Overview of Indonesia's Health Care System for Maternal and Child Health

Any description of Indonesia's health care system must be prefaced by a physical description of the country itself. Consisting of more than 13,000 islands spread over 1.9 million square kilometers and home to some 240 million people, Indonesia is the second most populous country in Asia and the fourth largest in the world. Its population is characterized by its wide diversity: demographic, economic, social, political, and cultural. About 56 percent of the population lives in rural areas. The country is divided into 34 provinces, each of which has a legislative council headed by a governor. The provinces comprise some 500 districts, divided into nearly 7,000 subdistricts in which there are almost 80,000 villages (Badan Pusat Statistik, 2012).

The Indonesian National Health Development Program is based on a primary health care concept: the community health center is the basic health care facility, supported by hospitals and other community-based health care facilities. The Ministry of Health (MoH) has overall responsibility for the nation's health care policy. It manages and operates health care programs, including staffing, education and training, and health services.

Community-based health care has been a cornerstone of the public health system in Indonesia since its inception. Early initiatives in maternal and newborn care focused on the provision of care through community health care centers (puskesmas) and village health posts (pustu), all aimed at supplanting the widespread use of traditional birth attendants (dukun) who, though unskilled, were part of the cultural fabric of pregnancy and childbirth throughout the country. However, it was quickly evident that more direct access was needed between trained health providers and the community for better maternal and newborn care. This led to the creation in 1989 of the village midwife program (Bidan di Desa) in which a trained midwife was placed in each village along with a village birth facility (polindes). The village midwife program also became an integrated part of the monthly community health extension post (posyandu) held in each village, thereby offering antenatal care and reproductive health consultations at the village level. These steps were accompanied by the engagement of community health volunteers (kaders)—a measure intended to facilitate outreach to the community and mobilization to promote the utilization of health care services. Since the establishment of integrated health services, several initiatives have been adopted in attempts to enhance this core system of community health care centers, village health posts, village midwives and birth facilities, community health extension posts, and community health volunteers. In addition, efforts have been made to overcome the traditional and sometimes deleterious practices fostered by local tradition and the use of the traditional birth attendants. This system is described in detail in this chapter.

Continuum of Care: From Primary Care (Health Centers) to Hospitals

The lowest level of primary care is found in the villages, where most facilities are community-based and provide service for primary health care and prevention programs. In each subdistrict, at least one health center is supposed to be headed by a doctor, supported by two or three subcenters of which the majority are headed by nurses. Health centers focus on health promotion, sanitation, mother and child health and family planning, community nutrition, disease prevention, and minor emergencies (Ministry of Health, 2004). Some health care centers, especially those in rural areas, have not succeeded in carrying out both curative and preventive tasks because the doctors who are supposed to work in these centers do not stay in rural areas. Large numbers of nurses posted to rural areas also open private practices in villages or cities (Webster, 2012). Few training centers for midwives are located in villages, and only 70 percent of midwives remain in villages; others migrate to cities (WHO, 2012).

Table 4-1 shows the organization of health service delivery in Indonesia at five levels: village, subdistrict, district, province, and central. The services and ratings listed are those required by government, but, as described later, not all levels of government comply with the requirements. Box 4-1 describes the facilities mentioned in Table 4-1.

TABLE 4-1

Health Facilities at Different Levels of Service Delivery, Indonesia.

BOX 4-1

Indonesian Health Care Facilities: Health Posts, Health Centers, and Hospitals Integrated Health Posts (Posyandus). At the village level, the integrated health post serves as the first line of care, followed by basic professional care at health centers (more...)

Standards of emergency obstetric and newborn care were set forth in the early 1990s by the World Health Organization, UNICEF, and United Nations Population Fund. These are the interventions that must be undertaken at the time of birth in order to address the sometimes unpredictable causes of maternal and neonatal mortality. These “signal functions” define the capabilities of facilities that must be available to birthing mothers to save lives in the event of common birthplace medical emergencies (Table 4-2).

TABLE 4-2

Signal Functions for Emergency Obstetric and Newborn Care.

