Perceptions and Expectations of Maternal and Neonatal Care

Views from patients and providers in Indonesia

Prepared by:

Karrie McLaughlin Seongeun Chun

Research Team:

Nelti Anggraini, Marzi Afriko, Agung Prabowo, Sari Damar Ratri,

Vitra Janne Siregar, Tasnim Yusuf

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Acknowledgements

The team received support from many, both in Jakarta and in the research locations. We would like

to extend our thanks to the numerous individuals who provided the input and guidance to make this

a truly cross-sectoral undertaking. These include members of teams supporting and implementing the

Australian Indonesian Partnership Health Systems Strengthening, the Australian Indonesian

Partnership for Decentralization, and the Australian Indonesian Partnership for Maternal and Neonatal

Health.

This study was only possible thanks to the time and information shared with the team by members of

district governments, health clinic staff and villagers. We thank them for welcoming us and sharing

their stories.

The views expressed within this report are those of the author(s) and not necessarily those of

Department Foreign Affairs and Trade of Australia (DFAT) or the Commonwealth of Australia. The

Commonwealth of Australia does not endorse its content and accepts no responsibility for any loss,

damage or injury resulting from reliance of any of the information or views contained within it.

All rights reserved. Reproduction and dissemination of material in this report for educational or other

non-commercial purposes are authorised without any prior written permission from the copyright

holders provided the source is fully acknowledged. Reproduction of material in this report for resale

or other commercial purposes is prohibited without permission of the copyright holders.

Applications for such permission should be addressed to:

DFAT Public Affairs

Public-affiars-jakt@dfat.gov.au

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Table of Contents

Acknowledgements ........................................................................................................................................ i

List of Abbreviations .................................................................................................................................... iv

List of Indonesian Terms ............................................................................................................................... v

Executive Summary ...................................................................................................................................... vi

1. Introduction and Objectives ..................................................................................................................... 1

1.1. Key Research Questions ................................................................................................................ 2

1.2. Methodology and Analysis ............................................................................................................ 2

1.3. Sampling ........................................................................................................................................ 3

2. Provision of Maternal and Neonatal Services ........................................................................................... 4

2.1. Health care financing ......................................................................................................................... 5

2.1.1. Access to and use of BPJS funding .............................................................................................. 6

2.1.2. Operational funding .................................................................................................................... 7

2.2. Staffing ............................................................................................................................................... 8

2.3. Bidan incentives ................................................................................................................................. 9

2.3.1. Monetary incentives ................................................................................................................... 9

2.3.2. Village facilities, medicine, tools and disposables .................................................................... 11

2.3.3. Careers, hierarchies and discrimination ................................................................................... 12

3. Accessing Maternal and Neonatal Care .................................................................................................. 13

3.1. Paying for Services: Cash and Credit ................................................................................................ 14

3.2 Transport and distance to facilities ................................................................................................... 16

3.2.1. Going to a facility ...................................................................................................................... 16

3.2.2. Accessing village level care ....................................................................................................... 19

3.3. Insurance .......................................................................................................................................... 19

3.3.1. Who gets state-assisted coverage? .......................................................................................... 20

3.3.2. Citizen perceptions of insurance ............................................................................................... 21

3.3.3. Accessing insurance for mothers: choices and complexity ...................................................... 22

3.3.4. Covering newborns ................................................................................................................... 26

3.3.5. Information about insurance options: why so many gaps? ...................................................... 27

3.4. Sanctions, threats and discrimination ............................................................................................. 28

4. Perceptions and expectations of maternal and neonatal care ............................................................... 30

4.1. Antenatal care .................................................................................................................................. 31

4.1.1. Access and quantity vs quality and accountability in antenatal care ....................................... 33

4.1.2. Poor communication and missing information ........................................................................ 34

4.1.3. Ineffective collaboration with village actors: dukun bayi and posyandu cadre ........................ 37

4.2. Delivery ............................................................................................................................................ 38

4.2.1 Delays: Seeking, Reaching and Receiving Care .......................................................................... 40

4.3. Postpartum and postnatal care ....................................................................................................... 42

4.4 Contraceptive use ............................................................................................................................. 43

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5. Recommendations .................................................................................................................................. 43

5.1. Strengthen patient – provider engagement .................................................................................... 43

5.2. Support bidan to provide quality, patient centered care ................................................................ 45

5.3. Improve access to identity documents ............................................................................................ 47

5.4. Improve access to insurance ............................................................................................................ 48

5.5. Additional opportunities for village and district governments ........................................................ 49

5.6. Key constraints in the health system ............................................................................................... 49

Annex A. Insurance Coverage and Health Costs ......................................................................................... 51

A.1. Insurance programs ......................................................................................................................... 51

A.1.1. Utilization of BPJS in regional programs ................................................................................... 52

A.1.2. Poverty letters .......................................................................................................................... 54

A.2. Costs without insurance .................................................................................................................. 54

References .................................................................................................................................................. 55

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List of Abbreviations ANC Antenatal Care

APBD Anggaran Pendapatan dan Belanja Daerah (District Budget)

BLSM Bantuan Langsung Sementara Masyarakat (Conditional Cash

Transfer)

BOK Biaya Operasional Kesehatan (Health Operational Fund)

BOS Biaya Operasional Sekolah (Education Operational Fund)

BPJS Badan Penyelenggara Jaminan Sosial (Social Insurance Body)

BPMD Badan Pemberdayaan Masyarakat Desa (Village Community

Empowerment Body)

BLUD Badan Layanan Umum Daerah (Regional Service Delivery Body)

