Many nations will not achieve the Millienium Development Goals (MDGs).1 This is because many parties were left out of the discussion, particularly civil society sectors directly involved with the issues at hand who have an understanding of the most significant needs to be addressed.2 This paper endeavours to capture experiences from the field conducted by community groups and organizations, and provide a list of recommendations for a working agenda to address certain public health issues, particularly Maternal Mortality Rates (per 100,000 live births). Maternal mortality is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. A maternal death can also be included in the period between six weeks up to one year after the women has given birth. 3
The MDGs have targeted MMR to 102 deaths per 100,000 live births by 2015. This target is difficult for Indonesia to achieve as up to 2007, the country’s MMR was 228 per 100,000 live births.4 This article will identify some of the causes why this is the case based on experiences and identification of community groups working in health. The paper will use a gender perspective to focus clearly on inequities apparent within the communities and why underlying concepts of gender equity and gender equality are important here. Gender equity approaches recognize that there are historical and social disadvantages which prevent one sex, often women, from benefiting fully from society’s resources. Equity would ensure fairness of treatment between men and women. Gender equality means that women and men have equal conditions for realizing their full human rights and for contributing to, and benefiting from, economic, social, cultural and politicsal development. Gender equality is therefore the equal valuing by society of the similarities and the differences of men and women, and the roles they play. It is based on women and men being full partners in their home, their community ad their society. Thus gender equity is the strategy needed to achieve gender equality.
Reducing the maternal mortality ratio is an important indicator for progress and development achievements of a nation. Concern towards maternal health is part and parcel of protection of human rights of the female person in society. Women are obviously a potential contributor to progress in achieving development priorities, and that would include the eradication of inequalities in gender, health, food security and water accessibility, and budgeting for all aspects of health to achieve societal prosperity.
Article 12.1 of The International Covenant on Economic, Social and Cultural Rights (1966) underlines that State parties recognize “the right of everyone to the enjoyment and the highest attainable standard of physical and mental health”, including reproductive and sexual health.
While the MDGs target of 102 MMR per 100,000 live births by 2015 looks to be unachievable5 , reproductive health and sexuality were only included in the MDGs (as Goal 5b) five years ago. Thus, much more time will be needed to implement and monitor results on the two additional items. This is why we feel maternal health, including seeking a way for the reduction of the MMR still merits top priority in the Post-2015 Agenda.
To scrutinize MMR in Indonesia and with the aim of seeking ways to reduce it, we also need to take a closer look at 1) services available related to reproductive health; 2) budgets allocated to maternal health; and only then can we take look at 3) the Maternal Mortality Rate in Indonesia.
Reproductive Health Services
Health services are guaranteed by the State. Article 171: 1 and 2 in Law No 36/2009 governing Health states that the State shall allocate five percent of the State Budget (not inclusive of salaries) and that Provincial Administrations shall allocate 10 percent of the Provincial Budget (not inclusive of salaries) for health. Article 171: 3 states that two-thirds of the allocation to be devoted to health services. To facilitate the provision of appropriate health services, the government through the RI Health Ministry has issued a Minimum Standard of Services (SPM). The SPM encourages provincial administrations to provide adequate services, and is a tool for the community to oversee government performance in such provision.6
Ruling No. 741/Health Minister/Per/VII/2008 describes the SPM for districts, so that local administrations can determine the community’s needs and their own capacity to service it while creating a priority list for each particular district. In general, SPM indicators cover Basic Health services, Health Referrals, Epidemiology Investigation, and handling of Extraordinary Emergency Cases, as well as Health Promotion and community capacity building. Unfortunately, indicators provided only give quantitative standards and compare yearly targets with achievement conditions in the field. In general, the indicators do not cater to the needs of the community at large. In Basic health Services, for instance, in its list for routine exams, the government only includes pregnancy, childbirth, babies, primary schoolchildren (and equivalent), and examination for only a few diseases. Services for reproductive health is not included in the SPM.
