The Millennium Development Goals (MDG) were introduced in United Nations Millennium Summit in 2000 (United Nations 2010). The MDG consist of 8 goals, which is a milestones for international cooperation in improving health and development of millions of people around the world that should be achieved in 2015. Three goals were directly related to health, which are MDG 4, reducing infant mortality, MDG 5, reduce maternal mortality and MDG 6, combating against HIV/AIDS, malaria and other infectious diseases. (United Nations 2010)
Ten years after the MDG were declared, progress has been shown by many countries. Maternal mortality, however, is the slowest of the indicators improved by many countries in developing regions and remains the greatest challenge and Indonesia is one the country (United Nations, 2010).
This essay are looking at how Indonesia is progressing towards MDG 5, the determinants affecting it, the existing policies and strategies in reducing maternal mortality, the challenges and the recommended strategy to move forward.
2. Indonesia Country Profile
2.1 Geographic, Demographic, Economic and Administrative Profile
Indonesia is the largest archipelago in the world. It consists of more than 17.000 islands with approximately 900 of them were inhabited permanently. It has 5 main islands, which lies between the continents of Asia and Australia as well as the Indonesia Ocean and the Pacific Ocean (Figure 1) (BPS Indonesia 2010).
Indonesia is the 4th most populated country in the world. According to the new census carried out by the Indonesian Statistic Bureau in 2010, the population consists of 237,556,337 inhabitants where 58% of the population is living in the island of Java. The land area is about 1,910,931 km2 so there are approximately 124 people in km2 (BPS Indonesia 2010).
Indonesia is categorized as a low middle-income country. The World Bank recorded that the GDP is around US $540 billion, with a GDP per capita of US $2230 (World Bank 2010). The population living below the national poverty line is 13.33% (31 Million) and it has been improving in as compared to at 24.34% in 1998 (BPS Indonesia 2010).
Indonesia divided its administrative system into provinces and then divided to districts and municipalities. There are 33 provinces and 399 districts and 98 municipalities. The districts consist of several sub-districts and then villages as the smallest administrative clusters (Depdagri 2010).
2.2 Organization of Health System and Service delivery
The Ministry of Health (MoH) is responsible for the national policy development and governs the Provincial Health Office (PHO) in Province Level. The PHO is responsible to provide technical support to the District Health Offices (DHO) at district level. The PHO and DHO are responsible to plan, monitor and evaluate the health program, which implemented through the puskesmas, a community health centers which located in the subdistrict level. The role of puskesmas is conducting the primary health care (PHC) services for the community. The implementation of the PHC and the maternal health services are carried out with the support of Sub Health Centers (pustu); village midwife clinic (polindes) where the village midwives work; and integrated health post (posyandu) which run by community health workers (WHO 2007).
3. Maternal Health Outcomes
3.1 Maternal mortality and the trends
Indonesia’s target for MDG 5 is to reduce three quarters of the maternal mortality ratio (MMR), from 390 (1994) to 110 (2015). The MMR is recorded at 228 per 100.000 live births in 2007 (UNDP 2007).
The MMR trends were significantly declining from 450 in 1985 to 228 in 2007 (Depkes RI 2009), however to reach 110 in 2015 Indonesia has to have a breakthrough strategies in addressing the challenges to move forward. (figure 3) (UNDP, 2007).
There is huge disparities of MMR within the population. The MMR among the poorest (lowest wealth quintile) were estimated at 700 while the richest (highest wealth quintile) estimated has nearly reach 200 (WHO 2008). The MMR also vary among different provinces the MMR in Papua in 1995 were recorded at 1025 per 100.000 live births, Maluku (796), West Java (686), East Nusa Tenggara (554) and Central Java (248) (UNFPA 2005). The disparities MMR is cause by the inequity of access to the of maternal health services which will be explained below.
3.2 Maternal health services key Indicators
|Table 1. Maternal Health Services indicators from National Demographic and Health Survey (NDHS) 2007|
|Skilled birth attendance||73.1|
|Health facility delivery||46.1|
|Antenatal care (ANC) (K1)||93.3|
|Four or more Antenatal Care (K4)||65.5|
|Use of contraceptives among currently married woman||61.4|
|Use of modern contraceptives among currently married woman||57.4|
The National Demographic and Health Survey (NDHS) conducted by the government of Indonesia in 2007 found that coverage of health facility deliveries is 46% and the skilled birth attendance is 73.1%. Percentage of woman ever receiving antenatal care (ANC) reach 93.3%, and 65.5% received complete ANC four times. The use of contraceptives among currently married women is 61.4% and 57.4% are using modern methods of contraceptives (Table 1) (Statistic Indonesia 2009).