DHO District Health Office

Jamkesmas Jaminan Kesehatan Masyarakat (Public Health Insurance)

Jampersal Jaminan Pembiayaan Pelayanan Persalinan (Maternity Insurance)

JKN Jaminan Kesehatan Nasional (National Health Insurance)

KIA Kesehatan Ibu dan Anak (Neonatal and Maternal Health)

KK Kartu Keluarga (Family Card)

MDGs Millennium Development Goals

NTB Nusa Tenggara Barat (West Nusa Tenggara)

NTT Nusa Tenggara Timur (East Nusa Tenggara)

PBI Penerima Bantuan Iuran (Beneficiaries)

PKH Program Keluarga Harapan (Family Hope Program/conditional

cash transfer to very poor households)

Polindes Pondok Bersalin Desa (Village Birth Post)

PONED Pelayanan Obstetrik Neonatus Esensial Dasar (Essential Obstetric

and Neonatal Services)

Posbumil Posyandu Ibu Hamil (Intergrated health post for pregnant

women)

Poskesdes Pos Kesehatan Desa (Village health center)

Posyandu Pos Pelayanan Terpadu (Integrated Service Post)

PNC Postnatal Care

PNS Pegawai Negeri Sipil (Civil Servant)

PTT Pegawai Tidak Tetap (Nonpermanent staff)

Puskesmas Pusat Kesehatan Masyarakat (district health clinic)

Raskin Beras Miskin (Low-price Rice for the Poor)

Revolusi KIA Revolusi Kesehatan Ibu dan Anak (Neonatal and Maternal Health

Revolution)

Sekcam Sekretaris Camat (District Secretary)

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List of Indonesian Terms Adat Custom, traditional law

Bidan Midwives

Camat District head

Desa Siaga Alert Village

Dinas Sosial Social Department

Dukun Bayi Traditional birth attendant

Dusun Hamlet

e-KTP Electronic Identity Card

Ijazah Terakhir Diploma

JKN Mandiri Private/Paid JKN

Judis Bitchy

Kabupaten District

Kecamatan Sub-district

Kartu Keluarga Family card

Kegiatan Luar Gedung Off-site Puskesmas Activities

KTP Identity card

Mama Literally means mother; but this refer also to traditional birth

attendant

Mutasi Mutation

Retribusi Retribution

Surat Keterangan Lahir Birth Declaration Letter

Surat pindah Moving letter

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Executive Summary This research brings provider and patient perspectives together to develop a clearer description of

gaps and constraints at the point of service provision. It responds to the fact that Indonesian maternal

and infant mortality levels remain high against the country’s economic status, despite the fact that

Indonesian mothers use the services available to them. It comes at a point of transition in the health

care sector, as Indonesia is shifting toward universal, single-payer insurance. By capturing multiple

perspectives in this moment of change, this study aims to foster innovative responses at the local level

that will improve Indonesian citizens’ access to quality health services. The study has been framed

around the following questions:

What are (community/ service provider) perceptions of community health needs, and how are

these determined?

What do (community members/ service providers) think health services should deliver in terms

of both quality and content?

How do these expectations contrast with the realities of health service delivery?

How do (community members/ service providers) respond to any gaps between ideal service

delivery and reality (including accountability actions, lack of trust, etc)?

What are (community/ service provider) understandings of and expectations around

accountability for health service delivery?

Who or what supports or obstructs change or effective collaboration?

Research was conducted in seven districts across three provinces: Flores Timur (pilot location), Sumba

Barat and Manggarai in Nusa Tenggara Timur (NTT); Dompu and Lombok Utara in Nusa Tenggara Barat

(NTB) and Situbondo and Malang in East Java. A team of two researchers spent one month each district,

spending roughly a week each at the district, a puskesmas (sub-district level health clinic) and two of the

villages in its catchment area. They employed qualitative research methods, including semi-structured

individual and group interviews, focus group discussions, and participant observation. It also traced

targeted medicines, supplies and provider actions around sources of maternal death and examined

budget and financing limitations to assess the impact of supply side constraints in the frontline space

and on provider patient relationships. Research findings are broken into a brief examination of factors

influencing the provision of care, followed by a discussion of perceptions and challenges related to

access to care and finally a consideration of perceptions and expectations about the quality of health

care, following key moments in pregnancy and childbirth.

Key elements influencing the provision of care at puskesmas include their budget arrangements.

There are at least four key problems that particularly impact on frontline service delivery. First, there are

problems accessing funds under the new health insurance program (JKN – Jaminan Kesehatan National).

Though puskesmas have been provided with capitation monies to purchase medicine and disposable

goods, lack of certified procurement personnel at the puskesmas mean that they cannot spend the

money. There are also delays in payment of claims for services rendered by bidan (midwives) and

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doctors, and in some locations, underpayment of claims due to inconsistencies between national and

local regulations. Puskesmas ability to use the funds effectively are dependent upon local government

abilities to find solutions to planning, regulatory and procurement problems, articulate them clearly and

provide support that let puskesmas feel at ease with spending money without fear of audit. Second,

operational funding comes from many sources, including informal savings from previous years budgets,

capitation payments and percentages on fee claims under JKN and district budget funds. These funds

are critical for the day-to-day operation of the puskesmas, including reimbursements for purchases of

missing or out of date drugs, and petrol for the ambulance among other things. However, late budget

disbursements mean that puskesmas or their staff must front months of payments. At best this

undermines accountability as they turn to informal funding sources and at worst it means that services

decline or they pass costs onto patients.

