TOWARD A BETTER MATERNAL AND CHILDREN CARE IN INDONESIA for MGIMS, India

TOWARD A BETTER
MATERNAL AND
CHILDREN CARE IN
INDONESIA
Lesson from India National
Rural Health Mission

Shela Putri Sundawa,
Universitas Indonesia
MGIMS, India
July 12th, 2012

Maternal Mortality Rate

Source: Report on the Achievement of the Millenium Development Goals Indonesia 2010. Bappenas. 2010

Child Mortality Rate


Maternal and infant Major cause of maternal
mortality death in Indonesia:
haemorrhage in post partum

Indicate inadequate
Indicate effectiveness in health management of 3rd satge
system functioning labor and failure in emergency
care in health system

Poor health system delivery in
Indonesia

Maternal Mortality

Need special attention
and improvement in
health care delivery
system

Skilled birth attendand delivery in urban >
rural


Health System Delivery

rural urban

Source: Millenium Development Goals India Country Report 2009. Central statistical organization, Ministry of Statistic
and Program Implementation. 2009

Health System Delivery

Urban Rural

National Urban
Health Mission National Rural
(not yet Health Mission
launched)

Different needs, different strategies

Source: Kishore J. National health programs of India: national policies and legislations related to health. 8th ed. New
Delhi: century publications. 2009

NRHM

212 in 2007-9

Report of the working group of national rural health mission for the tweleft five year plan (2012-2017)

INDONESIA:COUNTRY
HEALTH PROFILE

Basic Information Latest available value Year
Total population (million) 222.05 2006
Area (sq.km.) 1,860,360
Area as percent of world’s total 1,37
Density of population (per sq.km.) 116
2005
Administrative divisions 33 provinces,
349 regencies, and 91
municipalities
Development Latest available value Year
Gross national income (GNI) per 1280 2005
COUNTRY

capita (US $)
PROFILE

Population below poverty line – 5.9 2008
International $1 per day (%)
Population below national poverty 17 2004
line (%)
Adult literacy rate > 15 years (%) 91 2004
Net enrolment ratio – primary (%) 99.47 2009
Human Development Index 0.711 2004
Human Poverty Index (%) 18.5 2006
WHO. Mini Profile SEAR counties. 11 questions about the 11 SEAR countries. 2007

Indicators 1990 2000 2005 2010 2015 (Target)
PROGRESS OF HEALTH RELATED MDGS Poverty and hunger
Population below minimum level of 70 74 65 61,86 35
dietary energy consumption % (2000
kcal/capita/day)
Under-weight (<-2SD) children (%) 38 25 28 17,9 18
Child mortality
Infant mortality rate (per 1000 live births) 68 46 34 (2007) 23
Under five mortality rate (per 1000 live 97 58 46 44 32
births) (2007)
One year olds immunized against measles 45 60 77 >90
(%)
Maternal health
Maternal mortality ratio (per 100,000 live 390 307 228 (2007) 102
births)
Deliveries attended by health staff (%) 41 67 72 85
HIV/Malaria/Tuberculosis
HIV prevalence in 15-49 years (per N/A 93 149 Decrease
100,000 population at risk)
WHO. Mini Profile SEAR counties. 11 questions about the 11 SEAR countries. 2007.

Continued..

Malaria incidence (per N/A 850 N/A Decrease
100,000 population at risk)
Tuberculosis prevalence (per 443 786 262 244 Decrease
100,000 population) (2009
)
Tuberculosis detection rate N/A 19 29 73.1 70
under DOTS (%)
Water and sanitation
Population with access to 69 76 88 86
improved water source (%)
Population with improved to 54 66 78 77
access sanitation (%)

• Indonesia is on track to achieve MDGs
point 4 by 2015
• However, there is disparity in neonatal,
infant and uder-five mortality rates by
demography.
• Maternal mortality also shows higher rate
in rural areas than urban ares  related to
disparity in births assisted by skilled
personnel  higher in urban area

AVAILABLE RESOURCES FOR HEALTH SECTOR
Indicators Latest Available Value Year
Expenditure on health
Percentage of GDP 2.8 2003
Per capita (US$) 33 2003
Per capita (Intl.$) 118 2003
Food
Average dietary energy consumption 2880 2001-2003
(kcal.day/person)
Services
Health center (per 100,000 3.6 1998
population)
Antenatal care coverage (at least 81 2004
four visits) (%)
Deliveries by qualified attendant (%) 77,34 2009

continued
Children immunized (%) 2005
BCG 82
DPT-3 70
Polio-3 70
Measles 72
Primary Health Centre 31,581
Sub health centers 21,115
Community health centre 7,243
Integrated health post 243,783
Human resources
Doctors of modern system (per 2.0 2001
10,000 population)
Nurses (per 10,000 population) 13.0 2001
Midwives (per 10,000 population) 2.0 2004
Dentists (per 10,000 population) 0.3 2004
Community health worker (per 10,000 3.6 2004
population)
WHO SEARO. Improving maternal, newborn, and child health in south east asia region: Indonesia.