The lack of basic and comprehensive emergency obstetric and newborn care came to the public's notice in February 2013 in the press reports of baby Dera (Box 4-2).

BOX 4-2

The Case of Baby Dera. In February 2013, a baby named Dera, less than one month old, died after being refused admission to 10 hospitals in Jakarta. The reasons given were that the hospitals were full and that there were not enough neonatal intensive care (more...)

Aside from the lack of beds, few hospitals can provide the skilled health care workers, medicines, and equipment needed to meet the minimum standards of the World Health Organization (WHO) for emergency care. BEmONC health centers do not provide blood transfusions or cesarean sections, and patients requiring them must be referred to a hospital with CEmONC capabilities. Table 4-3 shows the readiness of public hospitals to provide CEmONC services.

TABLE 4-3

Readiness of Public Hospitals to Provide Comprehensive Emergency Obstetric and Newborn Care (CEmONC).

Community Involvement

Community involvement has a long history in maternal health in Indonesia. That involvement includes family, community, and midwives, as well as the traditional birth attendants. The integrated health post (posyandu) was introduced to facilitate access to services in the villages. Its primary health care workers are volunteers, kaders, who are selected by the head of the village or a village committee. They are typically literate and have completed primary school, but few have a secondary school education. They are supervised at the posyandu by staff from the health centers (puskesmas), who are in turn guided by a working group composed of representatives of the Ministry of Home Affairs, Ministry of Health, National Development and Planning Bureau, local government, Family Planning Coordination Board, and Women's Empowerment Movement (PKK). The kaders' primary task is to make it easier for villagers to visit the posyandu, to mobilize campaigns for immunization or vitamin A distribution, and to promote and educate the community about the importance of antenatal care and skilled attendance at birth. In many cases, kaders may be hired by nongovernmental organizations (NGOs) or receive short-term government stipends for specific health promotion programs or activities at the village level. Current evidence suggests that kaders are generally ineffective in fulfilling their roles in the community because they are not professionals and they serve as volunteers with little accountability. Several studies in Indonesia and elsewhere have indicated that well-trained community health promoters can have a substantial impact on maternal and newborn health. These findings thus emphasize another recurring theme: investment in human resources at all levels has been suboptimal in Indonesia.

During the joint committee's visit in September 2012 to one posyandu in Makassar, South Sulawesi, some volunteers related how they record all pregnant women in their area, taking specific note of high-risk pregnancies. One volunteer usually covers 10 households. The volunteers encourage women with high-risk pregnancies to seek prenatal care in due time, and they help these women to arrange transportation to a health facility. The volunteers are essential to the operations of the posyandus. Even so, some posyandus cannot recruit enough volunteers to serve the community, and in some places and cases the services provided are inadequate.

Since 1989, the Bidan di Desa (BDD) program has been the focus of the Indonesian effort to improve maternal and child health and offer family planning services. The plan was to put a midwife and village birth center (polindes) in every village. However, in many areas this has not yet been achieved. In this program, the existing trained nurses were given an additional year of training in midwifery skills, with the expectation that they would significantly improve the quality and quantity of antenatal, obstetric, postnatal, and contraceptive services in the villages, thereby reducing the morbidity and mortality rates for mothers and infants. Midwives employed in the public sector would be contracted by central, provincial, or district governments, or directly by health facilities. Most midwives work in hospitals, health centers, and village birth centers. They may also offer services in a home or in a structure that is the property of or was built by the village government for the specific purpose of serving as a birth center (polindes)— see Rokx et al. (2010). Although midwives are expected to use the village birth centers to provide services, many of these centers are poorly constructed, substandard structures that are poorly equipped (Hull, Rusman, and Hayes, 1998).

The role of the traditional birth attendant (dukun) continues to be an important one at the community level. Qualitative studies indicate that for many women the dukun is the preferred community-based provider to consult for assistance during delivery. This preference stems from both the perception that the majority of birth outcomes are positive and the role of the dukun in providing support services for household chores in the week after delivery. The role of the dukun in invoking the blessing of the spiritual ancestors of the community and family is also thought to be important. Though initially discouraged by the Ministry of Health, joint engagement of both a dukun and midwife is now gaining acceptance among midwives and the Ministry of Health, who recognize that these figures may provide a path toward facility-based deliveries and more extensive postnatal care.