Inflexibility in hiring and firing and an influx of “volunteer” bidan reduce the quality of services and

decrease accountability. Rigidities in recruitment and staff limits mean that DHO are unlikely to remove

staff, regardless of their performance. In addition, in many locations, staff shortages are being met (and

exceeded) with the acceptance of “volunteer” bidan and nurses, often politically connected fresh

graduates who work for free or a small stipend so as not to lose their skills. Since these individuals sit at

the edge of the formal system, they are generally not eligible for training, despite their general

inexperience. They are often posted in villages, farther from support networks and opportunities to

learn. Villagers and puskesmas heads alike dislike them since they are poorly qualified and hard to hold

accountable.

Bidan behavior is influenced by a large range of factors, including monetary incentives; availability of

medical tools, medicines and disposables; career opportunities; personal motivation and systems of

support, hierarchy and discrimination. The new health insurance program is creating challenges for

many bidan, since they cannot claim for their services unless patients have sufficient legal identification

which, particularly further east, many lack. Since many arrangements under JKN are still being clarified,

there are also challenges to claims being paid routinely or in full. Limited operational funding, medicines

and disposables mentioned at the puskesmas are even greater constraints in villages. Many bidan are

forced to buy their own tools, medicines and disposables, which they either charge to patients or

reimburse at the puskesmas. In addition, many face challenges paying for basic items such as soap and

electricity, which impact on patient perceptions of quality of care. Performance is evaluated based on

their ability to hit targets, which focuses their attention on the provision of quantity over quality of

service. In addition, in NTT and parts of NTB, many working at the village or puskesmas level do not find

support from their peers at the hospital, who often treat them as inferior and focus on their

shortcomings. This can impact patients who need to be referred to the hospital, and it undermines the

trust and knowledge sharing necessary in quality care.

Many citizens, especially poorer citizens, still struggle with access to health care services, particularly

for delivery, with the main barriers being transport and insurance costs. In all locations, access issues

were compounded by seasonal cash flows, resulting in periods of cash poverty. In NTT and parts of NTB

poor availability of credit exacerbated the problem further. In NTT, the Revolusi KIA policy dictates that

all women must give birth at a puskesmas or above, while in other provinces, village facilities are still

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considered acceptable locations for delivery. While there is variation in the implementation of the

Revolusi KIA policy, with Sumba Barat applying it quite strictly and Manggarai still essentially allowing

village births, poor infrastructure and transport networks made access in NTT particularly expensive and

difficult. In other locations, the ability to give birth in the village made access considerably easier, but

many patients still faced challenges if they were referred, as did patients in more remote parts of

villages. In one location, the bidan went to the homes of women delivering in the more remote part of

the village. Her responsiveness was highly appreciated by patients, since many fear giving birth on the

road or in a strange location, and her willingness to acknowledge citizen fears built trust that allowed

her to more easily refer if needed. The presence of posyandu (integrated service posts) were important

in most locations to allow for village level access to antenatal care, though in Situbondo, where more

people work as daily laborers, there is not the flexibility to attend mid-morning events, and many

women sought care at private providers who were available after work hours.

Challenges to insurance access revolved around the perennial problem of correct identification of

recipients of state-assisted coverage, and host of newer challenges related to whether those who

have or want JKN coverage can fulfill necessary requirements to access care. The dissolution of the

Jampersal program in 2014, which provided free antenatal, delivery, postnatal and family planning

services to all Indonesian women, has resulted in a large number of poor or near-poor women not

having access to health care. In NTB, district governments, in conjunction with the province, have

maintained a sharp focus on covering pregnant women and newborns through district programming,

but it has been difficult to negotiate through JKN. In other locations, pregnant women who do not

receive assistance must pay for their own coverage. In addition to cash constraints mentioned above,

the new policy that whole families must register together often pushes costs out of reach. In addition,

those that have or want coverage must present both a family card and an identity card. Many

individuals do not have these documents, particularly farther east, and getting them can require

multiple (expensive) trips to the district level to navigate opaque administrative systems, and potentially

additional documents such as marriage certificates, which further increase costs. Further barriers exist

for those who have moved locations (which many Indonesians do). In addition, confusion between

documents identifying current members of JKN and its predecessor program, Jamkesmas, are resulting

in some patients being denied coverage, despite the fact that the members of both programs are

theoretically the same. Finally, the newborns of those who have state-assisted coverage should be

automatically covered, per existing policy. However, complicated registration processes mean that it is

not at all automatic, and parents normally have to pay, often needing to organize coverage quickly if the

baby has a health problem at birth. Perceptions of insurance are complicated by lack of information, as

well as the belief that those using state assisted care will be discriminated against, receive poor quality

care and continue to pay hidden charges.

Access decisions are increasingly influenced by sanctions (formal or informail), to promote desired

health behaviors. Formal sanctions are normally written into village regulations. These are being

promoted, particularly in NTT, but also in NTB. Only one village in the study sample had a written

regulation. Bidan, however, used various sanctions and threats in all locations. Those levied against

women who had given birth at home included: fines; withholding of birth declaration letters; denial of

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postnatal care, particularly the first immunization; denial of birth control. These sanctions have a

number of impacts on both perceptions of service delivery and on the lives of the families to whom they

are applied. First, threats of withholding services exploit the power imbalance between families and

providers. It indicates that the State is uninterested in some of the very real problems facing many

families, and is willing to exacerbate them. Second, these sanctions can have lasting impacts on the lives

of mothers and children, blocking access to education, further health benefits and for women, control

over their fertility.

