IssueBriefs

UNICEF INDONESIA OCTOBER 2012

Maternal andIssue
child
Brief:health
Maternal and child health
Critical issues Patterns in child mortality
Critical issues

M
In both rural and urban areas and across all wealth

E
very three minutes, somewhere in Indonesia, ost ofprogress
quintiles, Indonesias child deaths
in reducing now take
the neonatal
Every threeunder
a child
child under
minutes,
the
somewhere
the age
age of five
in Indonesia,
of five years
years dies.
dies. a
Moreover,
Issue Brief: Maternal and child health place during the neonatal
mortality rate has stalled in recent years. period, theThe
first2007
Moreover, every hour, a woman dies from month
Indonesia of life. Theand
Demographic probabilities
Health Survey of the child2007)
(IDHS
everybirth
giving hour,ora woman diesrelated
of causes from giving birth or of causes
to pregnancy. dyingshows that bothages
at different under-five
are 19 mortality
per thousand rate and
for neonatal
the
related to pregnancy. mortality
neonatal rate have
period; 15 per increased
thousand in from
the highest
2 to 11wealth
months
Criticalprogress
Indonesias issueson maternal health, the fifth In quintile,
and both
10 per but
rural theurban
and
thousand reasons
from areand
areas
age unclear
oneacross (Figure
to five 2). As
allyears.
wealth
Indonesias progress on maternal health, the fifth quintiles,
Although progress in reducing
rural households the
still neonatal
have an under-five
Millennium
Every three
Millennium Development Goal
minutes, somewhere
Development Goal(MDG), has
has slowed
in Indonesia,
(MDG), a
slowed in inmortality
other developing
rate has
countries
stalled in
attaining
recent years.
middle income
mortality rate one-third higher than thatThe 2007
in urban
in recent
recent yearsthe
child under
years. . Its
Itsage
maternal mortality
of fivemortality
maternal years dies. ratio, estimated
Moreover,
ratio, estimated at status, Indonesias
Indonesia Demographicchild mortality
and Health due
Survey to infections
(IDHS
households, one study shows that rural mortality rates 2007)
every hour,
at around
around 228 a
228per woman
per dies
100,000
100,000 from
live
live giving
births,
births, hasbirth
has or of causes
remained
remained and other
shows thatchildhood
both illnesses
under-five has
mortality declined,
rateand as mothers
andthat
neonatal
are falling faster than urban rates, urban
related toabove
stubbornly
stubbornly pregnancy.
above 200 over
200 over thethe past decade,
decade, despite
despite mortality rate
education, have increased
household in the highest wealth
and environmental hygiene,
efforts to improve maternal health services. Poorer quintile, but the reasons are unclear (Figure
income and access to health services have improved.2).
efforts to improve
Indonesias maternal
progress health services.
on maternal health, thePoorer
fifth
countriesininthe
theregion
regionshow
show greater
greater progress
progress in Although rural households still have an under-five
countries
Millennium Development Goal (MDG), in this
has slowed thisin Neonatal mortality
mortality rate is higher
one-third now the main
than hurdle
that in urbanin reducing
regard (Figure
recent
regard years.
(Figure 1).1).
Its maternal mortality ratio, estimated at further child one
households, deaths.
studyMost
showsofthat
therural
causes of neonatal
mortality rates
around 228 per 100,000 live births, has remained are falling
deaths are faster than urban rates, and that urban
preventable.
stubbornly
Figure above
1. Maternal 200 over
mortality theselected
trends, past decade, despite
ASEAN countries
efforts to improve maternal health services. Poorer
Source: UN Maternal Mortality Estimation Group: WHO, UNICEF, UNFPA, World Bank

countries
Maternalin the region show greater progress in this
deaths
700 per 100,000 live
regard (Figure 1).
births

600

Figure 1. Maternal mortality trends, selected ASEAN countries

500
Source: UN Maternal Mortality Estimation Group: WHO, UNICEF, UNFPA, World Bank
Maternal deaths
400
700 per 100,000 live
births
300600

200500 Indonesia's MDG

target = 102
Philippines
100400 mortality has even increased in the neonatal period.
