The Millennium Development Goals had formulated eight goals; among others is related to maternal health. With regards to achieve this MDGs target, particularly on maternal health, it seems that Indonesia faced quite serious constraint to reduce the number of maternal mortality. Moreover, the number of maternal mortality in Indonesia is still debatable. As an illustration, in 2009 UNESCAP, UNDP, UNFPA, and WHO stated that there is an increase of number of maternal mortality in Indonesia from 307/100.000 to 420/100.000. Meanwhile, the national data published by Bappenas (National Planning Body) 2009 showed that the number of maternal mortality in Indonesia decreased from 307/100.000 in 2002-2003, to 228/100.000 in 2009. However, Bappenas indicates that Indonesia will difficult to achieve the MDG’s target to reduce maternal mortality to 102/100,000 in 2015 although the trend of the national number is decreasing. Bappenas projected that the number of maternal mortality in 2015 in Indonesia will be around 163/100,000, far lag behind from Malaysia and Thailand which number of maternal mortality each is 30 and 24.

 

The number of maternal mortality become one of the indicators to measure how far the Government successes in increasing the quality of women’s health. Why the number of maternal mortality in Indonesia is difficult to be decreased? There are many factors that contribute to inhibit the effort to decrease the number of maternal mortality. Among others is the access and utilization of health services, particularly the reproductive health services for women. The research done by Women Research Institute (WRI) in seven districts/ cities in Indonesia showed that factors such as poverty, culture and tradition, the uneven distribution of health workers and facilities become constraint for women when they need services during their pregnancies and delivering babies. These factors contribute to increase the number of maternal mortality.

WRI as a research institution that concern with women’s rights issues will conduct a book discussion and launching under the theme of “The MDG target to Reduce MMR in 2015 will be Difficult to Achieve”. The book is based on a research conducted in 2008 covered the district of North Lampung, Lebak, Indramayu, Jembrana, Central Lombok, West Sumba and the city of Surakarta

Objective

1. To socialize WRI’s research result in the seven areas in Indonesia that illustrate the access and utilization of health facilities and services for poor women, as well as the various factors that influence those access and utilization of facilities and services for poor women. 
2. To stimulate the strategic effort to achieve the MDG’s target to reduce maternal mortality in Indonesia.

Speaches

1. Sita Aripurnami (WRI’s Executive Director)
2. Dr David Hulse (Country Representative Ford Foundation Indonesia)
3. Dr Zahidul Huque (The Director of UNFPA)
4. Ibu Setiawati Arifin (Deputi II Bidang Kualitas Hidup Perempuan, Kementerian Negara Pemberdayaan Perempuan dan Perlindungan Anak)

Disscussant

1. Edriana Noerdin (WRI’s Research Director): The MDGs target to Reduce MMR in 2015 will be Difficult to Achieve 
2. Wilson T.P. Siahaan (MDG Campaign and Advocacy Analyst, UNDP): The MDGs target on Health particularly to Reduce Maternal Mortality 
3. Ibu Setiawati Arifin (Deputi II Bidang Kualitas Hidup Perempuan, Kementerian Negara Pemberdayaan Perempuan dan Perlindungan Anak): Various Effort by the Government to Decrease the Number of Maternal Mortality
4. Dr Roy Tjiong (Head of Expert Committee on Medical Reproductive Health of Indonesian Family Planning Federation/Helen Keller International): Various Effort that should be done to Decrease the Number of Maternal Mortality

The Discussion Process

 

Aris Arif Mundayat (Moderator)

Welcoming the audience and invited the discussants to present their thoughts.

Edriana Noerdin (Direktur Penelitian WRI)

As additional information, the book is based on WRI’s research in 2008. The research done by WRI combined the quantitative and qualitative methods. As a research institute, WRI illustrate more qualitative research result based on the experience and stories of women.

The presentation will explain about maternal mortality in relation to MDGs based on the research of WRI. The presentation wil be divided into three parts as follows: firstly, women’s health problems related to Law No 36/2009, secondly, access of poor women to health facilities and services, thirdly, the issue of women’s health budget.
Related to the Law on Health, there are some problematic articles such as articles on abortion, the use of contraceptive that is strictly for married (formal) hetero couples. These issues contribute to the increase number of maternal mortality.

According to WRI, the distance to access good quality heatlh services is an issue for poor women. Many midwives also seldom to live in the remote areas where mostly of the poor women lived. Thus, the availability of good health workers also become an issue for poor women. Its often found that only one single midwife that has to cover several villages, while the means of transportation is so rare.

Another important issue is the limited number of regulation that protect women’s reproductive rights and the low amount of women’s health budget. This situation also contributed to the increase number of maternal mortality. The Law No. 36/2009 on Health regulated that each of the local government should allocated 10 % of its Local Budget for Health outside the total amount for salaries. The budget should be used for public health services. Based on WRI’s research, the budget allocation for health in the seven district/city is around 4 – 7 %, still low compare to the regulation.