• Health expenditure on health is very low
• Public expenditure on health is 34%,
private expenditure 66%  ¾ private
expenditure is out of pocket
• One subdistrict at least 1 PHC  1 doctor,
1 public health nurse, midwive and other
paramedic
• Each center supported by 2 or 3 sub-
center
• At the village level: integrated healt post 
cover 50-100 household

WHO SEARO. Indonesia.:National Health system profile. 2007

WHO SEARO. Indonesia.:National Health system profile. 2007

Health Facility in Different Level

WHO SEARO. Improving maternal, newborn, and child health in south east asia region: Indonesia.

Challenges
• A lot of vacant place for health care
provider in PHC especially those in rural
area
• Wide disparity in rural-urban area
• Health needs are rapidly increasing


Basic Information Latest available value Year
Total population (million) 1028.61 2001
Area (sq.km.) 3,287,590
Area as percent of world’s total 2.43
Country Profile
Density of population (per sq.km.) 325 2008
Administrative divisions 35 states, 593 districts, 5161
towns, 638588 villages
Development Latest available value Year
Gross national product (in crores) 2812758 2005
Population below poverty line (%) 25.9 2005-
2006
Food poverty line (Rs. Per person 2004
per month) 160.20
Rural 185.17
urban
Literacy rate > 7 years (%) 65.49 2008

Indicators Latest Available Value Year
Expenditure on health
Percentage of GDP 0.91 2008
Household health expenditure (%) of 2008
total health 6
Rural 5
urban
No. Of Medical College 242 (2001-2006)
No. Dental Colleges 205 2008
No. Of Colleges ISM & H 219 2005
No. Hospital 15393 2003
Subcenters 144988 2005
Primary Health Centers 222699 2005
Community health centre 3910 2005
Services
Health center (per 100,000 population) 3.6
1998

Deliveries by qualified attendant (%) 58 2008

Children immunized (%) 2005
Measles 69.6
Human resources

Doctors per 100,000 population 70 2005

Dentists per million population 45 2005

Nurses ANM 527482 2007

Nurses GNM 930526 2007

Nurses LHV 51186 2007
Source: Millenium Development Goals India Country Report 2009. Central statistical organization, Ministry of Statistic
and Program Implementation. 2009

Public Health Care System in
India
• Urban
– Central government health scheme
– Goverment hospital
– Urban health services
– Urban family walfare centers
– Urban health posts
• Rural
– Community health center
– Primary health center
– Sub-center

Urban-rural disparity
urban rural


• Start: April 5th, 2005
• Aim:
– provide accesible, accountable, effective and
reliable primary health care, and bridging the
gap in rural health care
• Goals:
– reduction IMR and MMR by 50% from existing
level in 7 years
– universalize access to public health services

Park K. Park’s Textbook of Preventive and Social Medicine. 20th ed. Jabalpur (India):
Banarsidas Bhanot; 2009. P. 405-8.


• Plan of action:
1. ASHA
2. Strengthening Sub-Centers
3. Strenghtening Primary Health Centers
4. Strenghtening CHC for first referral care
5. District health plan
6. Converging sanitation and hygiene under
NRHM
7. Strengthening disease control program
8. Public private partnership
9. New Health Financing Mechanism
10.Reorienting health/medical education to
support rural health issues

Proposed NRHM Infrastucture

Park K. Park’s Textbook of Preventive and Social Medicine. 20th ed. Jabalpur (India):
Banarsidas Bhanot; 2009. P. 405-8.

ASHA
(Accredited Social Health Activists)
• Act as bridge between ANM and village and be
accountable to panchayat
• Receive performance based incentive
• Together with Anganwadi worker, community
wokers, and ANM develop Village Health Plan
• Responsibility:
– Create awareness and provide information to
community on determinants of health
– To counsel women about ANC, INC, PNC, nutrition,
immunization, contraception
– To mobilize community in accesing health serivice
– To provide primary medical care


Testimony from The Field
Mrs. S, 41, ASHA
Working as ASHA is enjoyful. First time I do this job , it is really
hard because no one knows what ASHA works is. I have to
make them aware of myself as ASHA and its work. But now, it
becomes easier. I like being ASHA. I like to do the work for my
community . By being ASHA, I can also increases my
knowledge in health issue. Until now, there is no major
obstacle. To communicate with medical officer or ANM in PHC
is easy because I have their mobile phone number. If there’s in
labor patient I only need to call ambulance from PHC. However,
they only paid salary based on my works, there is no fix salary.
Therefore, I have to work in the farm to secure my family
income.