3.3 Inequities affecting the maternal health services
To achieve MDG 5, not only the MMR were reduce but it is important to consider the most vulnerable (United Nations 2010), therefore evaluation of inequities is very crucial as relate to different health determinants.
3.3.1 Socioeconomic disparities
Socioeconomic disparities are the major inequalities affecting the achievement of MDG 5 in especially in developing countries (United Nations 2010). Such results in Indonesia, are related to inequities access to skilled birth attendance and/or health centers deliveries and other maternal health services indicators.
A huge gap between the richest and the poorest in term of maternal health services, especially regarding skilled birth attendance and health facility deliveries were existed. the fact can lead to a result that poor people die more due to the risk of untreated complication during delivery (figure 4).
3.3.2 Regional or Provincial disparities
The table 2 shows how different regional and provinces have different maternal health services. Papua, Maluku and North Maluku are provinces, which have the lowest maternal health services indicators compare to other provinces and provinces in java-bali region tends to have better indicators (Statistic Indonesia 2009).
3.3.3 Geographic disparities: urban vs rural
Globally, disparities between urban and rural in skilled birth attendance is likely be to equal (United Nations 2010), however in Indonesia the disparities remain high for skilled birth attendance and health facility deliveries (figure 5). The coverage of health facility deliveries only reach 28.9% in rural areas while urban areas reach 70.3% (Statistic Indonesia 2009).
3.3.4 Education Determinant
The education level of mothers also one of the factors associated with the low coverage of ANC (8 Titaley, C R 2010). The figure 5 clearly show the relationship between the coverage of ANC and skilled birth attendance and health facility deliveries with the level of education of the mothers.
4. Policies and strategies affecting the maternal mortality in Indonesia
4.1 Family Planning Program
The family planning programme in Indonesia were gained attention and political support during the 30 years leadership of the 2nd President, Suharto, which lead to the successfull introduction of the use of modern contraceptives. In implementing the family planning program, the president formed a semi-autonomous body namely the National Family Planning Coordinating Board (BKKBN) ( Shiffman,J. 2004) which was able to reach the sub district level. Family planning, considered forbidden before, then become essential which follow a dramatic increase in the use of contraceptives among woman in Indonesia (Utomo, Iwu Dwisetyani 2006). However since the end of the era, the family planning program were seem to have less support from the new reform government.
4.2 Safe Motherhood Program
The Ministry of Health (MoH) of Indonesia adopted the safe motherhood initiative in 1990. Given political support from key leaders in the government including the President at that period (Shiffman,Jeremy 2007). The priorities of safe motherhood initiative are to reduce the maternal mortality and morbidity and reduce the barriers to quality reproductive health services (Safemotherhood.org, 2002). The safe motherhood policy in Indonesia then introduced the village midwives program where the government of Indonesia sent midwives to rural areas, working in village midwifery clinic as one strategy to increase the coverage of skilled birth attendance to reduce the maternal mortality rate in the country (Shankar, A. 2008)
4.3 Making Pregnancy Safer (MPS)
In continuation of the Safe Motherhood Program, the MoH Indonesia launched the Making Pregnancy Safer (MPS) program in 2000. The MPS stated the critical role of skilled birth attendans in terms of reducing the maternal mortality especially to countries that have coverage below 85% (WHO 2004). The MoH continues increasing the number of village midwives, and, also introducing the establishment of Basic EmOC in the health centers and Comprehensive EmOC in the hospitals. In 2007, the village midwives increased up to 51.800 village midwives, the Basic EmOC (1.788) and Comprehensive EmOC (185). The village midwives program has increased the coverage of skilled birth attendance from 39.56% in 1993 (Hermiyanti, S. 2008) to 73.1%, although it is still below the national standard (90%) (Depkes RI 2003).
4.4 Rapid Decentralization of Governance System
After the 33 years leadership of 2nd President Soeharto ended in 1998, which is known by the Indonesian public as the reformation era, the governance system change dramatically. Indonesia started to implement decentralization, which started to be carried out in 2001 rapidly (WHO 2007).