Public versus Private

A main feature of the health care situation in Indonesia is the inequity between rich and poor and urban and rural. A 2010 study by the World Bank reported that the richest people, and those living in urban settings, are seven times more likely to access health facilities, public or private, than their poorest counterparts (World Bank, 2010).

In Indonesia, public health facilities such as public hospitals and health centers (puskesmas) are meant to be sources of revenue for local governments. These facilities receive subsidies from the central government for salaries and operational costs, but they are required to adopt the self-supporting (swadana) principle, which means relying on user fees to finance the nonsalary costs of medical care. However, they have never been allocated the resources they need to manage themselves profitably. The swadana principle forces local governments to raise revenue by any means, including contracting out services to the private sector. The system has led to growth in the number of private sector health institutions, and two-thirds of the financing and more than half of the services are now in private hands (Heywood and Choi, 2010).

Of the 1,800 hospitals in Indonesia, some 650 are private. Only about 50 percent of the private hospitals are accredited by the Ministry of Health, and only five hospitals have received international accreditation (Ministry of Health, 2012). Of the five, three hospitals are affiliated with internationally branded organizations: Siloam, Gleneagles, and Mount Elizabeth's.

The Ministry of Health does not regularly supervise the operational activities of hospitals or the quality of care offered by hospitals. In general, the private hospitals are profit-based medical institutions and are usually not considered agents for carrying out community health programs, including those aimed at reducing maternal and neonatal mortality.

Only 300 of the 650 private hospitals participate in the government-based health insurance (Jamkesmas). In Jakarta, where the municipality provides health insurance to the poor through the distribution of health cards, private hospitals are only required to offer 10 percent of their beds to health card holders, compared with 60 percent of public hospitals (Ministry of Health, 2011a). Some private hospitals have an associated midwifery school, but the quality of the training depends on the quality of the hospital and the organization or the owners behind it. The private midwifery school graduates can work in public hospitals or health centers after graduating, in the same way that the public midwifery school graduates can work in private hospitals or health centers. At public medical institutions such as health centers and hospitals, all midwives, either publicly or privately trained, must enter the government employment system. Similarly, both public and private midwifery school graduates must pass the private medical institution exam to work in the private sector.

To supplement their low government salaries, doctors, nurses, and midwives deployed at the local level are encouraged to open their own private practices in the areas in which they work. However, most of them leave the rural areas where they supposed to work on a daily basis and move to nearby urban areas for better private practice. Thereafter, they only occasionally visit their workplaces in rural areas.

Health Personnel

Since the mid-1970s, the windfall profits of the oil boom have allowed the Indonesian government to build health centers (puskesmas) with the goal of providing at least one per subdistrict. Many of these health centers were (and some still are) located in relatively isolated areas with limited infrastructure and access. Such health facilities are not considered ideal places to begin a professional career, especially for doctors who have already spent many years completing their studies and much money on their education. To staff these centers, the government turned to Law No. 8 (1961), Compulsory Labor for University Graduates (Wajib Kerja Sarjana), and applied it to a number of professions, including health personnel. In 1991 the government introduced Presidential Decree No. 37, which forced new medical school graduates to spend three years in a rural post as a dokter PTT (nonpermanent or contract staff doctor) as a condition for eligibility to earn their license to practice, most of them in the city, or to return to school to specialize. However, the program suffered from a variety of design problems.

This forced labor for doctors was discontinued when Indonesia ratified ILO Convention No. 105, Abolition of Forced Labor, as Law No. 19 on May 7, 1999. Since then, recruitment of doctors for placement in remote areas has been on a voluntary basis with reasonably attractive, and expensive, benefits. This change places greater pressure on local budgets, especially since decentralization when the recruitment and placement of doctors in community health centers became the responsibility of local governments with limited revenue.