These trends appear to be associated with rapid
0300
1990 1995 2000 2005 2010 2015 urbanization, leading to overcrowding and poor
200 Indonesia's MDG
target = 102
sanitation conditions amongst the urban poor,
100
Philippines
exacerbated
Inmortality
both rural and
has even byincreased
changes
urban in the
areas
in society
and that period.
across
neonatal have led to the
all wealth
Indonesia
Indonesia is doing
is doing muchmuch better
better in in reducing
reducing infant-
infant- loss
These of traditional
trends appear social
to be safety
associated nets. The
with suboptimal
rapid
quintiles, progress in reducing the neonatal mortality
and
and
0
under-five
under-five
1990 mortality,
mortality,
1995 thefourth
2000 the fourthMDG.
2005 MDG.
2010 The
The 1990s
20151990s rate quality of services
urbanization,
has stalled leading toinovercrowding
in recent poor urban
years. areas
and
The 2007could
poor also be a
Indonesia
showed a steady progress in reducing the under-five sanitation conditions
contributing amongst the urban poor,
factor.
showed a steady progress in reducing the under-five Demographic
exacerbated byand Health
changes Surveythat
in society (IDHShave2007)
led to shows
the
mortality rate, together with its components, infant that both under-five mortality rate and neonatal
mortality
Indonesiarate,istogether
doing much withbetter
its components,
in reducing infant
infant- loss of traditional social safety nets. The suboptimal
Child mortality is associated with poverty. Children
mortality and neonatal mortality rates. In recent years,
mortality
and and neonatal
under-five mortality
mortality, the rates.
fourth In
MDG. recent
The years,
1990s quality
mortality
in theof poorest
services
rate have in increased
poor urbangenerally
households areas
in the could also
highest
have be a
wealth
under-five
however, the reduction of neonatal mortality appears to contributing factor.
showed
however, thea steady
reduction progress
of in reducing
neonatal the
mortality
have stalled. If this trend continues, Indonesia may not under-five
appears quintile, but the reasons are unclear (Figure
mortality rates more than twice as high as those in the 2).
mortality rate,Iftogether with continues,
toachieve
have stalled.
the MDGthis trend
targets foritschild
components, infant may
Indonesia
mortality reduction by wealthiest
Although ruralquintile. This isstill
households because
have an
Child mortality is associated with poverty. Children
wealthier
under-five
mortality and neonatal mortality rates. In recent years, households have more access to quality
not achieve
2015, the
although MDG targets
it appeared tofor
bechild mortality
on track in earlier mortality rate one-third higher than that
in the poorest households generally have under-five inhealth
urbanand
however, the reduction of neonatal mortality appears to social services, better health-seeking practices
years.
reduction by 2015,
have stalled. although
If this it appeared
trend continues, to bemay
Indonesia on not
track households,
mortality rates one study
more thanshows that
twice as rural
high as those in theand
mortality rates
generally
wealthiest higher levels of education.
in earlier years.
achieve the MDG targets for child mortality reduction by are falling quintile. This urban
faster than is because wealthier
rates, and that urban
2015, although it appeared to be on track in earlier households have more access to quality health and
Patterns
years. in child mortality Child
social mortality
services, rates
better in poor peri-urban
health-seeking areas are
practices and
much higher
generally than of
higher levels the urban average. A study of
education.
