. Use of a SBA resulted in a 30% reduction in early infant mortality (RR, 0.70; 95% CI, 0.59 to 0.83; p <.0001), independently of any reductions due to multiple micronutrients. The community facilitators played a central role in improving health-seeking; however, the quality of the community facilitators' performance was associated with the impact of the micronutrient supplement on infant health. Systematic enhancements to the quality of implementation of SUMMIT led to significant increases in use of SBAs at delivery, resulting in a 30% reduction in early infant mortality independent of the impact of micronutrient supplementation. Therefore, if women were to consume multiple micronutrients on a regular basis and were to use a SBA at delivery, the risk of early infant mortality could be reduced by nearly 50%. The impacts of community facilitators in effecting changes in women health behaviours are notable and are applicable to other health programs.

Shefner-Rogers CL, Sood S, Shefner-Rogers CL, Sood S. Involving husbands in safe motherhood: effects of the SUAMI SIAGA campaign in Indonesia. Journal of Health Communication. 2004.

This research assesses the impact of the multi-media campaign on knowledge and active involvement of husbands (alertness) during and after child delivery. The authors present findings from an evaluation survey of the Suami SIAGA Campaign implemented in Indonesia in 1999/2000. The primary purpose is to understand the value added to the effects of media exposure by interpersonal communication about these campaign messages, and the impacts of this added value on intended behaviour change. The secondary purpose is to discuss the potential of involving men in birth preparedness activities that contribute to reducing maternal mortality. Results/Findings: When husbands were directly exposed to the messages from the Suami SIAGA campaign, new knowledge gain and birth preparedness activities occurred. However, the interaction of direct exposure to the campaign and the interpersonal communication stimulated by the campaign about Suami SIAGA was an even stronger predictor of knowledge gain and birth preparedness actions. Limitations of the study included post-only measures and a relatively short time period between the intervention and impact evaluation. The communication campaigns to educate husbands and to stimulate discussion about the innovative concept of birth preparedness may contribute to improved birth outcomes in Indonesia.


Shields L, Hartati LE, Shields L, Hartati LE. Primary care in Indonesia. Journal of Child Health Care. 2006.

This editorial gives a description of primary health care services for children in Indonesia and assesses services provided by the health care system (private and public) for children. Results/Conclusions: Primary Health Care clinics and hospitals are funded by the government. Over a third of hospitals in Indonesia are private. The quality of care available in these ranges from being well resourced to being understaffed. There are Hospitals in sub districts and health stations (community level). But, in remote areas services tend to be more sporadic. The government is trying to overcome these challenges by providing services to the village community and improving the nursing curricula so that it is more responsive to




community needs. Patients bear most of the burden for care including paying for admission, bed, nursing care, food and all medicines and materials used to treat them. This is a constraint for the poor to access health care. Nursing education now goes as far as university level. This is a good incentive to obtain and retain nurses particularly in remote areas where they are needed most.

Shiffman J. Generating political will for safe motherhood in Indonesia. Social Science & Medicine. 2003.

The paper presents a case study of the emergence, waning and re-generation of political priority for safe motherhood in Indonesia over the decade 1987-1997, to highlight how these four factors interacted to raise safe motherhood from near obscurity in the country to national-level prominence. Data was collected through conducting interviews, observing program implementation and collecting government documents and local research reports on safe motherhood, family planning and child immunisation policy. Results/Conclusions: Drawing from a scholarly literature on agenda setting, this paper identifies four factors that heighten the likelihood that an issue will rise to national-level attention: the existence of clear indicators showing that a problem exists; the presence of effective political entrepreneurs to push the cause; the organisation of attention-generating focusing events that promote widespread concern for the issue; and the availability of politically palatable policy alternatives that enable national leaders to understand that the problem is surmountable. While there are contextual factors that make this case unique, some elements are applicable to all developing countries. The paper draws out these dimensions in the hope that greater knowledge surrounding how political will actually has been generated can help shape strategic action to address this much neglected global problem.


