Inequity in FP and RH Services in Indonesia Kartono Mohamad Presented at Regional Consultation on FP in Asia and pacific Bangkok 8-10 Dec 2010
Background information Indonesia is divided into 33 Provinces, 370 Districts and 96 Municipalities Based on the decentralization law (2002), people s welfare is under the responsibility of the district/municipality District heads and mayors are directly elected by local people Health and FP policy is formulated and carried out at the local (district/municipality) level
After decentralization, Health and FP staffs are employees of district/municipality Most of district heads and mayors are not well prepared to take over the responsibility on health and FP programs (lack of understanding/knowledge) Population/Family Planning program is not in the list of 15 priorities of the current administration (and neither in the first term of President SBY administration)
Legal development (and ambiguity) New Health Law (Law no 36/2009) recognizes reproductive rights and permits safe abortion service for medical indications and for rape caused pregnancy (still needs implementation regulation) Population Law (Law no 52/2009) restricts the provision of contraceptives only for married couple Medical Practice Law states that any medical procedures can only be performed by medical doctor (is IUD insertion a medical procedure?) Legally hormonal contraceptives are prescribed medicines and need doctor s prescription
Social environment Health care system is still based on fee for service and paid out of pocket by the patients. 70% of health expenditures are contributed by the patients The rise of religious fundamentalism brings political pressure to the government The declining of family planning campaign and services and most of the FP field workers are disbanded The growth of provider induced demand on contraceptive method more expensive
Trends of Indonesian Health Expenditure (2001 2005) EXPENDITURES ON HEALTH 2001 2002 2003 2004 2005 Expenditure ratios Total expenditure on health (THE) as % of GDP 2.7 2.8 2.9 2.8 2.7 Financing Agents measurement General government expenditure on health (GGHE) as % of THE 33.1 33.7 31.6 34.2 34.7 Private sector expenditure on health (PvtHE) as % of THE 66.9 66.3 68.4 65.8 65.3 General government expenditure on health as % of GGE 4.2 5.3 4.6 5.0 5.0 Social security funds as % of GGHE 8.9 10.2 11.7 10.8 21.3 Private households' out-of-pocket payment as % of PvtHE 75.1 75.3 76.0 74.7 74.3 Prepaid and risk-pooling plans as % of PvtHE 4.1 5.1 5.6 5.9 6.0 source : World Health Organization, 2007
Inequity IDHS 2007 shows that higher TFR and unmet needs happen among the poor, the uneducated, and in the rural areas 1600 out of 9000 health centers have no doctor, mostly in the rural areas (in East Nusa Tenggara Province, there were 500 doctors in 2005 and now only around 280 left) Doctors are stationed in rural HC s for only 6 month (in the most remote areas) or 1-2 years in less remote areas Out of 60,000 village midwives in the late 80 s now only less than 10,000 remain in the village, mostly have their own private practice (this explains why injectable contraceptives are on the rise)
Data source: MEASURE DHS Statcompiler Method Mix in Indonesia (1987 2007)
Fertility Preferences and Contraceptive Method Use Among Women in Indonesia DHS 2007
Inequity Enhanced by political, administrative, legal and social conditions High rate of knowledge on FP and lack of services increased unwanted pregnancies and unsafe abortion Annually around 2 million illegal abortions performed in Indonesia Contributes 20-30% to MMR
Cause of inequity and low achievement Lack of understanding of FP/population programs among political elites in central, local, as well among the political parties The ambiguity of the laws Lack of strong commitment from the central government Lack of clear objectives of FP/population programs: MOH will expand the FP services to 50000 clinics both public and private (but how? Public health facilities belong to the local government and private clinics need financial motivation ) BKKBN will train 2500 doctors and 5000 midwives, despite most if the doctors will stay only for 6 months to 2 years in the rural HCs People has to pay for their contraceptives (may be until the universal health insurance be implemented in 2014)
Can we achieve MDG 5 in 2015?
Maternal Mortality Rate (BAPPENAS 2008)
Modern Contraceptive Use and Maternal Mortality Ratio Married Women Using Contraception Maternal Deaths Per 100,000 Live Births
Unsafe abortion in 2008: global and regional levels and trends. Iqbal Shah, Elisabeth Åhman Reproductive Health Matters 2010;18(36):90 101
What we need (to accelerate MDG 5 achievement) 5 achievement) Strong commitment, vision, clear objectives, and total football strategy to address the FP and RH needs to reduce the inequity in FP services and MMR Healthy team work and coordination among the government offices Seriously address the unsafe abortion, adolescent pregnancy (reduce AFR), and adolescent reproductive health needs (incl sexual education) Increase the number of Long Term Method contraceptive use Include IUD insertion and sterilization training in the medical curriculum especially for the last year students (they will be ready to provide FP services when they are stationed in the HC, even if it is only for 6 months or 1 year) Motivate the local government by giving them award (like in the Soeharto s era)
Be brave and firm Do not waver in the face of political pressure (don t just play safe) Complacency will make us lost our demographic bonus opportunity and brings economic and social disaster Thank you