|The high maternal mortality rate (MMR) remains a global public health issue. Regardless of zealous efforts, the world can only reach 2.6 out of the 5.5 percent average annual rate of decline required to meet the Millennium Development Goals (MDG) target by the end of 2015.
In 2013, around 800 women in the gestation period and childbirth died each day around the world. Sadly, 99 percent of the cases took place in developing nations where the health system was frangible, according to the WHO.
Indonesia is among the developing countries in which the MMR persistently exists.
In 2007, Indonesia was recorded as the country with the highest MMR in Southeast Asia. Further, in 2012 the Indonesia Demographic and Health Survey proclaimed that the MMR had climbed back up to 359 deaths out of 100,000 live births and hence went far beyond the targeted MDG set by the Health Ministry, which was 102 deaths per 100,000 live births.
Through national health insurance (JKN) coverage, the government is committed to boosting efforts to reduce the number of women dying in pregnancy or childbirth.
Taking effect on Jan. 1, 2014, the JKN was expected to provide more women — either in pregnancy, delivery and postpartum conditions — regardless of socioeconomic status, with accessible quality health services without sustaining financial hardship.
Thus, midwives, mainly those in primary health centers, have been pivotal in realizing such access.
Since its commencement, the JKN has been running for one year with some challenges that have thwarted its progress. The challenges include those affecting midwives and women, consequently as health providers and health recipients.
Funded by the US Agency for International Development (USAID) through Program Representative (ProRep), Indonesia, the independent Women Research Institute (WRI) carried out a study of JKN in late 2014.
This research aimed to magnify the impacts of the JKN on efforts to reduce the MMR, by investigating and providing recommendations on overcoming the challenges of the JKN to both midwives and women needing their services.
By the end of January 2015, the WRI will have held multi-stakeholder forums both in Jakarta and Bandung. In these forums, the country’s high-level stakeholders will listen to the study findings, discuss solutions and develop a plan of action aiming to greatly help reduce the barriers faced by midwives and women.
Below are the research overviews of some challenges that midwives and women confront in providing and receiving health services since the JKN’s implementation.
The study revealed that neither midwives nor women received comprehensive information on the JKN program. When midwives did not thoroughly comprehend what extent of reproductive healthcare coverage they could deliver to the women, the women did not fully understand the extent of health benefits offered to them as JKN members.
The study also showed that the JKN program did not reach the poorest women who needed the program the most. Additionally, women were confronted with difficulties when trying to enroll in the program.
Other conclusions reached were that the JKN did not offer the comprehensive health coverage needed by the women and health facilities were not well equipped.
In addition, the numbers of midwives from local to provincial levels were inadequate to provide quality health services, for different reasons.
When a limited number of midwives in public health centers were responsible for an increased number of patients, they also had to be in charge of several programs. Similarly, midwives in secondary and tertiary health facilities had to deal with an increased number of referred and self-referred patients.
The study showed that the tiered referral system did not work well. Patients bypassed primary health facilities, in the first place designed to be gatekeepers, to directly access secondary health facilities.
Similarly, midwives illegitimately bypassed secondary health facilities to refer patients to tertiary ones.
Regarding the payment system, midwives in private practice could not serve JKN members unless they cooperated with a physician’s office or other clinics collaborating with the Healthcare and Social Security Agency (BPJS Kesehatan), the relevant government body. With such a system in place, they had to go through tedious claim processing and payment issues.
If improved and regulated rigorously, the JKN will be a quintessential means that Indonesia can use to successfully achieve universal health coverage by 2019. Challenges are understandable with any newly introduced health reform, not to mention the JKN.
Notwithstanding this, political will and the strong commitment of multi stakeholders, including policy makers, can be very powerful in overcoming the challenges of Indonesia’s universal health coverage.
The writer was a leader in the study titled “The Portrayal of Jaminan Kesehatan Nasional implementation: Experiences of midwives and women in East Jakarta and Bandung City”. She is a researcher at the
WRI in Jakarta and is an alumna of Georgia State University’s School of Public Health, Atlanta, Georgia, US.
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