Under Act No. 22/1999 and Act No. 25/1999 regarding regional governance and economic balance between the central and regional governments, all ministry including the Ministry of Health, were implementing decentralization policy (Depkes RI 2009). The decentralization system has given regional autonomy to provinces, districts and ities to manage available resources in providing public services to the communities in their own areas. (WHO 2007)
4.5 “Indonesia Sehat 2010”
Responding to the decentralization system, the Ministry of Health launched a new strategic plan that include a new vision and several target indicators to be achieved in 2010, the document is called “Healthy Indonesian 2010”. The “Indonesian Healthy 2010”, become the backbone for the newly reformed Ministry of Health in setting up new targets for health indicators in 2010. Several indicators, including indicators those on maternal health, were determined. The MMR target was to be reduced to 150, the coverage of skilled birth attendance is to be increased to reach 90%, and the coverage of women under reproductive ages used contraceptives to reach 70% (Depkes RI 2003)
4.7 Social Health Insurance for the poor (Jamkesmas)
The development of social health insurance improved significantly when the government launched new policy in 2004 under Law 40. The policy introduced a new program namely Jamkesmas, a health insurance for the poor people. The program covered 74.6 million people significantly increase the coverage of population covered by health insurance to 47.3% (Chee, G 2009).
5. Challenges in reducing the maternal mortality
Indonesia still face many challenges to achieve the target of MDG in 2015, the challenges divided into the program challenges which related to the maternal health services and the root cause challenges which related to the health policies.
5.1 Program Challenges
5.1.1 Human Resources for Health
The numbers and the quality of human resources is one of the challenges exist for implementing the strategies to reduce the maternal mortality in Indonesia (WHO 2010). The ratio medical doctors and midwives were 19,59 and 42,92 per 100,000 population respectively (Depkes RI 2009). This ratio is effectively below international standards.
The area of human resources for health also one greatly affected by decentralization, the numbers were not increasing significantly due to most of newly graduates health workers going to the pricate sector du to lack of finances in the central government (Heywood, P.F. 2009).
The distribution of doctors and midwives also is not equal as most of them are based in urban areas (WHO 2010). This lead to the disparities of health services between urban and rural areas as well between different provinces.
5.1.2 Access to Emergency Obstetric Care (EmOC)
The village midwife program has significantly increase the skilled birth attendance (Hatt,Laurel 2007), (Ronsmans,Carine 2001) and reduce the gap between the poorest and the richest. However the gap in access to EmOC was still very high (Hatt,Laurel 2007). Although there is significant increase of EmOC facilities in recent years, the number still not reach the international recommended standard 1 per 500.000 and the utilization, especially C-section utilization, remain very low especially among poor people. (Ronsmans,Carine 2001).
A combination of social and economic backgrounds of the users is one of the barriers among poor people to gaining access to the EmOC. Although the government has implemented the social health insurance for the poor, the administrative procedures are very complicated and it is not totally free, the lack of motivation and stigmatization from the health care providers also affecting the quality of services to the poor (D’Ambruoso, Lucia 2010).
5.2 The Policy Challenges
5.2.1 Effect on Decentralization
The rapid implementation of decentralization still not bring great effect in health system performance in the district level especially in outer java-region, although there is huge authority on governing health services in district level, most of them do not have enough capacity and resources to manage it (Chee, G 2009).
A study in 15 districts in concluded that the rapid decentralization has little no effect to the health system performance in district level, despite the increase of public health funds. The study also found that although the coverage of ANC was very high and the health facility deliveries increased, it mostly conducted by private sectors (Heywood,P. 2010). The NDHS 2007 also found from 46.1% coverage of health facility deliveries, 36.7% were delivered in private sectors facility and only 9.7% in public facility (Statistic Indonesia 2009).
5.2.2 Health care financing
Another challenges is regarding health financing aspects. Less than 3 percent of Indonesia’s GDP goes to health (34 World Bank 2010), total health expenditure per capita was $33 (in 2003), and only 34% of that comes from the public while the rest comes from private sources (WHO 2010). About one third comes from out-of-pockets (World Bank 2010). The health expenditures were increased significantly over five years after the implementation of Jamkesmas, however in relation to the access of EmOC, the jamkesmas still need improvement to be effective in reducing the barrier of cost for the impoerished (Hatt, Laurel 2007).
5.2.3 Uncoordinated Private Sector involvement
The private sector health provider continues to emerge and continue role in providing health services for the community. The acceptance of community continue to increase (Chee, G’ 2009). The coverage of deliveries taking place in private health facilities has reached 36.1% and only 9.7% taking place in public health facility. Private sector facilities also play significant role in providing the family planning programs, 69% use of contraceptives being provided by private sector personel at private insitution (Statistic Indonesia 2009).