Most of Indonesias child deaths now take place mega-urban Jakarta (called Jabotabek1), Bandung
Patterns
during in child
the neonatal mortality
period, the first month of life. Child
andmortality
Surabaya rates in poor
in 2000 foundperi-urban areas are
child mortality rates up to
The probabilities of the child dying at different ages are much higher than the urban average. A study of
unite for children
19Most of Indonesias
per thousand for the child deathsperiod;
neonatal now take place
15 per
five times higher in Jabotabeks poor peri-urban
mega-urban
subdistrictsJakarta
than in(called
Jakarta Jabotabek 1), Bandung
city centre. The higher child
during the
thousand neonatal
from 2 to 11period,
monthstheandfirst
10 month of life.
per thousand and Surabaya
mortality is in 2000 found
attributed child mortality
to diseases rates up to
and conditions
from age one to five years. As in other developing are
The probabilities of the child dying at different ages fiveassociated
times higherwithin Jabotabeks
crowding, and poorbyperi-urban
poor water quality and
19 per thousand
countries attainingformiddle
the neonatal
incomeperiod;
status,15Indonesias
per subdistricts than in Jakarta city centre. The higher child
sanitation.
thousand from 2 to 11 months and 10 per thousand mortality is attributed to diseases and conditions
 ISSUE BRIEFS OCTOBER 2012

mortality has even increased in the neonatal period. Ministry of Health has projected a rise in HIV
These trends appear to be associated with rapid infection among children.
urbanization, leading to overcrowding and poor
sanitation conditions amongst the urban poor, Disparities in health services
exacerbated by changes in society that have led to

Q
the loss of traditional social safety nets. uality maternal and neonatal health services
The suboptimal quality of services in poor urban can prevent a large proportion of deaths. In
areas could also be a contributing factor. Indonesia, the neonatal mortality rate amongst
children whose mothers received antenatal care and
Child mortality is associated with poverty. Children delivery assistance by a medical professional was
in the poorest households generally have under-five one-fifth of that amongst children whose mothers
mortality rates more than twice as high as those in did not receive these services. Figure 4 provides an
the wealthiest quintile. This is because wealthier overview of the coverage of selected maternal and
households have more access to quality health and neonatal health services in Indonesia.
social services, better health-seeking practices and
generally higher levels of education.
particularly high in West Sulawesi, South Kalimantan,
particularly high in West Sulawesi, South Kalimantan, West Sulawesi
West Nusa
Child Tenggara
mortality andinWest
rates poorSumatra, exceeding
peri-urban areas are the West Sulawesi
Maluku
West Nusa Tenggara and West Sumatra, exceeding the Maluku
under-five mortality rates in better-off provinces such as West Nusa Tenggara
much higher
under-five thanrates
mortality the inurban average.
better-off A study
provinces suchofas West Nusa Tenggara
East Nusa Tenggara
Central Kalimantan, Central Java and Yogyakarta. East Nusa Tenggara
Central Kalimantan,
mega-urban Central
Jakarta Java Jabotabek
(called and Yogyakarta. South Kalimantan
generally), lower,
1 Bandung
Whilst the mortality rates in Java are South Kalimantan
North Maluku
Whilst
and the mortality
Surabaya in rates in
2000 found Java are generally
childnumbers
mortality lower, North Maluku
of rates up
Central Sulawesi
this nonetheless translates into large CentralGorontalo
Sulawesi
this nonetheless
to five women translates
times higher into large
in Jabotabeks numbers of
poor peri-urban
affected and children, an important NorthGorontalo
Sumatra
affected women and children, an important NorthBengkulu
Sumatra
subdistrictsinthan
consideration in Jakarta
targeting city centre. The higher
efforts. Bengkulu
consideration in targeting efforts. Papua
child mortality is attributed to diseases and conditions West
Papua
West Sumatra
Sumatra NMR
Children of less
associated witheducated
crowding, mothers
and by generally