Shrestha R. Family planning, community health interventions and the mortality risk of children in Indonesia The Ohio State University. 2007.

Using the Indonesian Family Life Survey (IFLS) conducted in 1993, 1997 and 2001, this thesis studies the impact of two major government programs on the decline in mortality rates: (1) the national family planning program introduced in 1970 and (2) the village midwife program initiated in 1989. A bivariate probate framework is used to overcome the bias that would arise in a single equation framework due to correlation between contraceptive use and unobserved individual characteristics of the woman. Results/Conclusions: The risk of child mortality reduces by 5% after a woman has used contraceptives, but there is no such effect of contraceptive use on infant mortality. Trained midwives placed in villages through the program provided antenatal, intrapartum and postpartum assistance to village women who would otherwise have relied on traditional birth attendants for help during the birth process. The program is associated with lower neonatal mortality rates, but it had no effect on post-neonatal mortality, which suggests an improvement in the birth process as neonate deaths are primarily caused by infections related to the birth process.

Under-5 Mortality MNCH interventions

Sparrow R, Sparrow R. Targeting This paper looks at targeting performance of the Indonesian health card programme that was implemented in Equity



the poor in times of crisis: the Indonesian health card. Health Policy & Planning . 2008.

August 1998 to protect access to health care for the poor during the Indonesian economic crisis. The key source of data is Indonesia’s main socio-economic survey (Susenas). The analysis starts with a static benefit incidence analysis of health card allocation and utilisation, and then investigates the factors driving observed benefit incidence patterns by focusing on the targeting instruments and barriers at three layers of the targeting process. Results/Conclusions: Targeting of the health card was pro-poor, but with considerable leakage to the non-poor. Utilisation of the health card for outpatient care was also pro-poor, but conditional on ownership, the middle quintiles were more likely to use the card. Targeting of the health card followed a decentralised design combining geographic targeting with community-based targeting instruments. This design facilitated the rapid implementation of the programme, but targeting performance suffered from a lack of information on the regional impact of the crisis, while at local level not all barriers to accessing health care services were overcome by the health card. Indirect and direct costs of seeking health care seem to be the main deterrent to using the health card, and are higher in more remote areas. Micro-simulations show that geographic targeting can contribute considerably to improving targeting performance, but most of the targeting gains are to be made at the local level, with district programme management and public health care providers. This study highlights the need for adequate and up-to-date social welfare indicators. In addition, further research would need to focus on how local knowledge can be utilised for signalling poverty dynamics and local barriers to access.


Supratikto G, Wirth ME, Achadi E, Cohen S, Ronsmans C. A district-based audit of the causes and circumstances of maternal deaths in South Kalimantan, Indonesia. Bulletin of the World Health Organization. 2002.

This paper conducts a district-based audit of maternal and perinatal mortality began during 1994 in three provinces of South Kalimantan, Indonesia. Both medical and non-medical factors were documented and an effort was made to progress from merely assessing substandard care to recommending improvements in access to care and the quality of care. The sources of information included verbal autopsies with family members and medical records, Between 1995 and 1999 the audit reviewed 130 maternal deaths. Results/Conclusions: The leading causes of death were haemorrhage (41%) and hypertensive diseases (32%). Delays in decision-making and poor quality of care in health facilities were seen as contributory factors in 77% and 60% of the deaths, respectively. Economic constraints were believed to have contributed to 37% of the deaths. The distance between a patient's home and a health provider or facility did not appear to have a significant influence, nor did transport problems. The audit led to changes in the quality of obstetric care in the district. Its success was particularly attributable to the process of accountability of both health providers and policy-makers and to improved working relationships between health providers at different levels and between providers and the community. With a view to the continuation and further expansion of the audit it may be necessary to reconsider the role of the provincial team, the need of health providers for confidentiality, the added benefit of facility-based audits, the need to incorporate scientific evidence into the review process, and

Maternal Mortality



the possible consideration of severe complications as well as deaths. It may also be necessary to recognise that village midwives are not solely responsible for maternal deaths.

