One Village, One Birthing Clinic, One Midwife
In 2010, the Human Development Index (HDI) for Indonesia, as published by the United Nations Development Program (UNDP), increased from 107 to 111. Several main HDI indicators are closely related to health, including Life Expectancy, Infant Mortality Rate and Maternal Mortality Rate (MMR). The high maternal mortality rate in Indonesia in 2009 resulted in the decrease of Indonesia’s position in the Human Development Index.
The high maternal mortality rate reflects the inadequate reproductive health services for poor pregnant women and the difficulties faced by poor women to access reproductive health services. What actions should be taken if the Regional General Hospital (RSUD) in cities, Puskesmas (Community Health Clinics) in sub-districts, and midwives living in villages are considered too expensive and too far for poor women who live in remote areas? Strategies that should be implemented are bringing reproductive health facilities closer to the community’s houses, urging the government to issue the “One Village, One Birthing Clinic, One Midwife” policy and allocating adequate funds to implement it, in order to overcome the lack of reproductive health services for poor, pregnant women.
The policy should oblige the government to provide a place to build a Village Birthing Clinic (Polindes), which should preferably be located in the center of the village. Since currently it is still the community who must provide the place for Polindes, they merely allocated a space in an isolated area which is inadequate for living purposes. This policy should also regulate that government should allocate sufficient funds to equip Polindes with electricity, clean water, sanitation, and adequate equipments for assisting births.
This policy should also regulate midwives to stay in Polindes, at least on midwife in each Polindes, to enable expecting mothers 24 hour access to a midwife. In order to become an effective pioneer in putting an end to the high maternal mortality rate in Indonesia, the “One Village, One Birthing Clinic, and One Midwife” policy must be supported with a general health insurance to provide protection for people living in remote areas. However, the general health insurance itself should not be treated as a spearhead in reducing maternal mortality rate.
The findings of Women Research Institute’s (WRI) research on Access and Utilization of Reproductive Health Service Facilities for Poor Women in Seven Districts/Cities in Indonesia (North Lampung, Lebak, Indramayu, Jembrana, North Lombok, West Sumbawa, and Surakarta) in 2007-2008 revealed that although the majority of the population is protected by health insurance provided by the government, such as Askeskin or Jamkesmas (Public Health Insurance, a state health insurance for the poor), and the Statement of Poverty Letter (SKTM), they still experience difficulties in accessing health services due to the considerable distance to the health facility. The topography which consists of hills, mountains, and poor roads, as well as the lack of public transportation, are causes for their obstacles. These health facilities cannot be accessed by poor women because they would have to pay relatively expensive transportation fees, as these fees are not covered by the health insurance. Ideally, all poor women should be covered by the insurance and could easily visit the Village Birthing Clinic in their respective villages to access free labor and delivery services.
Jamkesmas itself needs to improved to be an effective support facility for the “One Village, One Birthing Clinic, and One Midwife” policy. In the past, the dissemination of information on Askeskin was far from effective. WRI found that many poor people did not have any information about Askeskin or how to get access to it. The reasons for the high number of unregistered poor families in the insurance system are: 1) Poor people have no access to gain information about Askeskin, and 2) Poor people experience many difficulties in getting identity cards, due to the lack of information, lack of economic resources, or their status of newcomers in that area.
Poor people have a low bargaining position compared to those who could use their authority or family’s connection to force the officers in charge to register them under Askeskin. A Posyandu (Integrated Health Post) officer in Sangkrah admitted that the selection of Askeskin participants in subdistrict offices did not adhere to the criteria of poor people as determined by Statistics Indonesia (BPS). Instead, family connections and private or social reasons became the criteria, and as a result, even privileged people could get Askseskin cards.
The reimburse system of Askeskin/Jamkesmas claims should also be improved. The current time-consuming process for labor or delivery claims made midwives reluctant to provide free services for Askeskin patients. According to the regulations, claim process should be completed in two or three weeks, yet in practice, it requires a much longer time – sometimes even six months. This arduous and lengthy claim process problemitized Puskesmas’ financial condition.