Turning to experiences in maternal and neonatal care, the study found a number of factors that

undermine the development of a strong patient provider relationship. Many women access antenatal

care from both formal (bidan) and informal (dukun bayi- traditional birth attendants) providers. In NTT

and NTB, most antenatal checks take place at the posyandu, which usually public and rushed, meaning

that women are uncomfortable to ask questions, and bidan unlikely to have time to provide

explanations. In all locations, antenatal examinations were undifferentiated at different points in

pregnancy, which has consequences for the effective identification of pregnancy risk, development of

patient delivery plans and patient understanding of antenatal care (ANC) goals. Weak relationships

between the bidan and dukun bayi as well as cadre posyandu limited opportunities to provide

information and quality care to women.

Bidan struggled to communicate effectively with women on key topics in ANC, specifically: danger

signs in pregnancy, impacts of pregnancy risks and the need for delivery plans. While information on

danger signs is included in the book that women receive as part of their antenatal package, many

women were unclear on what danger signs were. More importantly, if they did go the bidan with a

problem, many were dismissed and told they were fine, often without an examination. Women’s

understanding of their own bodies was often seen as a lay concern, not a medical problem. For those

women who had pregnancy risks, bidan most often told them what to do (for example, eat less salt), but

did not explain the risk or the impact of the problem on the mother and the unborn baby. This is

important because many bidan felt that by providing this level of information, they were doing a good

job and helping their patients. Difficulties in communication are hard to untangle from bidan’s own

educational backgrounds and a work environment which also tends to be based on directives rather

than explanations. However, there were also indications that some bidan felt that patients would be

unable to understand information, or that even if they did, would be too lazy to take action. Some

bidan, particularly in East Java, did not communicate risks for fear their patients would move to another

provider. For their part, women are often uncomfortable asking questions of bidan who sit above them

in village hierarchy, and particularly uncomfortable questioning providers where they do not have other

options or fear sanctions.

Delivery experiences are shaped by perceptions of the facility as well as expectations of availability of

providers, whether providers will listen to patients and provide them with information about their

condition, whether patients think that they will be referred and whether the provider will cater to the

needs and values of the patient. Women hope that providers will listen to them when they are in labor,

but many feel that bidan conduct an initial examination and then tell them to wait. Bidan feel that they

are following medical procedure, and are surprised if labor proceeds faster than expected. This was

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experienced by women across locations and shows an important communication gap that needs to be

bridged. Similarly, women with difficult pregnancies who needed to be referred were often given little

information about their conditions, making them frightened, or if things turned out well, suspicious that

they were referred unnecessarily. Both feelings undermine confidence in providers. Finally, women

want to give birth in an environment where they feel comfortable and supported. For many women this

means having their husbands, mothers or dukun bayi in the room with them. However, practices remain

mixed as to whether these people can join women in delivery.

Despite increasing numbers of neonatal and baby deaths in several locations, the provision of

postnatal care was weak. Many bidan were reluctant to go to patients homes, citing a lack of time,

transport money and the dismay of other patients who find them absent from their posts. Many new

mothers, however, feel uncomfortable leaving home with new babies, feelings that are often supported

by traditions that tell them they shouldn’t.

Based on the above findings, recommendations are broken into five main categories and include the

following:

1. Strengthen the patient-provider engagement. At the national level, this includes adopting clear

values and dimensions for quality care that include patient-centeredness. At the district and village

levels:

- Reconsider support for sanctions around maternal and neonatal health care. The culture of

threats and sanctions undermines patient – provider relationships and ability to work together.

- Use moments such as the development of citizen charters or standard operating procedures

to open broader discussions about patient medical experiences and hopes as well as provider

constraints. A key example from the research is the way that labor estimations are made: bidan

measure dilation, estimate a birth time and then often tell the patient to just wait. Women want

to be able to express changes that they feel, and want more frequent checking-in by the bidan

(even if not a full examination).

- Make the partnership between bidan and dukun bayi an actual partnership. This is likely to

need support from the national level, but it can (and in some locations has) started locally. It can

be expanded by:

o Using trainings to provide information on ANC goals, pregnancy danger signs and risks.

o Seeking input from dukun bayi in developing ANC recommendations and

communication strategies.

- Support a more meaningful partnership between bidan and posyandu cadre, leading to more

substantive role for cadre.

2. Support bidan to provide quality, patient-centered care. While not replacing the need for ongoing

standardized training, efforts that can be undertaken by DHO or puskesmas to support for bidan to

develop professionally in ways that improve both their medical capability and their ability to

communicate and interact effectively with patients include:

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- Provide more opportunities for on the job support and learning. In two locations,

puskesmas were adding discussions and mini-training sessions to their monthly staff

meetings. Bidan found these useful, and they can be expanded beyond strictly “medical”

topics, such as:

o Assessment of routine events, such as seeking care or referrals. These identify and

acknowledge positive behaviors as well as recognizing challenges in a non-threatening

context. They should include discussions between village/ puskesmas staff and hospital

staff as well as between village/ puskesmas staff and citizens.

- Conduct discussions on communicating with patients.

- Establish and moderate discussion forums between bidan to encourage ongoing learning.

In addition, the study found some areas where performance targets need to be changed, more closely

monitored or adjusted for better quality care. Recommendations include:

- Focus on quality over quantity of ANC. Focus on providing four quality visits.

- More actively monitor the implementation of PNC and consider linking delivery and PNC

payments to ensure that visits take place.

- Develop and implement more functional referral plans and guidelines. This includes plans

that are not bound by sub-district boundaries, but are based on local transport networks

and plans that take into account existing facility capacity. Clarifications should also be made

to pre-referral policies.