poor waterhave quality
West Papua
NMR
Children of less educated mothers generally have West
Southeast Papua
Sulawesi
higher
and mortality
sanitation. rates than those born to better- Southeast Sulawesi
West Kalimantan
higher mortality rates than those born to better- West Kalimantan IMR
educated mothers. In the period 1998-2007, the infant Banten
IMR
educated mothers. In the period 1998-2007, the infant Banten
Riau Islands
mortality rate amongst children of mothers with no Riau Islands
Lampung
mortality rate amongst
Geographic disparitieschildren of mothers
are striking: with no
under-five South Lampung U5MR
education was 73 per 1,000 live births, whilst that Sulawesi
U5MR
education
mortality was 73 per
rates of
are 1,000
over 90live births, whilst
persecondary
thousandor that
inhigher
three South
SouthSulawesi
Sumatra
amongst children mothers with South Sumatra

D
West Java
amongst
eastern children of
provinces mothers
(Figure with
3). secondary
Neonatal or higher is
mortality
D
West Java
education was 24 per 1,000 live births. The difference is Riau
education washigh
particularly 24 per 1,000 Sulawesi,
in West live births.South
The difference
Kalimantan,is Riau
Jambi Figure 3. Under-five,
attributed to better health seeking behaviour and Jambi Figure
infant3. Under-five,
& neonatal
attributed to better health seeking behaviour and Bangka Belitung
infant & neonatal
knowledge
West Nusa amongst
Tenggara educated
and Westwomen.
Sumatra, exceeding BangkaEast
Belitung
Java mortality rates (U5MR,
knowledge amongst educated women. East Aceh
Java mortality rates
IMR,(U5MR,
NMR)
the under-five mortality rates in better-off provinces Aceh
North Sulawesi in the 10-year NMR)
IMR, period
in the 10-year period
Indonesia is seeing
such as Central an increasing
Kalimantan, feminization
Central Java and of
North
East Sulawesi
Kalimantan preceding the survey.
Indonesia is seeing an increasing feminization of East Kalimantan
Bali
preceding
Source:the survey.
IDHS 2007
the HIV/AIDS
Yogyakarta. epidemic. The
Whilst theThe proportion
mortality of in
rates women
Java are Bali
Source: IDHS 2007
the HIV/AIDS epidemic. proportion of women DKI Jakarta
amongst new HIV cases has grown from 34 per cent in Central DKI Jakarta
Kalimantan
amongst new
generally HIV cases
lower, has grown from
this nonetheless 34 per into
translates cent large
in CentralCentral
Kalimantan
2008 to 44 per cent in 2011. Consequently, the Ministry Java
2008 to 44 per
numbers of cent in 2011.
affected womenConsequently,
and children,thean
Ministry DICentral Java
Yogyakarta
of Health has projected a rise in HIV infection among DI Yogyakarta
ofimportant
Health hasconsideration
projected a rise
in intargeting
HIV infection among
efforts. 0 10 20 30 40 50 60 70 80 90 100
children. 0 10 20 30 40 50 60 70 80 90 100
children.
Disparities
Children of lessineducated
Disparities health
inrates
health services
mothers generally have
higher mortality than services
those born to better-
Quality
educatedmaternal andInneonatal
mothers. the periodhealth servicesthe
1998-2007, caninfant
Quality maternal and neonatal health services can
prevent a large proportion of deaths. In Indonesia,
prevent a large proportion of deaths. In Indonesia,no
mortality rate amongst children of mothers with
the neonatal mortality rate amongst children whose
education
the neonatal was 73 per
mortality 1,000
rate live births,
amongst childrenwhilst
whose that
mothers received antenatal care and delivery
mothers received antenatal carewith
and delivery
assistance by a medical professional was one-fifth ofhigher
amongst children of mothers secondary or
assistance
education by a medical professional was one-fifth of
that amongstwas 24 per
children 1,000
whose live births.
mothers Thereceive
did not difference
that amongst
is attributed children whose mothers did not receive
these services.to better4 health
Figure provides seeking behaviour
an overview of theand
these services. Figure 4 provides an overview of the
knowledge
coverage amongst
of selected educated
maternal andwomen.
neonatal health
coverage of selected maternal and neonatal health
services in Indonesia.
services in Indonesia.
