Michael J Dibley and Meiwita Budiharsana
Indonesia has had mixed results in its progress against two of the key Millennium Development Goals (MDGs) that relate directly to health. The fourth MDG aims to ‘reduce child mortality’, with a target of cutting the deaths of children under five years by two thirds between 1990 and 2015. Indonesia is close to achieving this target. Its progress against the fifth MDG has been less successful. The fifth MDG seeks to ‘improve maternal health’. It sets targets of reducing the deaths of pregnant women by three quarters between 1990 and 2015, and ensuring ‘universal access to reproductive health’ by 2015. Despite the decrease in maternal deaths since 1990, it is unlikely Indonesia will reach this MDG target.
Why has there been this difference? One explanation is inequalities in the Indonesian health system. There are fewer inequalities in access to preventive child health services in Indonesia than for women during pregnancy and delivery. The recently introduced universal health care scheme has gone some way to addressing issues of inequality, but one year after it was implemented it is unclear how successful this scheme will be in resolving these problems. What is clear is that for Indonesia to continue to reduce the numbers of children and mothers dying, better coordination within the government will be needed.
Different levels of success
Indonesia has made significant improvements in child health and is very close to achieving the MDG target for 2015. In 1990, nearly 10 out of 100 children died before their fifth birthday. By 2012, this had fallen to three out of 100 children. In contrast, Indonesia’s progress on meeting the target for reducing maternal mortality has been less successful. Despite 30 years of extensive inputs and the development of a widespread reproductive health service delivery system, death during childbirth is still a real risk for women in Indonesia. In 1991 there were 390 maternal deaths per 100,000 live births. Although this has been halved to 190 by 2014, Indonesia remains above the 2015 target of 110 maternal deaths per 100,000 live births.
The overall progress in reducing child mortality reflects improvements in child health programs. The coverage of immunisations has improved substantially. The coverage for measles vaccination in one year-old children increased from 45 per cent in 1991 to 80 per cent in 2012. There have also been increasing numbers of children with symptoms of pneumonia being seen by healthcare providers. Treatment of and recovery from diarrhoea has also improved. About two-thirds of children with diarrhoea are now given oral rehydration solution, increased fluids and continued feeding. Underpinning the reduction in childhood deaths from diarrhoea have also been improvements in water and sanitation, which reduces the risk children will become ill in the first place.
One obstacle to achieving similar success with maternal mortality targets has been difficulties with measuring the mortality rate. Maternal mortality is difficult to measure as it occurs at low frequency. Very large amounts of data are needed to produce reliable estimates. So it is difficult to obtain reliable estimates at provincial or district levels. Despite these limits, the maternal mortality rate is thought to be two to three times higher in provinces in eastern Indonesia than for the remainder of Indonesia.
The lower level of success in achieving maternal mortality targets is also due to the more complex nature of delivering services to pregnant women and mothers. The major causes of maternal deaths across Indonesia include bleeding following delivery, infection after delivery and complications arising from pregnancy-related high blood pressure (eclampsia). Because maternal deaths are hard to predict prior to delivery, ready access to effective emergency care for pregnant women is vital to prevent these deaths. As a result, death from giving birth or from pregnancy-related causes is more common in areas of Indonesia with fewer and more limited health care services.
Unequal access holding back progress
A key obstacle Indonesia faces in tackling both child mortality and maternal mortality is inequality in the delivery of health services. Despite the success in reducing child mortality, progress has not been uniform across Indonesia. The 2012 Demographic and Health Survey revealed large differences in the rates of under-five deaths between the poorest 20 per cent of households (70 under-five child deaths per 1000 live births) and the wealthiest 20 percent of households (23 under-five child deaths per 1000 live births). Similarly, child mortality is higher in rural than in urban populations, and the rate amongst uneducated women is five times higher than for women with the highest levels of education. There are also significant differences in childhood mortality rates across the country. Several provinces in eastern Indonesia, including Central Sulawesi, North Maluku, Papua and West Papua, having mortality rates more than twice the national average. These provinces in eastern Indonesia also have worse indicators of poverty, health, education and nutrition, contributing to their high child mortality.