3. Improve access to identity documents. Lack of identity documents is a key barrier to accessing

insurance. Efforts to lower costs and improve access to these documents can be effectively made by

district governments. However, national reforms will have larger impacts and should be simultaneously

pursued. Key recommendations for district and village governments include:

- Move KK and KTP service provision to the kecamatan level. Efforts at this were initiated

under the DFAT LOGICA program and should be continued for national scale up.

- Continue to support mass registration and integrated services that cover marriage, divorce

and birth certificates as well, but improve quality control to ensure documents match.

- Support local government record keeping of death certificates and citizens who have

moved.

- Encourage better coordination between bidan and village heads on identity documents.

At the national level, opportunities to streamline or reduce identity documents and processes.

Specifically, evaluate the value of family cards and requirements for registration in a new location.

4. Improve access to insurance. Key recommendations include:

- Reduce costs around registration with BPJS, both for pregnant mothers and newborns. In

Malang, patients are able to register at the puskesmas. In Dompu and Lombok Utara,

women can register for the regional program (run through BPJS) with their bidan.

- Ensure that the lack of a marriage certificates does not create a barrier to care for young

mothers.

xii

- Improve information flows about the program across local level actors, including bidan,

cadre and members of village government.

- Support district governments to implement effective regional health plans.

- Support local governments to effectively regulate service delivery costs and meet

procurement regulations. Inconsistencies between local regulations and BPJS and fears of

audit are blocking access to a significant amount of BPJS funding. Districts may need

technical assistance and opportunities to learn from each other.

At the national level, the key recommendation is to update the national poverty list. In doing so,

actuarial calculations should be made to make coverage of children of those receiving state-assisted

coverage truly automatic.

5. Finally, explore options for village government to help defray transport costs. BPMD oversees both

the implementation of the new village law (which increases village budgets considerably) and Desa

Siaga. They should work to ensure that rules for use of village funds are flexible enough to support

village level solutions to transport problems.

While this study did not focus on national level problems, there are several that impacted most heavily

on frontline service delivery. Quality is affected most by low bidan capability, inconsistent drug and

disposables distribution and late budget disbursements. Accountability is undermined by inflexible

recruitment systems and the use of volunteer bidan. Access is affected by poor infrastructure and health

systems that do not respond to the needs of an increasingly mobile population.

1

1. Introduction and Objectives Despite progress over time, Indonesia’s maternal and infant mortality levels remain high relative to the

country’s economic status and regional comparators.1 This is despite the fact that the health sector is

sufficiently funded to achieve better outcomes and that Indonesian mothers use the services available

to them. 2 The 2012 Indonesia Demographic and Health Survey indicates that 88% of mothers completed

four or more antenatal care (ANC) visits during pregnancy; 80% of mothers received postnatal care

(PNC) within two days of delivery and 63% of women gave birth at a facility.3

There are a number of factors that have been identified as contributing to problems in maternal and

neonatal health service delivery. These include: delays in financing to district health clinics,4 gaps in

supply-side readiness, particularly with regard to supplies needed to address primary causes of maternal

death,5 limited access to emergency obstetric services, poor quality of health services, and continued

use of traditional birth attendants.6

Most of the problems identified above are based on an analysis of national systems, down to the level of

the puskesmas (district health clinic), or on community (demand-side) needs. However, rarely is analysis

of puskesmas constraints pushed down to the frontline of village service delivery. In addition, supply and

demand side perceptions and expectations of care are rarely linked.

This research brings together provider and patient perspectives to provide a clearer description of gaps

and constraints at the point of service provision. It does so at a moment of significant change in the

health care sector, as Indonesia is shifting toward universal, single-payer insurance (Jaminan Kesehatan

National- JKN). By capturing multiple perspectives, this study aims to foster innovative responses that

will improve Indonesian citizens’ access to quality health services. Following an explanation of study

questions and methodologies, this report proceeds, in Section 2, with an examination of key constraints

in provision of services and the impacts those have on frontline service delivery. In Section 3, it connects

supply and demand elements that impact on patient ability to access services, including financial,

physical and administrative aspects of access as well as issues of equity, discrimination and sanctions

that can also push patients away from the formal system. Section 4 discusses issues of quality of

1 Kementrian PPN/ Bappenas (2014). Health sector review: Consolidated report. Jakarta. Note that data quality

issues mean that the exact ratios are not clear. 2World Bank (2014). Universal maternal health coverage? Assessing the readiness of public health facilities to

provide maternal health care in Indonesia. Jakarta: World Bank For example, Sri Lanka has similar levels of GDP and health spending per capita, but achieves better health outcomes. India has a similar maternal mortality ratio to Indonesia, but has both lower per-capita GDP and spends less per capita on health. 3 Priebe J, et.al. (2014). Availability and quality of public health facilities in Eastern Indonesia: Results from the

Indonesia Family Life Survey East 2012. Jakarta: TNP2K Working Paper 11c June 2014. 4Indonesian Health Policy Network. (2014). Primary health care financing and expenditure bottleneck study: East

Nusa Tenggara and East Java provinces. Yogyakarta: The Center for Health Policy and Management, Faculty of Medicine, University of Gadjah Mada 5World Bank (2014). Universal maternal health coverage?

6World Bank. (2010). …and then she died: Indonesia maternal health assessment. Jakarta: World Bank

2

maternal and neonatal health services, both from the perspective of patients and from that of midwives

and other health care providers, examining where their concepts of care overlap or diverge across key

moments in pregnancy, birth and care of the infant, including antenatal care (ANC), delivery, postnatal

care (PNC), breastfeeding and family planning. Finally, Section 5 makes policy recommendations.