The SEA-ORCHID Study Group. Use of evidence-based practices in pregnancy and childbirth: South East Asia Optimising Reproductive and Child Health in Developing countries project. PLoS ONE 2008.

This study is evaluating whether a multifaceted intervention to strengthen capacity for research synthesis, evidence-based care and knowledge implementation improves adoption of best clinical practice recommendations leading to better health for mothers and babies. Authors assessed current practices in perinatal health care in four South East Asian countries and determined whether they were aligned with best practice recommendations. Researchers audited 9550 medical records of women and their 9665 infants at nine hospitals; two in each of Indonesia, Malaysia and The Philippines, and three in Thailand between January-December 2005. They compared actual clinical practices with best practice recommendations selected from the Cochrane Library and the World Health Organisation Reproductive Health Library. Results/Conclusions: Evidence-based components of the active management of the third stage of labour and appropriately treating eclampsia with magnesium sulphate were universally practiced in all hospitals. Appropriate antibiotic prophylaxis for caesarean section, a beneficial form of care, was practiced in less than 5% of cases in most hospitals. Use of the unnecessary practices of enema in labour ranged from 1% to 61% and rates of episiotomy for vaginal birth ranged from 31% to 95%. Other appropriate practices were commonly performed to varying degrees between countries and also between hospitals within the same country. Whilst some perinatal health care practices audited were consistent with best available evidence, several were not. They concluded that recording of clinical practices should be an essential step to improve quality of care.

MNCH Interventions

The Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT) Study Group. Effect of maternal multiple micronutrient supplementation on fetal loss and infant death in Indonesia: a double-blind cluster-randomised trial. The Lancet. 2008.

This double-blind cluster-randomised trial in Lombok, Indonesia assesses the effect of maternal supplementation with multiple micronutrients (MMN), compared with iron and folic acid (IFA), on foetal loss and infant death in the setting of routine prenatal care services. 262 midwives were randomly assigned to distribute IFA (n=15486) or MMN (n=15804) supplements to 31290 pregnant women through government prenatal care services that were strengthened by training and community-based advocacy. Women obtained supplements, to be taken daily, every month from enrolment to 90 days post partum. The primary outcome was early infant mortality (deaths until 90 days post partum). Secondary outcomes were neonatal mortality, foetal loss (abortions and stillbirths), and low birth weight. Results/Conclusions: Infants of women consuming MMN supplements had an 18% reduction in early infant mortality compared with those of women given IFA (35·5 deaths per 1000 live births vs 43 per 1000; relative risk [RR] 0·82, 95% CI 0·70-0·95, p=0·010). Infants whose mothers were undernourished (mid upper arm circumference <23·5 cm) or anaemic (haemoglobin <110 g/L) at enrolment had a reduction in early infant mortality of 25% (RR 0·75, 0·62-0·90, p=0·0021) and 38% (RR 0·62, 0·49-0·78, p<0·0001), respectively.

MNCH Interventions Under-5 Mortality



Combined foetal loss and neonatal deaths were reduced by 11% (RR 0·89, 0·81-1·00, p=0·045), with significant effects in undernourished (RR 0·85, 0·73-0·98, p=0·022) or anaemic (RR 0·71, 0·58-0·87, p=0·0010) women. A cohort of 11[punctuation space] 101 infants weighed within 1 h of birth showed a 14% (RR 0·86, 0·73-1·01, p=0·060) decreased risk of low birth weight for those in the MMN group, with a 33% (RR 0·67, 0·51-0·89, p=0·0062) decrease for infants of women anaemic at enrolment. Interpretation Maternal MMN supplementation, as compared with IFA, can reduce early infant mortality, especially in undernourished and anaemic women. Maternal MMN supplementation might therefore be an important part of overall strengthening of prenatal-care programmes.

Thind A. Analysis of health services use for respiratory illness in Indonesian children: Implications for policy. Journal of Biosocial Science. 2005.