PHC
• PHC in NRHM plan of action
– Strengthening PHC for quality preventive,
promotive, curative, supervisory and outreach
service
– Adequate and regular supply of essential
quality drugs and equipment of PHC
– Provision of 24 hour services in 50% PHCs
– Standard treatment guideline and protocols


Mr. A, 28, Medical Officer
I just started to work here for 2 months. It feels really different to work here
compared to work in district hospital. There are many problems including
infrastructure and technical problem. Examination of Hb level also is not
really accurate. There are only 4-5 deliveries/month in this PHC. It is very
less, I think home deliveries are still common here.

Mrs. R, 42, ANM
I have worked here for 7 years. Before working in PHC, I worked in
subcenter for 13 years. Working in those 2 places have its own difficulty.
Working in PHC is more convenient because there are more facility to
help delivery than subcenter. But the workload is heavier in PHC than
subcenter. In PHC I work for larger population therefore it is more tiring.
Until now, I have never helped home delivery because government does
not promote it. I think patient’s satisfaction in PHC service is quite good.
The programs are very good here.

Rural Hospital
• Rural Hospital in
NRHM vision:
– Strengthening rural
hospital for effective
curative care and
made measurable
and accountable to
the community
through Indian Public
Health Standards
(IPHS)

Mr. V, 49, Lab Technician
I have worked in RH for 22 years. Before working in RH, I worked in other
hospital. I like to work as lab technician. It is very interesting. Working in RH is
better than working in any other I have worked before. The kits are al sufficient
and within expiration date. Some test which be done in this RH are free and
some are not. Free test are only for blood sugar level, PS 4 MP, and sickle
cell. For every patient I always use new needle. However I often do not use
hand gloves since it take sometime and most of the time, it is really rush here.

Mr. G, 53, Pharmacist
I have worked here for 5 years. Before working in RH, I have practiced
pharmacy for 22 years. Drugs in these RH are supplied by district hospital in
Wardha. Every once in a month, they will drop the drug supplies. Drugs in this
counter are all free. However not all essential drugs are availble here. If there
are some drugs in prescription which are not availble, I will give them the
substitute with same effect. Patients can also buy the drugs outside the RH.
Though there is NCD clinic, most of the drugs are not availble here. Drugs for
helping delivery and newborn baby are available here.

Mr. R, 50, patient
I like this hospital. It’s cheap. The services are also good
too. However, there are some drugs that I have to buy
outside the hospital because they don’t have it. I hope
the hospital can provide all the drugs needed.

Mrs. A, 42, patient
This hospital is too cheap. This is my second time
admitted here. My first time I only have to pay Rs 20 for
my 4 days admission. All of the doctors are really nice
here. However I hope they can provide X-ray and USG
examination so that patients do not have to go to other
hospital which is far away from here

NRHM Achievement

Update in NRHM: health outcomes final year of the first phase: 2005-2012.

• Janani Surakhsa Yojana is a safe motherhood
intervention under NRHM
• The aims is to have 100% institutional delivery
• ASHA is key component in this program

JSY Achievement

National health system resource center. Program evaluation of Janani Surakhsa Yojana. New Delhi: 2011.

NATIONAL HEALTH SYSTEM
COMPARISON

India Indonesia
• Different health sytem • Same health system
delivery in urban and delivery in urban and
rural area rural area
• Certain strategy for • Same strategy for
certain area (NRHM, different area
NUHM) • Health expenditure > 2%
• Health expenditure < 2% GDP
GDP • Lower ratio of health
• Higher ratio of health resources per 100,000
resources per 100,000 population
population

• Indonesia need to end disparity between
urban and rural area by improvement in
rural health system
• India and Indonesia are facing the same
problem including disparity in many health
indicators
• Both countries are practicing the same
scheme for health care system
• However India has developed their rural
health system since 2005 by implementing
National Rural Health Mission (NRHM)

• NRHM has succeded to improve health
indicators in rural area
• NRHM is a good example that can be
used as a model to design a rural mission
to improve rural health system in
Indonesia
• Improvement in health system will result in
better health indicator. Therefore maternal
and child care will also be improved

TOWARD A BETTER MATERNAL AND CHILDREN CARE IN INDONESIA for MGIMS, India

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