The government, in this case the District Health Office, doesn’t have the capacity to coordinate the private sector insitution or to involve them in critical public health programs, such as becoming the referral centers in term of maternal health services (Chee, G’ 2009).
6. Recommendation Strategies
Analyzing the current MDG 5 status, current maternal health outcomes data, existing health policy and strategies, as well as the challenges, below are some recommendations to move forward in reducing the maternal mortality ratio in Indonesia.
6.1. Main Strategy
6.1.1 increasing number of midwives to increase the skilled birth attendance deliveries
A study conducted in 12 teaching hospital in Indonesia founds that 81,6% of maternal deaths were caused by hemorrhage, infection and toxemia (Chi,I C. 1981) and the MoH also stated very much the same (figure 6) (Depkes RI 2008). The main priority to reduce maternal mortality, therefore, is to implement an effective intra-partum care strategy, in this case by increasing the number of skilled birth attendans, improve their training, and increasing the numbers of births attended by them, plus providing greater access to emergency obstetric care in the health facilities. (Campbell, OMR 2006).
High coverage of skilled birth attendance can reduce maternal mortality ratios to 50 or less per 100,000 (Koblinsky, M A. 1999). Therefore, with current skilled birth attendance coverage rate, disparities and outcomes across regions (table 1,2), the MoH should increase the numbers of midwives, especially in rural areas and outer Java-Bali region with viable numbers of EmOC as the refferal system.
6.1.2 Increasing access to EmOC facilities and barrier reduction
The intra-partum care strategy has to include increasing access to EmOC (Campbell,OMR 2006), which been proven effective to deal with direct obstetric complications which leading to the higher maternal mortality (Paxton, A. 2005). The government should increase the number of health centers with Basic EmOC and hospitals with Comprehensive in order to reach international standards.
The EmOC strategy should consider both supply and demand sides. The increased number of EmOC, therefore, has to be supported with programs to reduce the other barriers of access among the community especially the poor. The MoH needs to continue to increase the number of basic and comprehensive EmOC with the added combination of providing transportation and community cost-sharing schemes to reduce the existing barriers, especially among the poor proven to be effective in reducing the maternal mortality ratio (Fournier, P. 2009).
6.1.3 Improving and modifying the current routine antenatal care
The percentage of woman receiving antenatal care is considered very high; however nearly twenty eight percen drop out in completing four times recommended ANC (table 1). One Study has demonstrated that increasing coverage of ANC may lead to increase of other maternal health services, especially skilled birth attendance, health facility deliveries and preparedness for complications (FAUJDAR,R.A.M. 2006). However, the quality of routine ANC should be improved and modified by adding counseling activities about the need of ANC, as well as preparing the family dealing with the high risk pregnancies and prepared them to use the referral system.
6.1.4 Increasing use of contraceptives
The family planning program can reduce the absolute of maternal death by 15%. It can also decrease the maternal mortality by reducing the risk from delivery through better distribution of births and loweing the parities through facilitating use of contraceptives. (15 Stover,J. 2010). The family planning program, therefore, should be maintained, improved by broader scale intervention to reach more people, especially poor people through subsidizing the price of contraceptives, thus lowering cultural and attitudinal barriers and increasing the contraceptives demand (Schoemaker, Juan 2005).
6.2 The policy strategy
There are some policy strategies that need to be taken in account by the government of Indonesia, in this case the MoH, to ensure the smooth implementation of the main strategies above:
- Increase public health expenditures to support the implementation of the main strategy above.
- Reduce the effect of decentralization through increasing the capacity of public health officials in district level and ensure effective utilization of the public health budget to increase health outcomes.
- Engage the private sector in providing quality maternal health services through public-private partnerships.
- Review and improve the implementation of jamkesmas to reach the targets and ensure the quality of services received by the beneficiaries.
Indonesia has to increase efforts in reaching the target of MDG 5 for 2015. The number of village midwives must increase significantly. Access to EmOC, ANC services should be radically improved and modified to ensure that mothers give birtsh with skilled birth attendant presents, or at health facilities. The health care team must be funded and trained to prepare the familiy to deal with the complicatios. Family planning should be maintained and improved to reach more impoverished and underserved people, in rural and urban settings. The strategies, however will need great financial resources to be implemented, therefore Indonesia has to increase public health expenditures. Enggaging private sector agencies and institutions and reviewing the current implementation of jamkesmas are two key approaches as part of this overall strategy to improve and strenghen public health driven maternal health services. If the MoH fails to start implementing of all theses strategies, and perhaps more added on, it is unlikely that the MDG 5 target will be achieved by the target date in 2015.
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