Indonesia is seeing an increasing feminization of
The
theproportion
HIV/AIDSof births attended
epidemic. by skilled
The proportion ofhealth
women
The proportion of births attended by skilled health
personnel
amongst has has improved
newimproved steadily
HIV casessteadily
has grownfrom 41 per
34 cent in
personnel fromfrom
41 per per cent
cent in
1992 to 82 per cent in 2010. The indicator includes
1992
in to 82toper
2008 44 cent
per in 2010.
cent in The indicator
2011. includes
Consequently, the
only doctors and midwives or village midwives. Still, in
only doctors and midwives or village midwives. Still, in
seven
1 The eastern provinces,
urban area oneJakarta:
surrounding out of every three birthsand
seven eastern provinces, one out of Bekasi; and Bogor
every three births
took
Depokplace without
in West assistance
Javaassistance from any
Province; Tangerang type of health
took place without from anyand South
type Tangerang
of health
staff, attended
in Banten only by traditional birth attendants or
Province.
staff, attended only by traditional birth attendants or
family members.
family
2 members.
The proportion of births delivered in a health facility
The proportion of births delivered in a health facility
remains low at 55 per cent. Over half the women in 20
remains low at 55 per cent. Over half the women in 20
provinces were unable or unwilling to use any type of
provinces were unable or unwilling to use any type of
 ealth
cent in
des OCTOBER 2012 ISSUE BRIEFS
till, in
births
ealth
women received the complete set of the first five
or
interventions, according to Riskesdas 2010. Even in
Yogyakarta, the province with the highest coverage,
facility this proportion was only 58 per cent. Central Sulawesi
n in 20 has the lowest coverage at 7 per cent.
e of
es. Some 38 per cent of reproductive aged women
kely to reported having received two or more tetanus
n care toxoid injections (TT2+) during pregnancy.
e with The Ministry of Health recommends that women
receive two tetanus toxoid injections during the first
pregnancy, with booster injections once during each
made subsequent pregnancy to maintain full protection.
their The lowest TT2+ coverage was found in North Sumatra
ent) in (20 per cent) and the highest in Bali (67 per cent).
the
h. About 31 per cent of post-partum mothers received
and 8 The quality
The proportion of births
of care attended
received duringbyantenatal
skilled health
visits timely postnatal care. This means care within 6
enatal personnel has improved steadily from
is inadequate. Indonesias Ministry of Health41 per cent in to 48 hours after birth, as defined by the Ministry of
recommends
1992 to 82 perthecent
following components
in 2010. of quality
The indicator includes Health. Good postnatal care is critical, as most
antenatal care:
only doctors (i) midwives
and height andor weight measurements,
village (ii)
midwives. Still, maternal and neonatal deaths occur in the first two
in seven eastern provinces, one out of every three days and postnatal care is necessary to treat
births took place without assistance from any type 2 complications following the delivery. Riau Islands,
of health staff, attended only by traditional birth East Nusa Tenggara, Papua are the worst performers
attendants or family members. in this respect, the coverage of timely postnatal care
being only 18 per cent in Riau Islands. Some 26 per
The proportion of births delivered in a health facility cent of all post-partum mothers never received any
remains low at 55 per cent. Over half the women in 20 postnatal care.
provinces were unable or unwilling to use any type of
health facility, delivering instead in their own homes. Amongst maternal health services, facility-based
Women who deliver in a health facility are more likely delivery has the greatest disparities (Figures 4 and
to have access to emergency obstetric and newborn 5). The proportion of facility-based deliveries in
care services, although this is not necessarily the case urban areas is 113 per cent higher than that in rural
with all health facilities. areas. The proportion of women from the highest
wealth quintile delivering in health facilities is 111 per
Some 61 per cent of women age 10-59 years made cent higher than that from the poorest quintile.