In the past decade, reproductive health has become an increasingly important issue. Yet, many instances of remiss occur due to lack of knowledge about it. In the SPM manual, there is only one article that deals with reproductive health, concerning the active usage of contraceptives,7 with no instruction for handling of sexually transmitted diseases. Is it any wonder that diseases related to reproductive health are on the rise, while bearing in mind that Indonesian society still considers reproductive and sexuality issues taboo subjects?
Neither does the government consider the need among teens and young adults to obtain reproductive health services. There is a dire need among youths for wide-ranging information on reproductive matters, to assist them in making wise life choices, including on how to maintain health and well-being in connection with sexuality. This glaring lack of information is directly related to the high numbers of Unwanted Pregnancies in Indonesia, both among teenagers and among married women.8 Ignorance on matters concerning reproductive health leads to pregnant girls and women conducting unsafe practices, e.g. through consumption of herbs, drugs or traditional potions to induce menstrual periods. Others go to physical means, such as violent jumping to induce miscarriage, while yet others seek out practitioners to conduct unsafe abortion. Non-existent services for safe abortion by the government lead to back-street practices, and counseling services are not available. The whole thing is directly related to the stigma inherent in cases of unwanted pregnancies. Going deeper, these practices put women very much at risk, and some could very well lead to death. Lack of facilities, information and support for adequate reproductive health services provided to women are part of the reason why MMR in Indonesia is high.
Gender Budget on Health
Law No. 36/2009 article 3 clearly states the State’s obligation to provide sufficient health services. As already mentioned, the Health Budget is based on allocations of five percent from the State Budget and ten percent from Provincial Budgets.9 But, a good-proportioned Health Budget apparently has not created an improvement in health and well-being in the community.
Budget allocations for women’s reproductive health can be seen through program identification and activities related to reduction of MMR. A study by Women Research Institute (WRI) in seven areas (Jembrana, Lebak, Central Lombok Tengah, West Sumba, dan North Lampung) revealed that only Jembrana District (10 percent) and Lebak District (10,7 percent) complied to Law No.36/2009 governing Health. Other districts and regions use their Real Regional Income, Retributive Funds and General Funds Allocation to fulfill local needs. And it is this very fact that is used as the main reason why the law is not being fulfilled. This is an irony, because Central Lombok, West Sumba, and North Lampung’s fiscal capacity is on par with Jembrana and Lebak. Even more ironically, Surakarta and Indramayu, with twice the fiscal capacity of Jembrana and Lebak, have claimed incapable of complying to the Health Law.10 It is thus very apparent that the lives of poor women can be saved through the political capacity of local administrations complying to the Law, whether budgets are derived from state budgets or local incomes.
A study by Fitra concerning Provincial Budgets in 41 Districts/Town revealed that they allocate very minimum budgets for health. Only 12 of the 41 Districts/Towns allocated 10-16 percent of their Provincial Budget for health, while the others allocated less than 10 percent.11 Fitra’s research also showed local governments’ severe lack of interest in allocating budgets for Maternal and Child Health Care. Of 34 Districts/Towns reviewed, 32 had a per capita budget for Maternal and Child Health Care of less than Rp.46.000,-, while other studies have shown that an adequate Maternal and Child Health Care scheme needs a minimum standard of Rp.65.000,- per capita. In Kendal, maternal health care is allocated a pittance of Rp.2.000,- per capita per year.12 In the 2006 – 2012 period, growth of the health budget in Indonesia averaged at 14 percent. Budgets distributed to the regions were the biggest contributor to this budget growth in the 2010 – 2011 period. The Health Basic Allocation funds amounted to Rp.913,3 billion from Rp.2,7 trillion in 2010 to Rp.3,6 trillion in 2011.13 Still, the budget allocation for health remained under five percent in total State Budget expenditure. Even though nominally, budget allocations for health increased by 167 percent between 2005 – 2012, proportionally, this allocation has never gone much higher than three percent of total State Budget expenditure.14
Maternal Mortality Rates
Of all the MDG targets, the one calling for a reduction of maternal mortality ratios has the lowest achievement. In Indonesia, the Maternal Mortality Rates decreased from 390 in 1991 to 228 per 100,000 live births in 2007. Despite improvements in antenatal care and during childbirth by caregivers, certain high risk factors such as at-risk pregnancies and abortion still require attention.15 The reduction of MMR in Indonesia has not even reached half set-point.