The main purpose of this paper is to outline the policy implications of health services utilisation for respiratory illness among Indonesian children. This study uses the Indonesia Demographic and Health Survey to study the determinants of private, public and non-formal provider utilisation for respiratory illness. Multinomial logistic regression models for predicting use were constructed using the Andersen Behavioural Model as the conceptual framework. Results/Conclusions: Age, household size, maternal education, religion, the asset index, location and illness severity play a role in determining use of private, public or non-formal providers. This implies that costs, insufficient information regarding the importance of services provided by the health system and perceived low quality of services are still barriers to accessing the health system. From a policy perspective, the Indonesian government needs be inclusive rather than exclusive in the choice of providers that are contracted by the managed care plans, in order to safeguard the health of the under-five population.


Thind A, Banerjee K. Home deliveries in Indonesia: Who provides assistance? Journal of Community Health. 2004.

This paper aims to understand the determinants of the use of birth attendants by mothers delivering at home and uses the Andersen Behavioural Model as a theoretical framework to understand the determinants of the use of a trained provider, traditional birth attendant, or no trained assistance during home deliveries in Indonesia. The 1997 Indonesia Demographic and Health Survey (IDHS) was used, and data from the most recent home delivery (n=10,692) was abstracted for analysis. Results/Conclusions: Majority (53%) used the services of a TBA, 40% had a doctor, nurse or midwife in attendance, and only 7% delivered with the help of family and/or friends. A multinomial logit model was used to predict determinants of use. The results indicate that maternal education, religion, asset index quartile and number of antenatal visits are significant determinants among all choice sets. There is still an socioeconomic barrier for people to access skilled birth attendants even for home deliveries.


Titaley CR, Dibley MJ, Agho K, Roberts C, Hall J. Determinants

This study aimed to identify the determinants of neonatal mortality in Indonesia, for a nationally representative sample of births from 1997 to 2002. The data source for the analysis was the 2002-2003 Indonesia

Under-5 Mortality Equity



of neonatal mortality in Indonesia. BMC Public Health. 2008.

Demographic and Health Survey from which survival information of 15,952 singleton live-born infants born between 1997 and 2002 was examined. Multilevel logistic regression using a hierarchical approach was performed to analyse the factors associated with neonatal deaths, using community, socio-economic status and proximate determinants. Results/Conclusions: At the community level, the odds of neonatal death was significantly higher for infants from East Java (OR = 5.01, p = 0.00), and for North, Central and Southeast Sulawesi and Gorontalo combined (OR = 3.17, p = 0.03) compared to the lowest neonatal mortality regions of Bali, South Sulawesi and Jambi provinces. A progressive reduction in the odds was found as the percentage of deliveries assisted by trained delivery attendants in the cluster increased. The odds of neonatal death were higher for infants born to both mother and father who were employed (OR = 1.84, p = 0.00) and for infants born to father who were unemployed (OR = 2.99, p = 0.02). The odds were also higher for higher rank infants with a short birth interval (OR = 2.82, p = 0.00), male infants (OR = 1.49, p = 0.01), smaller than average-sized infants (OR = 2.80, p = 0.00), and infant's whose mother had a history of delivery complications (OR = 1.81, p = 0.00). Infants receiving any postnatal care were significantly protected from neonatal death (OR = 0.63, p = 0.03). Public health interventions directed at reducing neonatal death should address community, household and individual level factors which significantly influence neonatal mortality in Indonesia. Low birth weight and short birth interval infants as well as perinatal health services factors, such as the availability of skilled birth attendance and postnatal care utilisation should be taken into account when planning the interventions to reduce neonatal mortality in Indonesia.