the required four antenatal care visits during their
last pregnancy. Most pregnant women (72 per cent) in With respect to other services, wealth disparities are
Indonesia make the first visit, but drop out before the greater than urban-rural disparities. The urban-rural
four visits recommended by the Ministry of Health. differential is 9 to 38 per cent for services relating
Some 16 per cent of women (25 per cent of rural and 8 to antenatal care, TT2+, delivery and postnatal care
per cent of urban women) never received any antenatal services, but the differentials between wealth quintiles
care during their last pregnancy. range from 34 to 68 per cent. The relatively low
coverage of timely postnatal care services is more
The quality of care received during antenatal visits likely due to the lack of priority amongst women for
is inadequate. Indonesias Ministry of Health these services, than to difficulties in access or
recommends the following components of quality availability.
antenatal care: (i) height and weight measurements,
(ii) blood pressure measurement, (iii) iron tablets, (iv) Barriers

tetanus toxoid immunization, (v) abdominal
examination, and in addition, (vi) testing of blood
and urine samples and (vii) information on the signs
of pregnancy complications. Some 86 and 45 per cent
of pregnant women respectively had blood samples
taken and were informed on the signs of pregnancy
complications. However, only 20 per cent of pregnant
T
he poor quality of antenatal, delivery and postnatal
health care services is a major barrier to reducing
maternal and child deaths. Across all population
groups, the coverage on indicators relating to service
quality (e.g., quality antenatal care) is consistently
lower than that relating to quantity or access (e.g.
four antenatal visits). A 2002 study showed that the
3
 ISSUE BRIEFS
poor quality of care was a contributing factor in 60
per cent of the 130 maternal deaths examined.
The poor quality of public health care shows the
need to increase government spending on health.
Indonesia has one of the lowest total health
expenditures, at 2.6 per cent of its gross domestic
product in 2010. Public health expenditures
constitute just under half of total health spending.
At district level, the health sector receives only 7 per
cent of the total sub-national funds, and the Special
Allocation Fund (DAK) for health constitutes, on
average, less than one per cent of the total budget of
the local government.
Planning processes for DAK need to become more
efficient, effective and transparent. At central level,
parliamentary representatives play significant roles in
determining funding allocation for their respective
districts, and in doing so, slow down the DAK
process considerably. Health funding is available at
district level only late in the fiscal year.
Various barriers prevent poor women from fully
realizing the benefits of Jampersal, the Governments
health insurance programme for pregnant women.
The barriers include insufficient reimbursement
levels, especially when the costs of transport and
complications are included, and a lack of awareness
amongst women of the eligibility for and benefits of
Jampersal.
On the supply side, there needs to be more health
facilities offering Comprehensive Emergency
Obstetric and Newborn Care (CEONC) services
and more obstetrician-gynaecologists. Indonesias
CEONC facility-population ratio (0.84 per 500,000) is
still below the ratio of one per 500,000 recommended
by UNICEF, WHO and UNFPA (1997). Indonesia has
around 2,100 obstetrician-gynaecologists (or one per
31,000 women of reproductive age), but not equitably
distributed. More than half the obstetricians-
gynaecologists practice in Java.
Inappropriate behaviour and the lack of knowledge
contribute to child deaths:
Mothers and community health workers lack
knowledge on preventing or treating common
childhood diseases. In Indonesia, one in three
children under the age of five suffers from fever
(which could be due to malaria, acute respiratory
and other infections), and one in seven suffers from
diarrhoea. A large proportion of deaths from these
diseases is preventable. However, this requires
knowledge, timely recognition, treatment and
4
OCTOBER 2012
behaviour change amongst mothers and health
workers. For example, the IDHS 2007 reports that
only 61 per cent of children under age five with
diarrhoea were treated with oral rehydration therapy.
Mothers are not aware of the importance of
breastfeeding. The 2007 IDHS showed that less than
one in three infants under the age of six months
were breastfed exclusively. The majority of infants
in Indonesia are therefore not receiving the benefits
of breastmilk in terms of nutrition and protection
against disease.