1.1. Key Research Questions The study seeks to bring together community and service delivery provider perspectives on constraints

to provision and use of maternal and neonatal health care services in puskesmas and their networks,

identifying and challenging commonly held narratives on what these constraints are and reasons for

them. It explores issues of trust between communities and service providers and examines gaps in

perceptions of health needs and expectations of service delivery, bearing in mind that there may be

asymmetries in knowledge. It attempts to respond to the following broad questions:

1) What are (community/ service provider) perceptions of community health needs, and how are

these determined?

2) What do (community members/ service providers) think health services should deliver in terms

of both quality and content?

3) How do these expectations contrast with the realities of health service delivery?

4) How do (community members/ service providers) respond to any gaps between ideal service

delivery and reality (including accountability actions, lack of trust, etc)?

5) What are (community/ service provider) understandings of and expectations around

accountability for health service delivery?

6) Who or what supports or obstructs change or effective collaboration?

1.2. Methodology and Analysis The study employed ethnographic methods, including in-context, semi-structured individual and group

interviews, focus group discussions as well as participant observation. To understand perceptions and

experiences around maternal and neonatal care, it elicited pregnancy histories, experiences of antenatal

care, decision-making in the delivery period, postnatal care, infant feeding and family planning practices.

Perspectives on these “key moments” were elicited from mothers (and mothers-to-be), their family

members, village and sub-district health providers, traditional birth attendants and village government

actors. The research also explored women’s living, economic, and social circumstances.

In addition, the study traced the availability and use of “tracer” tools and medicines critical to identifying

and treating the two main causes of maternal death in Indonesia. These included blood pressure

monitors and stethoscopes, protein urine tests and magnesium sulfate for the identification and

treatment of hypertensive disorders, including eclampsia and preeclampsia and Oxytocin, for the

treatment of postpartum and antepartum hemorrhage.7 These “tracer supplies,” were combined with

questions about behaviors around their use (e.g. was blood pressure routinely taken? Were protein

7 These were identified through discussions with DFAT’s health team, the WB health team and based on WHO

SARA guidelines. See World Health Organization. (2013). Service Availability and Readiness Assessment (SARA): An annual monitoring system for service delivery. Reference Manual, Working document 2.1. Geneva: World Health Organization.

3

sticks used? Did bidan have any experience using key medicines?) and information provided to mothers

about risks associated with these conditions. Together, these “tracer issues” provided a lens through

which to understand both the impact of supply side constraints on bidan, but also have a more concrete

understanding of the content of the interaction and relationships between frontline providers and their

patients. Researchers also collected data on the puskesmas budget and sources of financing,

information on numbers of insured individuals in each location and local policies impacting on maternal

and neonatal care.8

A team of two researchers spent one month each district, spending roughly a week each at the district

level, at one puskesmas and in two villages in its catchment area. Researchers documented interactions

with and observations of participants by taking notes during interviews, and audiotaping if participants

agreed. Researchers developed fieldnotes: descriptive and analytic accounts of research interactions

and observations. Audiotapes of interviews were selectively transcribed. Researchers completed

description sheets of standardized information at the village, puskesmas and district level, including

basic descriptions of the area, budget, and tracer issue details. Finally, they wrote case studies on key

elements of maternal and neonatal care in the locations that they visited.

The lead researcher and senior researcher analyzed data sources to index and code topic areas, and

identify emerging themes. They then interpreted perceptions, practices, and sociocultural context of

participants’ lives and providers’ incentives to generate findings.

1.3. Sampling In line with the approach of the Australian aid program in Indonesia, the study focused on rural service

delivery in East Java, Nusa Tenggara Barat (NTB) and Nusa Tenggara Timor (NTT). Seven district were

studied, as detailed below.

Table 1: Study locations

Nusa Tenggara Timor (NTT) Nusa Tenggara Barat (NTB) East Java

Flores Timur (pilot location) Dompu Situbondo

Sumba Barat Lombok Utara Malang

Manggarai

A purposive sampling approach was undertaken at both the district and puskesmas level, in an attempt

to better understand how the two levels can drive or block effective service delivery. At both levels,

maternal and neonatal mortality figures were considered. At the puskesmas level, perceptions by district

actors of puskesmas management were also included as a factor in selection. Within the puskesmas

catchment area, one close and one far village were chosen, taking maternal and neonatal mortality, into

account.

8 Researchers could not always get full budget information or populations of insured individuals.

4

2. Provision of Maternal and Neonatal Services A basic understanding of key drivers and constraints in the provision of maternal and neonatal care at

the puskesmas level is useful to frame provider expectations about the services that they feel they

should and can provide and any coping mechanisms that they adopt to work around obstacles. This

study did not undertake a comprehensive examination of supply-side but asked specific questions

around puskesmas-level planning, budgeting, financing, and supply side-readiness with the goal of

tracing key issues down through the system and into the provider- patient interface. Questions around

puskesmas level financing included understanding how changes in puskesmas funding (ie due to the

recent introduction of JKN) or delays in funding9 impact service provision. With respect to supply-side

readiness, the study traced the availability and use of tools and medicines critical to identifying and

treating the two main causes of maternal death in Indonesia, preeclampsia, eclampsia and postpartum

hemorrhage. These “tracer issues” were less an assessment of supply-side readiness strictly speaking,

but a lens through which to understand the impact of availability (or lack) of key supplies on a bidan’s

ability to provide care to mothers.

This section briefly sets out key puskesmas-level targets and services related to maternal and neonatal

care. It then looks at health care financing, providing some initial reflections on the impact of JKN

implementation, and then examining how financing constraints impact the services that bidan provide

and how patients perceive care. Finally, it examines staffing needs and bidan incentives, considering

opportunities and constraints for district health office (DHO), citizens and local government to improve

service delivery.