The village midwives program (Bidan di Desa) was initiated in 1989 when the government was still highly centralized and only one policy decision was needed for the nation. At the time, it was regarded as an imaginative and successful program because over 50,000 midwives were placed in villages throughout the archipelago in less than a decade (Shankar et al., 2008). The midwives were under contract to the central government as nonpermanent staff (Heywood and Choi, 2010).

When decentralization was adopted, the central government was no longer required to provide health staff for local communities, and delivery of services became the responsibility of local governments. However, not all local governments consider midwives a priority (Heywood and Choi, 2010). Many village midwives have therefore left for urban centers, where opportunities in private practice are far greater.

Regional Variation in Health Services

As in most countries, in Indonesia doctors tend to be concentrated in the cities, and midwives tend to follow a similar path, seeking more urbanized areas to practice their profession. In terms of number of doctors per unit of population, Jakarta's position with respect to that of less densely populated provinces is not clear.¹ Jakarta covers only some 660 square kilometers, and yet it is home to almost 10 million people, according to the population census of 2010. On the basis of population, Jakarta is not overly supplied with health services providers and facilities; it has 39 medical staff, 87 nurses and midwives, and 4 community health centers per 100,000 population. Some other provinces are better served, such as Yogyakarta, which has 68 medical staff, 182 nurses and midwives, and 3 community health centers per 100,000 population. However, in terms of geographic density, Jakarta has more than 5,000 doctors, more than 12,000 nurses and midwives, and more than 500 puskesmas per 1,000 square kilometers, implying a well-developed demand for health services. The second-highest density of health services is found in Yogyakarta, and the third-highest in Bali. Both of these provinces are small and relatively well developed. Yogyakarta is known as an educational center, and Bali is world renown as a tourist destination, where availability of quality health care is important. Most other provinces fall far below, especially the rural provinces in Eastern Indonesia (Table 4-4).

TABLE 4-4

Number of Health Providers and Facilities per 100,000 Population and per 1,000 Square Kilometers, Indonesia.

These data show that the nature of the regional imbalance in health care delivery in Indonesia is not simply a matter of distribution of facilities among provinces and districts, but of geography. The provinces are much larger than Jakarta, and although they may have a comparable number of health providers per capita, those providers are sparsely distributed, and, for women, reaching the necessary facilities during childbirth may be extremely difficult in many areas. Reducing the practical effects of this imbalance would require more than simply adding health providers to existing facilities, because many of the facilities themselves are inaccessible to many families. This problem is inherent in a country with more than 13,000 islands, and it must be addressed with commensurate actions.

Demand for Maternal Health Services

Demand for maternal health services, particularly for services more commonly associated with safe and secure delivery remains an issue in much of Indonesia. According to the 2012 Indonesia Demographic and Health Survey, or IDHS (Badan Pusat Statistik et al., 2012), about 37 percent of births in the five years preceding the survey occurred “outside of a medical facility, almost all of these being within the woman's own home” (Table 4-5). This figure represents a significant improvement over the 2002 IDHS when closer to 60 percent of births were recorded as taking place outside a medical facility and the level recorded in the 2007 IDHS of about 54 percent. However, even these figures need to be treated with caution because. as in Table 4-5, the term medical facilities includes not just organized hospitals or clinics but also places such as the home of a nurse or qualified midwife. Changes in classification of birth location also make comparison to earlier rounds of the IDHS difficult, although it is worth noting that surveys in the 1990s in which the homes of local midwives were in the same classification as those of the pregnant women seeking their services showed closer to three-quarters of births occurring “at home.”

TABLE 4-5

Percent Distribution of Live Births in the Five Years Preceding the IDHS by Place of Delivery and Place of Residence, Indonesia: IDHS, 2002, 2007, 2012.

Attendance at birth is also an issue, with only a small proportion of births attended by doctors or obstetrician/gynecologists. The latter, in particular, are mainly confined to urban areas (Table 4-6).

TABLE 4-6

Percent Distribution of Live Births in the Five Years Preceding the IDHS by Type of Assistance at Birth and Place of Residence, Indonesia: IDHS, 2002, 2007, 2012.