The percentage of childbirth assisted by health caregivers increased from 66,7 percent in 2002 to 77,34 percent in 2009 (National Statistics Survey). This continued to increase to 82,3 percent in 2010 (Riskesdas, 2010). The disparity between regions for assistance provided by trained health caregivers is still a major problem. Susenas data of 2009 showed that provision of care had risen to 98,14 percent in the Jakarta Capital City while Maluku only received 42,48 percent.16
Figures for unmet needs vary from province to province, district to district and within different social-economic groups. The lowest Unmet needs figures are found in Bangka Belitung (3,2 percent) with the highest in Maluku (22,4 percent). Unmet needs in villages (9,2 percent) are higher compared to those in urban areas (8,7 percent). Unmet needs among uneducated women are higher than those with education (11 percent against 8 percent). This indicates that the higher the education and prosperity levels, the higher the woman has access to information and reproductive health care. High unmet needs are caused by fear of side-effects and discomfort in use of contraceptives. A total of 12,3 percent young women between the ages of 15-19 do not wish to use contraception devices/drugs for fear of side effects, 10,1 percent for health reasons, while 3,1 percent don’t because their husbands prohibit it.17
Challenges to Reduce MMR in Indonesia Include
Inaccessibility to quality health care facilities, particularly for poverty-stricken people in remote, underdeveloped areas or communities in border areas and living on islands.
Lack of trained health care-givers in terms of numbers, quality and distribution, in particular of midwives.
Lack of knowledge and awareness in the community on the importance of maintaining maternal healthcare and safety.
Low health status and nutritional levels of pregnant women.
Low level usage of contraception and high levels of unmet needs.
Inaccurate measurement of MMR, due to inadequate recording systems on causes of maternal mortality.
Maternal healthcare needs to prioritize quality care-giving, comprehensive obstetrics services, improvements in family planning services and dissemination of communications, information and education to the community. Lack of availability, uneven distribution or inaccessibility of comprehensive emergency neonatal obstetrics services, basic emergency neonatal obstetrics services, village clinics and blood transfusion units by communities have to be addressed as high government priorities in the effort to reduce MMR in Indonesia. Referral systems from the home to the village healthcare unit to the hospital have not been optimal. Moreover, communities face geographic impediments, transportation difficulties, and limiting cultural factors. Other than that, the government needs to improve record-keeping on MMR reduction efforts in Indonesia so that data can provide an accurate picture of current conditions in maternal health.
Regarding budgets to improve women’s health, the government could use figures as indicators for targets and objectives, but also make use of input indicators and processes such as women’s health budgeting, creating even accessibility of health caregivers and provide reproductive health education for women.
MMR continues to be a serious problem in Indonesia. Real efforts still need to be taken to achieve the targets for reducing MMR to 102/100.000 live births by 2015. Several conclusions can be made i.e.
Central government, regional administrations and stakeholders involved in MMR have differing perceptions on MMR and these need to be aligned.
Central government and provincial administrations lack the commitment to implement the spirit of Law No.36 /2009 concerning health, to allocate budgets amounting to five percent of the State Budget and 10 percent of Provincial Budgets outside of salaries.
Of the current budget, practically all regions do not have a specific allocation set aside for MMR.
Reproductive health services have not been made priority as one of the tools to prevent MMR.
Certain policies to reduce MMR are in place, but lack implementation and monitoring mechanisms to maximize effect.
The need for contraceptives are as yet unfulfilled and unmet needs remain high
There is lack of socialization and community involvement in the effort to reduce MMR, particularly in isolated areas.
Health facilities in remote areas are unevenly distributed, while areas with facilities do not necessarily have adequate caregivers to provide neonatal examination services and assistance during childbirth.