Wilson Siahaan (MDG Advocacy Analyst, UNDP)

The biggest challenge for MDGs target in Indonesia is the issue of maternal mortality. The effort that should be done is to prepare a five years planning to achieve the MDGs target for 2015. The Government of Indonesia should produce a comprehensive planning not only involving the Ministry of Health but also the Ministry of Transportation as well as the Ministry of General Work for Infrastructure to improve the road and means of transportation.

The next important effort that should be done is related to the availability of data. The debate of which number is the real number should be overcome by conducting a study to gauge the data. The implication of the availability of data is the low amount of women’s health budget in many districts/cities in Indonesia. The Law Number 36/2009 on Health already regulated that each local government should allocate 10 % of its local budget for health. The minimum precentage can be achieved if the data picturing the situation of maternal health also available.

Therefore, advocacy to the Ministry of Health is an important steps to push the minimum allocation of budget for Health 10 % at the local level and 5 % at the national level. Apart from that, The Ministry of Welfare will conduct a coordination meeting on MDGs to compile the MDGs achievement by the GoI in the past 10 years. WRI’s research should also be added to this meeting. UN also attempt to facilitate to form a Working Group on MDGs in the Parliament and support the implementation of the Law Number 36/2009 on Health. By doing so, it is hope that the budget allocation and regulation to improve the situation of maternal health may be resulted and may decrease the number of maternal mortality in Indonesia.

Roy Tjiong (Head of Expert Committee on Medical Reproductive Health of Indonesian Family Planning Federation/Helen Keller International)

The most important aspect that we should always remember regarding research on AKI is about the disclaimer of the data. For instance, the data that UN published stated that the number of maternal mortality is an adjustment of the 2005 data. Therefore, we should really be careful on data.

If we see the Midterm Development Planning of the GoI, the target are : 1) Increase the life expectancy from 70.5 to 72.5; 2) decrease the number of infant mortality from 34 to 24/1000; 3) decrease the number of maternal mortality rate from 228 to 117.7/ 100,000; 4) decrease the number of mal nutrition of under five age child from 18.5% to 11% and 5) increase the coverage of health services for all.

We also had four points of the 100 days program of the national summit on health day. There are: 1) The rights of each individual to get health services with the program of public health insurance (jaminan kesehatan masyarakat); 2) Increase the health of the society by achieving the MDGs target by through decreasing the number of infant mortality rate, maternal mortality rate, etc; 3) Preventing diseases and disaster dan 4) Equal distribution on health workers to remote areas, island. So, if there are mistargets from these four points, all of us can demand the GoI to achieve it.

The core of the problem is the low access of poor people towards the health services. So, their health status is lower than the people who belong to the middle upper class. The regulation also does not give incentives towards the health workers to work more with the poor.

Ibu Setiawati Arifin (Deputi II Bidang Kualitas Hidup Perempuan, Kementerian Negara Pemberdayaan Perempuan dan Perlindungan Anak)

First of all appreciation to WRI for its work. The ministry of Women’s Empowerment and the Protection of Child always work collaboratively with the Ministry of Health through the program of desa siaga. This program is an effort to support a village so its community have an awareness to prevent and handle the emergency health issues, such P4K (Perencanaan Persalinan dan Pencegahan Komplikasi). This program is implemented since 2008 at villages that the number of delivery is under 70 % among others are vilages in Papua, Gorontalo, West Jawa, North Maluku, North Sulawesi, West Sulawesi, Riau, Maluku, Banten, Central Kalimantan and West Kalimantan.

It is important that from this discussion both the government and non government organisation should follow up the issue of the limited facilities and services for health, including the budget allocation and regulation to decrease the number of maternal mortality.

Aris Arif Mundayat

Invited participants to comments on the presentations.

Questions and Answers

Rifa (Yayasan Kesehatan Pendidikan Perempuan –YPKP-)

I am interested with the comparative data on budget allocation and the number of maternal mortality. Does WRI has the data on budget specific on maternal mortality? In areas where the maternal mortality is high, how is the comparison between budget and the total of local budget?

Fifi (Tenaga ahli Siti Mufatahah, anggota Dewan Komisi 9)

I would like to clarify here, that abortion is allowed but only for formally married couples. The data on abortion usually involved the dta from married or unmarried couples?
How far is the working group on MDGs at the parliament progressing? How this link to the local parliament? How far contraceptive for men may contribute to decrease the number of maternal mortality?

How is coordination between the goverment at the national level with the local government regarding the policy on women’s empowerment and the protection of children?

Titi Sumbung (Pusat Pemberdayaan Perempuan dalam Politik)

I apreciate the discussion just now, but no speakers speak about BKKBN. This institution is important, since this institution also contribute to the decrease number of maternal mortality. What is the role of BKKBN nowadays?

Etna Maria (BKOW)

My question is simple. What is actually MDGs and why its difficult to achieve in 2015? I received this invitation from Asosiasi Peta Putih Indonesia (APPI) or Association of Midwives, I see that this research is relevant to our work and would like to organize a collaborative work.