Puskesmas develop their plans to implement care under the guidance of the DHO, and subject to

national rules and targets. There is considerable political pressure to be seen to be meeting the 2015

Millennium Development Goals (MDGs), and governors (and therefore DHO) pay significant attention to

numbers of maternal and child deaths. In order to prevent maternal and neonatal death, and to support

the general health of mothers and their babies, the government has also set minimum service

standards, which are composed of targets around key events during pregnancy and after birth. The most

salient for this study include: 1) 95% of women attend four ANC visits during their pregnancy, including

the first in their first trimester; 2) 95% of deliveries attended with a health staff with midwifery training

and 3)90% of women receive at least three postpartum visits within the first 42 days after childbirth.10

The puskesmas proposes to meet these targets by providing a range of services. Antenatal care in sites

in NTT and NTB is provided primarily at the village level, this includes support for the monthly posyandu

or posbumil (integrated service post or post for pregnant women), where women receive prenatal

checks by the bidan, free for all women in most locations. In all locations except Sumba Barat, bidan

were also present in the village to provide services. National requirements for delivery indicate that they

should take place in “an adequate facility,” but local governments have the discretion to define what is

9 Indonesian Health Policy Network (2014) Primary health care financing and expenditure bottleneck study: East

Nusa Tenggara and East Java provinces. 10

Kementerian Kesehatan RI, (2008). “Petunjuk Teknis Standar Pelayanan Minimal Bidan Kesehatan di Kabupaten/Kota,” No 828/MENKES/SK/IX/2008.

5

“adequate.” In NTT, the provincial “Revolusi KIA” policy dictates that women should give birth at a

puskesmas or higher level facility, while in other study provinces, village level clinics were seen as

adequate. Postpartum care can be provided at home, but many providers are not doing this, as

discussed below. In all locations, attempts have been made to develop puskesmas PONED (Pelayanan

Obstetri Neonatus Essensial Dasar) which can bring more advanced obstetric and neonatal care closer to

clusters of other puskesmas, so that they may not have to refer patients to the hospital.

2.1. Health care financing Financing is a critical but highly complex constraint for all puskesmas. How much they get, from what

sources, how well they manage it and how “brave” they are in their spending are all important factors in

how financing constraints play out across various puskesmas.

Most puskesmas receive most of their funding from three sources:

- BPJS (Badan Penyelenggara Jaminan Sosial -Social Insurance Body). Funding from the national

level, broken into capitation funding and claims for services. Capitation is based a formula based

on the population covered by the puskesmas and the number of doctors at the puskesmas.11 It is

paid directly to the puskesmas, covering provider fees for outpatient care, medicines, medical

instruments, disposables and operational costs. 12 Claims (or fees for services) are made either

collectively by the puskesmas or by individual service providers and are paid for in-patient

services, including delivery and referral transport. They now also include specific allocations for

antenatal and postpartum visits.13 These are paid to the DHO, which then transfers to the

puskesmas.

- Bantuan Operational Kesehatan (BOK- Health Operational Assistance). Funding from the

national level to the puskesmas via the DHO to support the accomplishment of MDGs and

Minimum Service Standards. It can primarily be used for off-site puskesmas activities (kegiatan

luar gedung).

- District Budget (APBD). Funding from the district level, composed of ‘cash’ and goods. Money

disbursed directly to the puskesmas covers operational costs and limited project activities.

Goods purchased by the district include medicines and disposables.

The cash revenue derived from retribusi, or locally regulated fees for uninsured patients, also deserve

mention. These fees are set in local regulation. Puskesmas are not allowed to manage this money, and

theoretically must deposit it with the DHO.

11

Kementrian Kesehatan RI, (2014). “Penggunaan Dana Kapitasi Jaminan Kesehatan Nasional untuk Jasa Pelayanan Kesehatan dan Dukungan Biaya Operasional pada Fasilitas Kesehatan Tingkat Pertama Milik Pemerintah Daerah,” Permenkes No. 19 tahun 2014. 12

Presiden RI, (2014). “Pengelolaan Dan Pemanfaatan Dana Kapitasi Jaminan Kesehatan pada Fasilitas Tingkat Pertama Milik Pemerintah Daerah,” Perpres No. 32 tahun 2014. Puskesmas are considered “first level service providers.” Some districts are requiring that capitation monies go into the regional budget and therefore be subject to local tax. This was the case in Dompu, where the puskesmas received the money from BPJS, but had to then transfer it to the district budget. It was then partially re-transferred back to the puskesmas under a complicated formula set out in SK Bupati Dompu No. 800 year 2014. 13

Kementrian Kesehatan RI, (2014). “Pedoman Pelaksanaan Program Jaminan Kesehatan Nasional,” PMK, No 28 Tahun 2014.

6

General observations about puskesmas funding echo those presented elsewhere. First, district budget

contributions to puskesmas are generally nominal, and influence change at the margin if at all, meaning

“local innovation” is hard to fund.14 Second, though BOK makes up a large portion of puskesmas funding,

it is consistently late, often becoming accessible only mid-year.15 Categories of spending cut across

funding sources, which can help buffer if one source is late, but more frequently creates obstacles in

planning, budgeting and spending. Medicines, disposables and patient transport are funded both from

BPJS and APBD. Operational funding comes from all sources.

