A Paradox of Women's Health Rights under Decentralized Indonesia

Transcription

1 A Paradox of Women's Health Rights under Decentralized Indonesia Edriana Noerdin Women Research Institute Decentralization, Local Power and Women s Rights: Global trends in participation, representation and access to public services Organized by IDRC-UNDP November 2008, Mexico City

2 Policy Context Since the fall of the authoritarian government of Suharto in 1998, Indonesia has introduced a series of reform policy to make the government more responsive to the needs of the marginalized, including fulfilling the health rights of poor women. Laws on Decentralization (2001) and Elections (2003) have brought decision making closer to the people. Planning and budgeting that used to be conducted at the national level are now conduced by the Executives and Legislatives at the district/city level that are directly elected by the people.

3 Continue Presidential Instruction No. 9/2000 on gender mainstreaming instructs all government offices to integrate gender into the planning, formulation, implementation, and monitoring and evaluation processes of national development policies and programs. Election Law No. 12/2003 also provides affirmative action for women s participation in politics by ruling that 30% out of the total number of every political party s candidates for the national and local parliaments should be women. However, there has been a gap between the policies and their effective implementation. The gap has created a paradox of women s rights to health.

4 Key Issues: A Paradox of Women s Rights to Health (1) On the one hand, the reform policies have allowed the emergence of government champions in some 20 districts who address the health-related needs of poor women. A poor district of Jembrana (Bali), for example, implements local insurance policy that gives free health care services to the poor, including women. The case of Jembrana shows that it is the government s political will, and not funding availability, that stands on the way of the fulfillment of women s rights in health.

5 Key Issues: A Paradox of Women s Rights to Health (2) On the other hand many district/city governments treat public services, especially in health, as local revenue generation opportunities, hence draining money from the poor and marginalized people they are supposed to serve. The district of Bantul and the city of Yogyakarta (in central Java), for example, increased the fees at community health centers by 500% to 700% respectively. The district of North Lampung issued regulations that turned public health facilities at the community and district level as local revenue sources. These are taking place amidst the fact that Indonesia s maternal mortality rate is the highest in Southeast Asia.

6 Maternal Mortality in Indonesia Indonesia has become a middle-income country with GDP per capita of US$ 3,843 in 2005 (UNDP). Economic growth, however, has been accompanied with growing inequality. In the period of , maternal mortality rate in the country was as high as 310 per 100,000 births, lagging far behind the neighboring Philippines and Vietnam (170), Malaysia (30), and Thailand (24). ( The persistently high rate of maternal mortality makes maternal health the most important poor women s health rights issue in Indonesia.

7 Causes of High Rate of Maternal Mortality in Indonesia There are three causes of the high rate of maternal mortality in Indonesia: 1. insufficient budget allocation; 2. scarcity of competent maternal health service providers; 3. inadequate public health facilities for maternal health check up and delivery.

8 1. Insufficient Budget Allocation At the district/city level, the average amount of health budget is as low as 6% to 10% of the local budget. Ideally, it should reach at least 15%. At the department level, budget allocation for Reproductive Health only comes to less than 3% of the total budget of the Health Department. Ideally, it should come to at least 15%. At the national level, allocated budget spending for health only comes to US$ 4 per capita per year. In order to reach the MDG targets on reducing maternal mortality from 307 to 125 in 2015, the yearly per capita spending allocation should be US$ 12.

9 2. Scarcity of Competent Maternal Health Service Providers The number of physicians working in remote districts only come to less than 13% of the ideal ratio between them and the population. Physicians tend to live in the urban areas, adding transportation costs to the already relatively expensive fee. Only around 20% of all villages in Indonesia have professional midwife residing in their place. Many of them are inexperienced in handling medical emergencies because of the lack of standardized medical training.

10 Continue The midwives are overworked because they have to cover several villages under severe road conditions and inadequate transportation. Many midwives refuse to be stationed in remote areas due to safety concerns since many of them are singles.

11 3. Inadequate Public Health Facilities for Maternal Health Check up and Delivery Every sub-district now has a Community Health Center (Puskesmas). In the rural areas, however, the distance from a village to the subdistrict is quite far, especially when road condition is bad and transportation is scarce. Not all villages have a Junior Puskesmas, and the existing Junior Puskesmas are not adequately staffed. Ideally, there should be a general practitioner, a dentist, and a midwife in every Junior Puskesmas.

12 Continue Most Junior Puskesmas only has 2 rooms and are not equipped with adequate furniture, lighting, electricity, refrigerator to keep medicines safe, and clean water supply. Hospitals are only available in the city, or sub-district capital at the most, making it inaccessible to the poor in the rural areas.

13 The insufficient budget allocation, scarcity of competent maternal health service providers, and inadequate public health facilities for maternal health check up and delivery have made only 10.2% of women deliver their baby under the service of an obsgyn and only 55.3% are assisted by midwives. That leaves 31.5% of them to deliver their baby with the help of traditional baby shamans who are not equipped to deal with medical emergencies that require serious medical attention.

14 Continue A large number of women in the rural areas, 59 % of them, deliver their babies at home with the help of traditional baby shamans. The service of traditional baby shamans contributes greatly to the persistence of high maternal mortality rate in Indonesia.

15 Policy Recommendations 1. To address the insufficient budget allocation, Indonesia needs a gender budget policy that necessitates the government to allocate at least 15% of the national or local budget for health, and 20% of it should be allocated to provide free contraceptives and free maternal health check up and delivery for poor women. 2. To address scarcity of competent maternal health service providers, Indonesia needs a policy that would enable the government to send young doctors to the villages, and train more midwives and provide them with decent compensation and fast reimbursement system for the services that they provide to poor women.

16 Continue 3. To address inadequate public health facilities for maternal health check up and delivery, Indonesia needs a policy that would allow the government to prioritize the development of adequate health facilities at the village level. 4. To address the scarcity of competent maternal health service providers and inadequate public health facilities for maternal health check up and delivery, Indonesia should issue a policy that prevents public officials from reallocating budget that has been specifically allocated for maternal health.

17 Areas for Future Research 1. Study on whether the spending allocation of existing health budget at the national level and in some selected districts/cities is responsive to the need to reduce maternal mortality. 2. Impact study on the relation between budget reallocation conducted by government champions in selected districts/cities and the improvement of maternal health among poor women.

18 Thank you.