There has been a fairly steady shift over the years from use of traditional birth attendants to midwives, but the use of TBAs remains strong among less educated women and those in rural areas. As well, it should be noted that here midwives include village midwives, many of whom are unable to offer much in terms of service when any significant complications occur. Although dealing more with neonatal mortality than with maternal mortality, a 2009 study by Hatt et al. (2009) using pooled IDHS data between 1991 and 2002 concluded that they could find no measurable relationship between overall declines in neonatal mortality and the increased availability of health personnel, notably through the village midwife program that got under way in 1989 and in theory provided for replacements for less trained birth attendants for deliveries in the home elsewhere in the village.

Interestingly, this situation can be contrasted with the demand for antenatal care, which has apparently benefitted from long-standing public programs to encourage at least four check-ups during pregnancy. According to the just released 2012 IDHS (Badan Pusat Statistik et al., 2012), during the five years preceding the IDHS more than 95 percent of women received at least one check-up from doctors, nurses, or trained midwives (Table 4-7). The same survey also found that nearly three-quarters reported the requisite four visits or more.

TABLE 4-7

Percent Distribution of Live Births in the Five Years Preceding the IDHS by Antenatal Care Provider during Pregnancy for the Most Recent Birth and Place of Residence, Indonesia: IDHS, 2002, 2007, 2012.

Cost and distance are among the most obvious factors affecting the use of trained attendance and institutional deliveries (Titaley et al., 2010). Particularly in more isolated regions and among poorer and less educated women, even carrying out an effective referral for difficult deliveries is far from easy. As shown in Table 4-6, the change in the most qualified attendant in rural areas is largely reflected in shifts from TBAs to trained midwives—still largely in a community setting. In urban areas, the shift is more from midwives toward doctors and ob-gyn's, which is one indication, among others, of the much easier access to health personnel and particularly to more professional care when it is needed.

Some recent initiatives designed to increase the use of health institutions include the maternity insurance scheme, Jampersal. It is specifically designed to ameliorate the cost implications of institutional deliveries as well as encourage an increase in the number of community health centers with a capacity for basic emergency services in neonatal obstetrics (BEmONC)—see Faizal (2011). The data in Table 4-5 are supportive of these initiatives, showing a recent marked increase in the demand for institutional deliveries, along with a more moderate increase in the use of highly qualified providers such as ob-gyn's (Table 4-6). The results also tie in with international experience in the positive impact of some of these supply-side initiatives, particularly in the use of health insurance.

However, another factor noted by Titaley et al. (2010) and others as well (e.g., Faizel, 2011) is simply the preference of women who have a normal pregnancy to give birth in more familiar surroundings, According to this view, trained attendants and institutional deliveries are in effect aimed primarily at women experiencing obstetric complications. This finding is in some ways of greater concern because it suggests that purely supply-side measures may not be sufficient in and of themselves to bring all deliveries into fully safe and secure surroundings. It is also of interest that, although public efforts appear to have been largely successful in convincing women of the importance of regular antenatal check-ups more or less irrespective of how they feel, the same cannot be said of institutional deliveries, even where they involve institutions such as health clinics where the quality of service may still be relatively low.

Thus, although the emphasis on supply-side interventions designed to address concerns related to access and cost remain critical, there also appears to be a need for a greater focus on the demand side, particularly at the community level. It should include efforts to educate families about the importance of giving birth under safe conditions and to inform them that a normal pregnancy without obstetric issues is no guarantee that a medical emergency during childbirth affecting the health of either the mother or the newborn child will not arise.²

References

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Footnotes

1

Jakarta has special status (like Washington, DC). Even though in terms of geography it is more resembles a municipality, it is treated more like a province.

2

The 2012 IDHS noted, for example, that while nearly all women who undertook antenatal check-ups received basic checks such as weight, blood pressure, stomach exam and consultation, only about half said they had received any specific information on symptoms of pregnancy complications or about the dangers of childbirth outside of surroundings where basic emergency services are not available (Badan Pusat Statistik et al., 2012).