Nursyahbani Katjasungkana (Kartini Asia Network)

I apreciate very much WRI’s research. The problem of maternal mortality is still the same since Kartini era. Ibu Kartini also died because of child birth on September 17. Thus, I agree that September 17 launch as women’s reproductive health day in Indonesia. This is to commomerate that maternal death happened almost one century in Indonesia and the situation had not changed much.

Rosalia Sciortino (AUSAID)

What is lacking from the work of women’s organization, is the network with the health institution, particularly regarding the health insurance. The discussion today did not touch upon this important issue. Because, if we talk about health services for pregnant women than we have to talk about the package of health insurance for women.

We also have to be aware that the problem with budget is not only asking the increase of budget. But, also the use of budget and the danger of budget manipulation. There are may examples that budget that supposed to go for the poor through the public health insurance evaporate for something else.

My question, what kind of program that we need. Is posyandu program since 20 years ago implemented in Indonesia still relevant? Or now we need program like gerakan sayang ibu? Or gerakan desa siaga ?Do we ned to revitalize to create a new model of reproductive health services?

Mela (UNFPA)

I agree with the person who asked about what is MDGs. This is important refelection, that we still need to socialize MDGs. Discussing MDGs remind me that we tend to forget about universal accsess to reproductive health, such as CPR.. The Demography Survey on Helath in Indonesia ( SDKI) showed that women at fertity age who already has 2 or 3 children does not want to have children anymore, only using contraceptive pil. Thus, we should do a deper research on it and see the link with the effort to decrease maternal mortalilty. Another point is regarding ISFR that is not supported by a regulation. In our society, health services should be based on moral and religion, meanwhile human do not have the capacity to measure it. Every health regulation always should be link with morality. It is time for us to redefine this bravely.

The Answers

Edriana Noerdin (WRI’s Research Director)

In WRI’s book there are data on budget, but only related to our research areas. Responding to Rosalia, many districts can not use the budget and all about this information can be read in WRI’s book.

Regarding abortion, Roy may answered that. What is MDGs? It seems that pak Wilson has a lot home work to do. We are using the word MDGs to stimulate the discussion on women’s health, particularly on maternal mortality. WRI also attempt to bring forward women’s experiences on health services. WRI is hoping that through this book, we can start to improve the process of achieving MDGs target.

Ibu Setiawati Arifin (Deputi II Bidang Kualitas Hidup Perempuan, Kementerian Negara Pemberdayaan Perempuan dan Perlindungan Anak)

The Ministry of Women’s Empowerment and the Protection of Children has close link with the Ministry of Health. Since PP 41, the government formed a Women’s Empowerment Body (BPP). Before its only up to eschelon 4, but now already up to eschelon 2 all over Indonesia.

Since the Law on Population, BKKBN change into Badan Kependudukan dan Keluarga Berencana. This may create problems, because it may dilluted the BPP at the district/city level. In the context of decentralization this is an important work to be done to enhance the position of Women’s Empowerment Body at the local level and not change it to the Family Planning Body.

I agree with Ibu Nursyahbani regarding the commomeration of women’s reproductive health day in Indonesia, since the situation did not change almost in the past century.

Roy Tjiong (Ketua Panah Medik Kespro PKBI)

With regard to budget, there is no account number (nomenklatur) for reproductive health budget allocation in the financial system of Indonesia. This is the problem. Abortion cases happened not only for married couples but also unmarried one. 600,000 cases of abortion happened because of the contraceptive failure., and this came from married couples.

Wilson Siahaan (MDG Advocacy Analyst, UNDP)

MDGs is a commitment by 189 head of states in 2000 to overcome poverty in the world. The MDGs commitment became a tool between develop countries and the third world countries to address institutional, policies and budget issues related to poverty alleviation. Developed countries should provide 0,7% of their national income to support the third world countries.

The Pro Poor Policy already being implemented by the government, however it also should link its work with the parliament. With regard to this endeavor, UN formed the working group to facilitate the MDGs issues. I inform the working group with other countries experience, such as the Phillipine. In the Philippine there is a standing comittee on MDGs which is powerfull. All regulations should be approved through this committee to see whether the regulation push the MDGs target or not. UNFPA in Indonesia also had set up an Indonesian Forum for Parliamentary on Population and Development. This Forum facilitate by UNFPA drafted five regulation on population and development. Moreover, UNFPA facilitate two local ordinance related to HIV AIDS and reproductive health. This same attempt is what UN thinks that can be implemented by the committee at the parliament at the national level.

Conclusion

• The research done by WRI may be useful for the bases of health facilities and services in Indonesia, as mentioned by Dr Roy Tjiong that reliable data is important to make improvement.
• The small amount of budget allocation for reproductive health will also contribute to the access of poor women to good quality health services. Therefore, the budget allocation should be increased. 
• Up till now there is only a few numbers of regulations on reproductive health services towards women. It is time for us to draft new health regulations that regulate reproductive health services to reduce maternal mortality. 
• To form multi stakeholders collaboration to monitor and improve regulations and budget allocation on health facilities and services for poor women to reduce maternal mortality. By doing so, this attempt will start to improve the achievement of MDGs target.