UNDP. Goal 5 - Improving maternal health. UNDP. 2004. (http://www.undp.or.id/pubs/imdg2004/English/MDG_IDN_English_Goal5.pdf)

This report gives a brief look at the status and trends MDG5 in Indonesia. Results/Conclusions: Indonesia does not have the vital statistics systems to directly collect information on this indicator. Direct age-specific estimates of maternal mortality from the reported survivorship of sisters were obtained from the series of Indonesia Demographic and Health Surveys (IDHS). With the current trends, the Millennium Development Goal (MDG) target is unlikely to be achieved unless extra efforts are made to reduce the MMR. Besides the medical causes of maternal mortality in Indonesia, this report discusses the challenges of increasing demands. Issues of decentralisation, problems of service delivery and utilisation, and importance of the coordination between institutions and with the donors. Lastly, required policies and programmes are discussed.


UNDP. Goal 4: Reducing child mortality. UNDP. 2004. (http://www.undp.or.id/pubs/i

This report looks at the trends and progress of MDG 4 in Indonesia. Results/Conclusions: The three main causes of infant mortality were acute respiratory infections, prenatal complication and diarrhoea. The high mortality rate of infant aged up to one year was associated with the low

Under-5 Mortality Constraints/Strategies

http://www.undp.or.id/pubs/imdg2004/English/MDG_IDN_English_Goal5.pdf



http://www.undp.or.id/pubs/imdg2005/English/GOAL%204.pdf



mdg2005/English/GOAL%204.pdf)

health status of the mother and the newborn infant, low quality and access to health services, and un-conductive care-seeking behaviour of pregnant women, families and communities. Health protection and services for the poor and the vulnerable groups living in villages and remote areas, as well as in the slums in urban areas is one of the strategic keys to reduce the child mortality rate. The health decentralisation remains a great challenge for health services because institution and personnel roles have not yet been fully addressed. With the implementation of Law No 40/2004 about National Social Security System, improved access to health services will be enhanced by health protection program for the poor, using insurance system with the premiums being paid by the government.

United Nations. United Nations Common Country Assessment Indonesia. United Nations. 2004. (http://www.undp.or.id/pubs/docs/CCA_30Nov2004.pdf)

This report (CCA) aims to provide a comprehensive assessment and analysis of the development situation in Indonesia and to establish a strategic vision for the UN agencies working in the country. This document is the first step to producing a medium term planning framework to support the Government of Indonesia in achieving its national development goals. This planning framework, known as the UN Development Assistance Framework (UNDAF), will cover the period from 2006 to 2010. The overarching framework of this CCA is the Millennium Declaration. The analysis in this document draws on and aims to support existing and on-going national planning processes including the draft Poverty Reduction Strategy Paper (PRSP), the National Human Development Report - that focuses on costing the MDGs in Indonesia - and the government’s Transitional Development Plan 2005 and Medium Term Development Plan 2006-2010. Results/Conclusions: All the MDGs are discussed briefly including a chapter on MDG 4 & 5. This Includes an overview of the health sector including the impact of decentralisation on the health sector, health financing and the burden of disease. Decentralisation has broken the health system into smaller independent health systems. Some are thriving while others are doing poorly. The Ministry of Health is not able to provide adequate monitoring, standards and supervision of the local health authorities. Human resource issues including lack of accountability, low salaries and unclear roles prevail. There are regional variations in child mortality with Yogyakarta having the lowest under five mortality rate. In maternal mortality there are delays in referring complications to hospitals. Although all district hospitals provide emergency obstetric care these are underutilised due to costs. Lastly, three key entry points for increasing the role of the UN in partnership building are highlighted. Firstly, there is potential for UN field level staff at the provincial level to facilitate the exchange of information and explore opportunities coordination between various partners and local government. Secondly, scope for the UN, in collaboration with the World Bank, to support more actively the Consultative Group for Indonesia (CGI) thematic working groups. Thirdly, potential role for the UN system to support the government in coordinating and developing MDG monitoring mechanisms that draw on inputs from all major development partners in Indonesia.


http://www.undp.or.id/pubs/docs/CCA_30Nov2004.pdf

http://www.undp.or.id/pubs/docs/CCA_30Nov2004.pdf



Utomo ID, Arsyad SS, Hasmi EN, Utomo ID, Arsyad SS, Hasmi EN. Village family planning volunteers in Indonesia: their role in the family planning programme. Reproductive Health Matters. 2006.