The issue is how to boost the “One Village, One Birthing Clinic, and One Midwife” policy in order for it to run effectively with adequate support from the budget allocation. According to Prof. Mahmoud Fathalla, the main obstacle in making policies and allocating budget is that the policy-makers, a majority of them men, do not view poor women’s lives as worthy enough to be saved. The reality of gender inequality, causing difficulties in promoting gender-based policies and budget allocation, is one of the most difficult obstacles in reducing maternal mortality rate in Indonesia. The “One Village, One Birthing Clinic, and One Midwife” policy will only succeed as a pioneer in drastically reducing maternal mortality rate if followed with gender equality and equity education for policy-makers, in order for them to understand that women’s lives are as worthy as men’s.
The success in influencing policymakers to issue and allocate the funds for the “One Village, One Birthing Clinic, and One Midwife” policy must however be accompanied by public education about gender equality and equity. WRI’s research findings documented the large number of cases where poor women have no authority over their own bodies and the life-and-death decisions during her labor are in the hands of their husband and family. The status quo of gender inequality within the community, which places men in a higher position than women, will reduce the effectivity of the “One Village, One Birthing Clinic, and One Midwife” policy in reaching poor women in isolated areas. Taking a pregnant woman, upon experiencing bleeding and complications, to the Polindes in another part of the village is considered as no use by the husband and family because they deem her life unimportant enough to be saved.
The transformation of Jamkesmas to Jamkesnas (National Health Insurance) will support the effectiveness of the implementation of the “One Village, One Birthing Clinic, and One Midwife” policy. The implementation of Jamkesnas is to fulfill the mandate of Article 5 Paragraph 1 Law No.36/2009 on Health that states, “Every person has equal rights for an access to resources in health.” Article 5 Paragraph 2 Law No. 36/2009 on Health states, “Every person has the right to receive safe, quality, and affordable health services.” This means that the Government of Indonesia views healthcare as every citizen’s right. Everyone, both men and women, either financially stable or categorized as the poor, have the right to healthcare. To strengthen the commitment for this health right, Indonesia ratified the Convention of Economic, Social, and Cultural Rights in 2006. One of the consequences is that the state must guarantee the fulfillment of health rights, including affordable health facilities and the mechanism of legal settlement for entities who violate the health right. The government’s responsibility to guarantee the public’s health is strengthened with Article 20 Law No. 36/2009 on Health which states, “The government is responsible to guarantee the public’s health through a national social insurance system aimed at individual health.” This regulation indicates that the government must cover health insurance for its citizens by implementing a Comprehensive Health Insurance program.
In response to the number of suggestions to evaluate Jamkesmas, the Minister of Health Endang Rahayu Sedyaningsih expressed her concern on the previous health insurance reimburse system, such as the claim reimburse process. To ensure that the process went smoothly, the Minister studied various existing regulations related to health insurance. Furthermore, the Minister also explained that the Jamkesmas system is indeed contradictive with the Law of National Social Security System. The Minister is currently drafting a map of the national health program. Jamkesmas is gradually being changed into a national insurance. In 2014, the national health system is expected to cover every single member of the population. “The fees of the poor will be paid by the government, while civil servants will be paid by employers and employees,” the Minister of Health stated.
Jamkesnas will be a complementary element in assisting the execution of the “One Village, One Birthing Clinic, and One Midwife” to run effectively. The case of Jembrana shows that there are beneficial impacts from the fulfillment of women’s reproductive health if the government has a political will to introduce a health insurance that protects everyone. Another point that makes the Jembrana case even more interesting is because Jembrana is categorized as a poor district in the Poverty Index published by SMERU Research Institute. The limited resources did not discourage the Local Government of Jembrana to implement an insurance policy at the district level, which provides free healthcare for its community, including poor women. The allocation of health budget in Jembrana in 2007 was very high, at Rp. 151,043 per person – much higher than Surakarta, which is financially superior yet only allocates Rp. 65,934 per individual. It is thus unsurprising that the maternal mortality rate in Jembrana is very low – 55/100,000 live births, much lower than the national average – surpassing the 2015 target of MDGs at 102/100,000 live births.***