Poor sanitation and hygiene practices are widely
prevalent. Riskesdas 2010 reports that some 49 per
cent of households in Indonesia use unsafe means of
excreta disposal, and 23 to 31 per cent of households
in the poorest two quintiles still practice open
defecation. Such practices are associated with
diarrhoeal disease. Riskesdas 2007 reports diarrhoea
as the cause of 31 per cent of deaths between the
ages of 1 month to a year, and 25 per cent of deaths
between the ages of one to four years old.
Poor feeding and other care practices contribute
to maternal and child malnutrition, an underlying
cause of child death. One out of every three children
is stunted, and in the poorer quintiles, one out of
every four to five children is underweight. Nationally,
six per cent of young children are severely wasted,
which places them at high risk of death.
Opportunities for action
O
verall, Indonesias health spending needs to
increase, including the proportion of DAK going
to the health sector. Increasing health spending
should go hand-in-hand with tackling the remaining
financial and other barriers that prevent poor women
from accessing quality health services.
A clear delineation is needed between the roles of
central and sub-national levels in health care provision.
Standards and regulation are part of the central level
stewardship function and should not be devolved to
sub-national level.
Maternal and child health services need a shift
in focus to quality, including delivery at facilities
equipped with emergency obstetric and neonatal care
services. The shift to quality needs action at several
levels.
The central level needs to develop and enforce
standards and guidelines on the quality of services.
Rigorous monitoring is needed to ensure the
 OCTOBER 2012
implementation of standards by both public and
private health care providers.
Private health care needs to be part of government
health policies and frameworks. Current efforts to
improve health care standards are disproportionately
targeting government facilities. Yet three times as
many deliveries took place in private facilities than
in public facilities in the period 1998-2007. Private
health care providers and training facilities are
already significant parts of the Indonesian health
system and therefore need to be part of government
health policies, standards and information systems.
Regulation, inspection and certification should
ensure the compliance of private providers with
government standards and information systems.
More facilities providing CEONC services need to
be established. At the same time, referral systems
should be strengthened to promote appropriate use
of these facilities.
The move towards quality will require additional
resources to develop and motivate health staff.
The performance of staff depends on both skills and
motivation. Building skills requires not just more
training, but rather, facilitative supervision of case
management, and for professionals, peer-review
assessment, periodical supervision, and critical event
or mortality audits. Continuous feedback, monitoring
and supervisory sessions play an important role,
not only in improving quality but also in motivating
teams. Indonesia may wish to consider incentives for
health staff. These could be non-financial (enhanced
role, ownership, and professional recognition),
financial (adding a performance-based component
to the salary), or institutional and team-based
(measures such as accreditation systems and friendly
competitions).
A robust information system is one of the
components of quality health services. Health
information systems across Indonesia are not
performing as well as they did before decentralization.
Administrative data is poor in many of the districts,
making it impossible for the district health team to
effectively plan and target interventions. The central
level needs robust data for discharging its stewardship
function. The situation may require re-centralizing
and harmonizing certain functions relating to health
information systems, especially with regard to
processes, reporting and standards.
At national level, the existing minimum service
standards (SPM) need review and reformulation.
Many poor districts consider the current standards to
ISSUE BRIEFS
be unattainable. The standards should accommodate
Indonesias wide disparities and different baselines,
for example, by formulating progress in terms of
percentage increase rather than a fixed level. This
would allow districts to develop more realistic
action plans. The setting of certain standards will
need to consider geographic realities, population
density and the availability of human resources.
The Government should support districts or cities
that lack the infrastructure to achieve the minimum
service standards.
To realize the full benefits of decentralization,
district health teams need central and provincial
support in evidence-based planning and
implementation. Decentralization increases the
potential for local governments to plan, budget,
and implement programmes tailored to local needs,
but this will happen only if the local capacities are
adequate. The province level needs resources to help
districts plan and implement interventions that
improve quality and coverage.