This paper reports on a study in 1997-98 to investigate the role of the village family planning volunteers in the implementation of the family planning programme in West Java, Central Java and DI Yogyakarta, in Indonesia. A total of 108 village family planning volunteers, 108 family planning cadres, 108 local leaders and 324 couples eligible for family planning from 36 villages in the three provinces were interviewed. Results/Conclusions: The village family planning volunteers have made family planning services and information available at the community level for families with children under 5. The programme was effective in reaching community levels even though it entrenched existing perception of gender roles. Consequently there was no remuneration because it was mostly women doing the work. Furthermore, the work associated with the family planning programme added to existing tasks the women had at the village and household level increasing their workloads. For programmes to be sustainable those implementing it need to be remunerated and acknowledged for their work. Furthermore, to be effective careful study needs to be done of those implementing family planning programmes so that they do not reinforce gender roles and increase the vulnerability of women by making them solely responsible family planning in a patriarchal society.


Walker D, McDermott JM, Fox-Rushby J, Tanjung M, Nadjib M, Widiatmoko D, et al. An economic analysis of midwifery training programmes in South Kalimantan, Indonesia. Bulletin of the World Health Organization. 2002.

Three in-service training programmes were carried out in South Kalimantan, Indonesia during 1995-98. The objectives of these programmes were to improve the knowledge and skills of midwives at health facilities and those based in villages. This paper assesses the incremental cost-effectiveness of these programmes from the standpoint of the health care provider. Results/Conclusions: The study estimated that the first scheme could be expanded to increase the number of competent midwives based in facilities and villages in South Kalimantan by 1% at incremental costs of US$ 764.6 and US$ 1175.7 respectively, and that replication beyond South Kalimantan could increase the number of competent midwives based in facilities and villages by 1% at incremental costs of US$ 1225.5 and US$ 1786.4 per midwife respectively. It was also estimated that the number of competent village midwives could be increased by 1% at an incremental cost of US$ 898.1 per intern if replicated elsewhere, and at a cost of US$ 146.2 per intern for expanding the scheme in South Kalimantan. It was not clear whether the training programmes were more or less cost-effective than other safe motherhood interventions because the nature of the outcome measures hindered comparison.

MNCH Interventions Funding/Costing

Windisch R, Wyss K, Prytherch H. A cross-country review of strategies of the German development cooperation to strengthen human resources.

This paper looks at how governments and donors in Cameroon, Indonesia, Malawi, Rwanda and Tanzania have translated such policies into action. This qualitative study systematically presents different approaches and stages to human resources for health development in a cross-country comparison. An important reference to capture implementation at country level was grey literature such as policy documents and programme reports. In-depth interviews along a predefined grid with national and international stakeholders in the five countries




Human Resources for Health. 2009.

provided information on issues related to human resources for health policy processes and implementation. Results/Conclusions: All five countries have institutional entities in place and have drawn up national policies to address human resources for health. Only some of the countries have translated policies into strategies with defined targets and national programmes with budgets and operational plans. Traditional approaches of supporting training for individual health professionals continue to dominate. The country case studies illustrate the range of initiatives that have surged in recent years and some main trends in terms of donor initiatives. Though attention and priority attributed to human resources for health is increasing, there is still a focus on single initiatives and programmes.

