2014年-世界发展银行全球_Universal_Maternal_Health_Coverage__Assessing_the_Readiness_of_Public_Health_Facilities_to_Provide_Maternal_Health_Care_in_Indonesia_88页_1mb

Summary of "Universal Maternal Health Coverage? Assessing the Readiness of Public Health Facilities to Provide Maternal Health Care in Indonesia"

Core Content

This policy note evaluates the readiness of Indonesia's public health facilities to provide essential maternal health (MH) services, such as antenatal care (ANC), basic and comprehensive obstetric care, and neonatal care. It assesses whether the country's universal maternal health coverage is "real" and identifies key challenges in service delivery that could undermine maternal health outcomes, even with high utilization rates.

The report focuses on the period 2011–2013, during which Indonesia had universal maternal health coverage, and analyzes the implementation of this coverage using facility-level data. It highlights the importance of understanding the supply-side readiness of health facilities, including the availability of trained staff, essential equipment, and medicines, in ensuring effective delivery of maternal health services.

Main Findings

1. Maternal Health Coverage and Utilization

• Universal Coverage: Indonesia had universal maternal health coverage for its population during 2011–2013.
• Utilization Rates:
  • 96% of mothers received antenatal care from skilled providers.
  • 88% of pregnant women received the WHO-recommended four or more ANC visits.
  • 83% of births were attended by skilled attendants.
  • 80% of mothers received postnatal care within two days of delivery.
  • Facility-Based Deliveries: Only about 63% of all deliveries occurred at health facilities, despite high skilled attendance rates.

2. Maternal Mortality

• High Maternal Mortality Rate (MMR): Despite progress, Indonesia's MMR remains high, especially in poorer and more remote provinces such as West Papua, North Maluku, Papua, Gorontalo, and West Sulawesi.
• MMR Trends:
  • The MMR declined by an average of 3.5% per year from 1990–2013.
  • However, it increased slightly between 2007–2012.
  • The UN-WB model-based estimate for 2013 is 190 maternal deaths per 100,000 live births, while the 2012 IDHS estimate is 359, based on a small sample of maternal deaths.

3. Regional Disparities

• Eastern Provinces:
  • Lower utilization of maternal health services.
  • Weak public facility service readiness.
  • Higher maternal mortality rates.
• Western Provinces:
  • Higher utilization of maternal health services.
  • Private sector dominance in service delivery.
  • Need for improved stewardship and accountability in private facilities.

4. Service Readiness

• General Service Readiness:
  • Public health facilities generally lack basic amenities, including water, sanitation, and electricity.
  • Provinces like West Papua are close to the WHO's recommended facility density.
• Antenatal Care (ANC):
  • ANC service readiness is uneven across provinces.
  • Puskesmas (public primary care facilities) often lack the capacity to provide comprehensive ANC services.
  • There is a gap between service readiness and actual service provision.
• Basic Obstetric Care:
  • PONED (Basic Emergency Obstetric and Neonatal Care) puskesmas are not adequately equipped or staffed.
  • They lack essential diagnostic tools, medicines, and specialized equipment.
  • PONED puskesmas are less equipped than public hospitals.
• Comprehensive Obstetric Care:
  • Public hospitals are better equipped for comprehensive emergency obstetric care.
  • However, there are still gaps in staffing, training, and response times.
  • Blood transfusion services and response times are inconsistent across facilities.

Key Issues and Policy Recommendations

1. Supply-Side Deficiencies

• Diagnostic Capacity: Limited availability of essential diagnostic tools, such as urine tests, for detecting hypertensive disorders and hemorrhage.
• Medicines and Commodities: Shortages of key medications, such as magnesium sulphate for eclampsia and preeclampsia, and injectable antibiotics.
• Specialized Equipment: Lack of specialized equipment for managing obstetric emergencies.
• Training and Protocols: Inconsistent training of midwives and adherence to protocols, especially in rural and eastern provinces.

2. Policy Recommendations

• Special Focus on Eastern Provinces: Strengthen public facility readiness in these areas, where service delivery is weak and maternal mortality is high.
• Improve Stewardship and Accountability in Private Facilities: Implement an independent accreditation process to ensure quality and consistency in private sector service delivery.
• Clarify Accountability Structures: Given the decentralized nature of health services, it is essential to define clear roles and responsibilities at different levels of government.
• Accelerate Strengthening of PONED and Referral Systems: Enhance the capacity of PONED puskesmas and improve the effectiveness of referral networks to ensure timely access to comprehensive care.
• Delay and Coordinate Termination of Jampersal: Ensure continuity of maternal health benefits during the transition to JKN.
• Clarify Supply-Side Implications of JKN Benefit Package: Define clear guidelines for service readiness and provider payment mechanisms to align with the intended coverage.

Conclusion

Indonesia has made progress in reducing maternal mortality, but the high rate remains a concern, especially in remote and underdeveloped regions. The transition to JKN presents an opportunity to improve maternal health outcomes by ensuring that the supply-side readiness of health facilities is adequate to deliver the intended benefit packages. Addressing deficiencies in diagnostic capacity, medicines, and specialized equipment is crucial. Furthermore, improving the quality and consistency of care, especially in the private sector, and ensuring effective referral systems will be key to achieving real universal maternal health coverage.

Key Information

• JKN (Jaminan Kesehatan Nasional): The national health insurance program that aims to merge existing schemes into a single-payer system.
• PONED (Pelayanan Obstetrik dan Neonatal Emergensi Dasar): Puskesmas designated to provide basic emergency obstetric and neonatal care.
• PONEK (Pelayanan Obstetrik dan Neonatal Emergensi Komprehensif): Public hospitals that provide comprehensive emergency obstetric and neonatal care.
• SARA (Service Availability and Readiness Assessment): A framework used to assess the readiness of health facilities to provide maternal health services.
• IDHS (Indonesia Demographic and Health Survey): A key source of data on maternal health utilization and outcomes.

Data and Methodology

• Data Sources: Included the 2012 IDHS, MOH reports, and facility-level data.
• Analysis Framework: Based on the SARA methodology to evaluate service availability, readiness, and quality.
• Geographic Focus: The report highlights regional disparities, with eastern provinces lagging behind in service readiness and utilization.

Final Notes

• Challenges: High maternal mortality, uneven service readiness, and supply-side deficiencies in essential commodities and equipment.
• Opportunities: Strengthening PONED and referral systems, improving accountability, and clarifying the JKN benefit package to ensure effective depth of coverage.