Preventive health programmes need to be promoted
and accelerated. This will require promoting a
continuum of care starting from the adolescent and
pre-pregnancy period and continuing throughout
pregnancy, delivery and childhood. Interventions
should include proven, cost-effective interventions
such as community-based case management of
common childhood illnesses, breastfeeding
promotion and counselling, provision of folic acid
supplementation in the preconception stage, maternal
anthelmintic therapy, maternal and infant
micronutrient supplementation, and maternal and
infant use of insecticide-treated bed nets.
Elimination of parent to child HIV transmission will
require provider-initiated HIV testing and counselling
for all pregnant women as part of routine
antenatal care, more rigorous follow-up, and better
public education.
Resources
Adair, T. (2004). Child Mortality in Indonesias Mega-
Urban Regions: Measurement, Analysis of Differentials,
and Policy Implications. 12th Biennial Conference of the
Australian Population Association, 15-17 September 2004,
Canberra.
BPS-Statistics Indonesia (2011): Susenas 2010: National
Socio-Economic Survey. Jakarta: BPS
BPS-Statistics Indonesia and Macro International (2008):
Indonesia Demographic and Health Survey (IDHS 2007).
Calverton, Maryland, USA: Macro International and
Jakarta: BPS.
5
 ISSUE BRIEFS
Lawn, J.E., Cousens, S., and Zupan, J. (2005): 4 million
neonatal deaths: When? Where? Why? Lancet, 365: 891-900
Ministry of Health (2000): Petunjuk pelaksanaan program
imunisasi di Indonesia (Guidelines for the implementation
of immunization program in Indonesia) Jakarta, Indonesia:
Ministry of Health
Ministry of Health (2001a): National Strategic Plan for
Making Pregnancy Safer (MPS) in Indonesia 2001-2010.
Jakarta, Indonesia: Ministry of Health
Ministry of Health (2001b): Yang perlu diketahui petugas
kesehatan tentang kesehatan reproduksi (What health
service providers need to know about reproductive health)
Jakarta, Indonesia: Ministry of Health
Ministry of Health (2008): Laporan Nasional: Riset
Kesehatan Dasar (Riskesdas) 2007, Jakarta: Ministry of
Health, National Institute of Health Research and
Development.
Ministry of Health (2011): Laporan Nasional: Riset
Kesehatan Dasar (Riskesdas) 2010, Jakarta: Ministry of
Health, National Institute of Health Research and
Development.
6 This is one of a series of Issue Briefs developed by UNICEF Indonesia. For more information, contact jakarta@unicef.org or go to www.unicef.or.id
OCTOBER 2012
Nguyen, K.H., Bauze, A.E., Jimenez-Soto, E. and Muhidin,
S. (2011). Indonesia: developing an investment case for
financing equitable progress towards MDGs 4 and 5 in
the Asia-Pacific region: Equity Report. Brisbane, Australia:
School of Population Health, the University of Queensland
SMERU (2008): The Specific Allocation Fund (DAK):
Mechanisms and Uses. Jakarta: SMERU Research Institute
Supratikto, G, Wirth, M.E., Achadi, E., Cohen, S. and
Ronsmans, C. (2002): A district-based audit of the causes
and circumstances of maternal deaths in South Kalimantan,
Indonesia. Bulletin of the World Health Organization,
80(3):228-34.
UNICEF, WHO and UNFPA (1997): Guidelines for
Monitoring the Availability and Use of Obstetric Services.
New York: UNICEF.
World Bank (2010): Indonesia Health Sector Review.
Accelerating Improvement in Maternal Health: Why reform
is needed. Policy and Discussion Notes, August 2010.
Jakarta: World Bank
World Bank: World Development Indicators database.
Available from: http://data.worldbank.org/data-catalog/
world-development-indicators Accessed 7 August 2012.