World Bank. Improving Indonesia's health outcomes. World Bank. 2003. (http://siteresources.worldbank.org/INTEAPREGTOPHEANUT/Resources/health.pdf)

This policy brief assesses the state of Indonesia's health system and proposes strategies to improve health outcomes for its population. It outlines the status of the health system including finance, maternal mortality and inequity in accessing health care. Results/Conclusions: Health financing is inequitable as 75-80% of health costs are out of pocket and health insurance only covers a third of the population most of which work in the formal sector. Public funding is lower than neighbouring countries.Utilisation of public health services by the poor is less than for the wealthier quintiles. Consequently the poor benefit less from public subsidies. The poor are disproportionally affected by health problems with children less likely to be immunised and higher infant deaths. Indonesia is undergoing a health transition and the health system is struggling to provide services for both communicable and non-communicable diseases. The use of public health services is declining as people opt for private health services as well as the use of non-medical health staff for the poor. Decentralisations poses both an opportunity for positive change through locally responsive public health care or have a negative effect by increasing regional disparities and not providing essential health information and services. Indonesia is in the process of reforming its health financing and should set up a task force to develop a strategy for this. With the private health sector having a more prominent role in the provision of health care, the Ministry of Health should ensure that it is accountable, provides quality services and services the poor (through vouchers and health insurance).

Funding/Costing Constraints/Strategies

World Bank. Indonesia’s doctors, midwives and nurses: Current stock, increasing needs, future challenges and options. World Bank. 2009

This paper presents a comprehensive overview of human resources for health in Indonesia. It compiles and examines the available information with a view of determining the stock and distribution of health workers; establishing the main weaknesses in workforce planning methods; reviewing current human resource policies and outlining broad lines of action. Reviews project information document is an update on the Indonesia-Health Workforce and Services project funded by the World Bank and implemented by the Indonesian Ministry of Health which outlines problems with the health system including the workforce, health financing and health system structure.


http://siteresources.worldbank.org/INTEAPREGTOPHEANUT/Resources/health.pdf





Results/Conclusions: The number of doctors, specialists, midwives and nurses rose significantly in the last decade. However, there are serious concerns about the quality of their training and there is a shortage and inequitable distribution of doctors and specialists. An estimated 60-70% of health providers who are employed as public servants also have second jobs or operate their private practice after hours. The dual set-up has created perverse incentives in the system that would need to be reviewed. A comprehensive overhaul of workforce planning is required to meet the new challenges:

World Bank. Investing in Indonesia's health: Challenges and opportunities for future public spending. Health Public Expenditure ReviewWorld Bank. 2008. (http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/11/06/000333038_20081106012008/Rendered/PDF/463140WP0HPER11086B01PUBLIC100final.pdf)

This Report provides a comprehensive review of the public health challenges in Indonesia and the implications for fiscal space, health insurance coverage and private expenditure. It discusses the performance and results of the health system, with focus on health outcomes, including maternal and child mortality, services utilization and equity. An overview of the healthcare delivery system in Indonesia is also presented. This discussion provides the background for an in-depth analysis of public expenditures on health, out-of-pocket spending and health insurance reforms. The report also provides a preliminary assessment of efficiency and quality of the health system. Results/Conclusion: The key policy options outlined in the report include: (i) Improving the efficiency of existing resources by introducing more incentives for efficiency by local governments and individual healthcare providers. (ii) Increase the amount of resources available for reproductive health and institutional deliveries. (iii) Improve allocation for preventive care. (iv) Make more resources available for public goods. (v) Improve health outcomes and financial protection for the poor as well as the efficiency of the Askeskin program. (vi) Improve Health Information Systems.


World Bank. Maternal Health Policy Assessment (Unpublished Draft). 2009

This report is part of a comprehensive Health Sector review and Health System Performance currently being undertaken by the World Bank. It provides a rapid review of the current policies and programmes in the area of maternal health, while examining the current maternal health situation in Indonesia. Includes a discussion of key maternal health and mortality indicators, health system inputs (providers, facilities and financial resources), utilization of services and information systems. Results/Conclusion: The current maternal health policy is too narrowly focused on providing midwives. Critical issues remain to be resolved if Indonesia is to make progress on MDG 5. They include addressing the human resources gap; increasing availability of emergency obstetric care, particularly for poor women; improving the linkages between community-based delivery facility and hospital services; higher quality of health care and enhancing the role of the national health insurance system.


http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2008/11/06/000333038_20081106012008/Rendered/PDF/463140WP0HPER11086B01PUBLIC100final.pdf