Knowledge and awareness on prevention of MMR is still very low among communities in Indonesia, while the majority of isolated regions still face issues of hunger and nutrition deficiency which also has a big impact on pregnant women.
Recommendations for health services Post 2015 in Indonesia:
Uphold the concept that health services are a human right for every citizen
Government commits to allocate a health budget of five percent of the State Budget 2013 and ensure that provinces adhere to the 10 percent allocation from the Provincial Budget 2013
Ensure that two-thirds of the total health budget is devoted to services and to infrastcutre as has been the case in many regions
Government provides policies on budgets to increase female health, e.g. 20 percent for Maternal and Child Health activities and ensure that such budgets are implemented
Government provides even distribution of comprehensive emergency neonatal obstetrics services, basic emergency neonatal obstetrics services, village health clinics and blood transfusion units particularly to areas with no access to services
Ensure availability of health caregivers in remote areas to support servicing of pregnant women and those in labour
Ensure that referral systems from the home to the village health centre to the hospital works at optimum levels
Improve road and health facility infrastructure as part of a multi-sector effort
Improve record-keeping systems on MMR so that data can provide an accurate current picture of the state of Indonesian women’s health
Introduce reproductive health education to teenagers and women into the SPM indicators, and provide availability of reproductive health services for teens in Village Health Centres, while actively intoducing reproductive health education in schools according to age groups
Create peer counseling for teens pertaining to reproductive health
Provide consultation facilities for Unwanted Pregnancies including health services and information on menstrual periods
Eradicate unsafe abortion practices which have the potential to increase MMR in Indonesia
Conduct cultural approaches in communities to change entrenched outlooks so that reproductive health issues, particularly pertaining to youth and teens, can be points for open discussion and not be kept taboo
Government not only use figure indicators as a target, but also input indicators and processes, such as determination of women’s health budgets, even distribution of accessible health caregivers, and reproductive health education for women.
1http://www.presidensby.info/index.php/fokus/2012/06/23/8054.html, MDGs to be Replaced with the SDGs through an Objective Evaluation (accessed on 18 January 2013, at 10.12 Western Indonesian Time)
2Heru Prasetyo, Deputy I Oversight and Control for the Climate Change and Sustainable Development Inisiative UKP4, conveyed at WRI Seminar and Film Screening, December 2012
3http://mdgs-dev.bps.go.id (accessed on 18 January 2013, at 10.58 Western Inodnesian Time)
5See “Meeting the MDGs in South East Asia: Lessons & Challenges from the MDG Acceleration Framework”, Biplove Choudhary, Programme Specialist UNDP Asia Pacific Regional Centre, paper presented in Escap/ADB/UNDP sub-regional accelerated achievement of MDGs & the Post 2015 Development Agenda in South East Asia, 21-23 November 2012, UNCC Bangkok, Thailand.
6Kushandajani, Minimum Standard of Services (SPM) and Improvement of Services in the Era of Regional Autonomy.
7Indicator Table for National SPM 2012, http://www.spm.depkes.go.id/tabelindikator_18indikator.php (accessed on 11 January, 2013, at 14.42 Western Indonesian Time)
8Research results by Central PKBI, Facts on Women’s Needs for Services on Inducement of Menstrual Periods in 13 Towns 2008 – 2011. Presented at PKBI Study Results, 18 December 2012
9Chapter 171 article (1) and (2) Law No.36 /2009 governing Health
10Spearheading the Decrease in Maternal Maternity Ratios in Indonesia, Women Research Institute, 2011
11Fitra, Analysis of Regional Budgets in Indonesia: A Study on Management of Provincial Budgets in 41 Districts/Towns, 2010, page.32
12Yuna Farhan, Rights-based Public Policies in Budget Allocations, in Manual to Create Rights-based Public Policies for Legislators, Demos, 2011
13A Directive for an Alternative State Budget Expenditure, TA.2013, Fitra
15Report on Achievments of Millenium Development Goals Indonesia 2010. National Development Planning Agency, 2010, page. 66
16Ibid, hal. 67