In the case of maternal mortality, attempts to address problems of unequal access to health services have managed to achieve substantial reductions in the mortality rate since the 1990s. But they have also encountered serious problems. For example, in the mid-1990s Indonesia launched a program to provide every village with a midwife. The rapid implementation of this program resulted in limited training for these midwives and new graduates had skills below the standard required to safely manage birth complications. These midwives increased the level of care for pregnant women and provided improved access to family planning services. However, they had less impact than expected on maternal deaths. In ‘pockets’ or ‘remote areas’ where the public health program failed to reach communities, many poor families continued to choose traditional birth attendants to help with the delivery of their newborns, which took place at home.
Indonesia made further attempts to accelerate reductions in maternal mortality by addressing inequality in access to maternal health services. In 2005, the government mandated a social health insurance scheme for the poor called Askeskin. In 2011, the government launched Jampersal (Universal Delivery Care), another central government social health insurance program that targeted pregnant women who were not covered by any other health insurance scheme. The objectives were to promote deliveries in health facilities and improve the referral system. This program encountered a range of difficulties, including a lack of coordination between the various sectors involved. This resulted in women misunderstanding many aspects of the program. For example, Jampersal allowed women to choose private or public providers for free delivery, but many women believed that the free deliveries were only available at community health centres and public hospitals. Further, many women also felt that free services also meant low quality of services and unnecessary out-of-pocket expenses for drugs and injections.
In an important intervention to further reduce poverty and inequality, Indonesia passed Law No. 40/2004, which introduced the concept of a national social security system with universal health coverage. It took 10 years to start implementing this program, which began on 1 January 2014. After one year of implementation, a number of issues have emerged that suggest the scheme may not be able to address all of the shortcomings in the current system. For example, funding is distributed by the scheme to community health centres according to the number of people who nominate the clinic as their primary health care provider. As community health centres in remote areas only receive limited funding, this particular scheme will not be able to address the problem of asymmetrical distribution of doctors, nurses and midwives to remote areas. Another problem is that the current funding model does not make it clear how community health centres spend the money they receive. As a consequence, it is not clear to what extent maternal and newborn health is a priority. Further, the current model does not provide incentives to improve the quality of care.
A healthier future for women and children
As Indonesia moves beyond the MDGs and considers options for the post-MDG era, there are a number of issues that need to be taken into account to ensure child and maternal mortality continue to decrease.
Reducing inequality in access to and use of health services will be critical to further reducing childhood deaths in Indonesia. Although coverage of measles vaccination has improved, the current gap in coverage between the wealthiest and poorest children is of a similar magnitude to 2001. Accelerating programs and extending coverage of child health services for the provinces in eastern Indonesia high child mortality rates will also be critical. Many of these provinces are the least developed in Indonesia and have particular problems, such as geographic isolation and ongoing conflicts. In addition, delivering more effective interventions to reduce newborn deaths will also be important to ensuring that child deaths continue to fall. In 2012, approximately half of Indonesia’s under-five child deaths occurred during the first 28 days of life. Compared to the death rates of older children, the death rates for newborns (deaths within one month of birth) have fallen more slowly, especially over the last decade. This stagnation is linked to the slow progress with maternal health, as many interventions to improve neonatal health need to start in pregnancy.
Strategies to improve maternal health must include broadening access to quality obstetric care, especially in eastern Indonesia. Studies have shown that encouraging women to use midwives for normal deliveries is not enough. Better coordination between different levels of the health system (primary and secondary health care facilities, public and private sectors) is needed to ensure more appropriate and timely referrals of women experiencing obstetric emergencies or in need of C-Sections.
Finally, a strategy that has not yet been tested is mapping inequality through an integrated health information system. An integrated health information system could serve as a coordination device for cross-sectoral planning with the goal of using universal health coverage to reduce maternal and newborn deaths, as well as deaths and disabilities caused by infectious diseases. For such a strategy to work, the central and local governments would have to agree on and be willing to share one data set. But more importantly, they would have to be willing to really work together. Without such coordination, further reductions in the deaths of Indonesian mothers and newborns will continue to be slow.
Michael J Dibley (Michael.firstname.lastname@example.org) is a Professor of Global Public Health Nutrition at the University of Sydney. He does research about maternal and child health and nutrition in Asia, and has been engaged with health related research in Indonesia for 40 years.
Meiwita P Budiharsana has worked as a lecturer in the Department of Biostatistics and Population, Faculty of Public Health, University of Indonesia for 30 years. She has 15 years experience conducting operations and social science research in reproductive health, domestic violence and health information system strengthening during her work for the Population Council and the Ford Foundation.