There are two key challenges. The first, access to and use of BPJS funding highlights ongoing challenges

in providing required medicines and supplies (using capitation funding) and problems in paying claims to

bidan. Both problems impact bidan incentives and performance. In different ways, both can be linked to

problems in the regulatory environment, and the ability of the local government to navigate it. The

second, challenges around operational funding, is not new, but here we attempt to more clearly

describe the impact of these challenges on service delivery and efforts to hold service providers

accountable.

2.1.1. Access to and use of BPJS funding

Prior to JKN, all planning, budgeting and procurement for medicines and supplies took place at the DHO,

based on puskesmas input and historical trends. This system has a number of problems, and routinely

results in shortages in medicines and materials at the puskesmas level. 16 Many respondents at the

district level see JKN as part of a solution to this problem, allowing puskesmas to have flexibility to

purchase the medicines and materials that they need when they need them. While this is true, there are

also at least two key problems. First, if well implemented, BPJS must be more than a mechanism to fill

the gaps in puskesmas and district planning processes. It needs to meet the medical needs of the

insured puskesmas population. Therefore, there needs to be clear planning and budgeting processes.

However, by disbursing directly to the puskesmas, JKN has essentially fractured the planning and

budgeting process between both administrative levels and covered/ uncovered populations. It has also

undermined economies of scale in purchasing and disrupted potentially efficient distribution channels if

puskesmas actually make their own purchases. Second, and perhaps more crucial, is the reality that

many puskesmas cannot even access BPJS capitation money because they do not have staff certified to

undertake procurement.

Puskesmas ability to use the funds for medicines and supplies varied considerably, dependent upon local

government ability to find solutions to planning, regulatory and procurement problems, articulate them

clearly and provide support that let puskesmas feel at ease with spending money without fear of

breaking audit rules. In all three NTT locations, puskesmas studied were waiting for further instructions

(via Bupati instruction) before using BPJS monies for buying medicines or disposables, meaning that

14

Situbondo was unique as it received significant funding from the Bupati (APBD) and province for “innovation.” 15 Indonesian Health Policy Network (2014) Primary health care financing and expenditure bottleneck study: East

Nusa Tenggara and East Java provinces. There are two reasons for this. The funds are often disbursed late, but technical guidelines are finalized even later, and no puskesmas will use the money without the guidelines for fear

of audit problems. 16

Ibid

7

neither they nor the DHO had used them at all in 2014. Other locations have been more successful in

spending, largely by keeping the procurement in the health department. In Dompu, puskesmas

transferred its capitation money back to the DHO, which kept money for drugs and supplies, releasing

only operational funds back to the puskesmas. In Lombok Utara, the DHO undertakes procurement, but

the puskesmas is responsible for ordering and paying for goods, often from suppliers in Mataram or

Surabaya. This meets audit requirements, but is highly inefficient. All challenges impact puskesmas

access to needed medicines and disposables.

Claims were also problematic in most locations due to late and sporadic payment. Delays or

underpayment impact both the puskesmas and bidan. In all locations, a portion of the bidan fee is used

to pay cleaning staff and security, and may help subsidize drivers or other voluntary staff. Unlike

capitation, claims under BPJS are paid to the health department, not the puskesmas. This study did not

go into detail on the different steps required to verify and pay claims, but documented that most

locations received only a portion of claims for 2014. In addition, in Sumba Barat, bidan were told that

they simply could not claim for three months. Differences in how claims are paid also impact on their

effectiveness as incentives. In both locations in Java and one in NTT, claims are only being paid at the

end of the year as a bonus. Bidan complain about this, and it undermines the incentive approach, since

payments are made at the discretion of the puskesmas, and are not linked to work performed.

Separate to getting claims paid is the issue of how much bidan (or the puskesmas) can legally receive for

their services per local regulations. In Sumba Barat, local regulation has established the fee for a normal

birth at Rp 350,000, but under BPJS it is Rp 600,000. There is confusion as to whether it would be legal

for bidan or doctors to be paid the BPJS amount as it differs from what is locally mandated. Until clearer

advice is provided, puskesmas are only accessing the amount allowed under the local regulation. Similar

problems exist in Flores Timur. This issue deserves highlighting as it is an area where the lack of

government capacity or poor legal advice has a huge impact on the puskesmas and the bidan. It is

critical to note that there were discrepancies between the local regulations and BPJS regarding fees in

other locations (indeed, only in Manggarai was the amount the same), but all other locations were able

to allow puskesmas and bidan access to the funds they are entitled to under the program.

2.1.2. Operational funding

Operational funding is opaque, but critical. Operational funding provides the puskesmas with the

flexibility and ability to provide basic services. For example, if the puskesmas is short of medicine (as is

often the case) bidan buy from private sources and claim back from operational funds. Similarly, while

petrol for the ambulance (either for insured patients or routine meetings) can be claimed after the fact,

the cash to actually buy it also comes from operational funds. Village clinics should have operational

funding from the puskesmas, but often don’t receive it, leaving bidan to pay electricity, water and

incidental expenses on their own. This impacts the desire of the bidan to stay in the village. If patients

lack water or have to pay for electricity during delivery, it impacts their perceptions of the facility as

well. Other studies have noted that much operational funding comes from (illegal) savings on BOK

funding.17 BPJS operational funding also helps, but the study found indications in some locations that it

17 Ibid

8

was being used to meet other needs- to pay incentives for volunteer staff or additional doctors, or to

cover costs associated with the elimination of the registration fee. Cash from retribusi can become

important in this environment: fees for general patients for registration, ambulance use etc., all

generate cash. In general, if savings cannot cover gaps due to delays in disbursement or payment of

claims, puskesmas have little incentive to report or deposit the money they take in and greater incentive

to pass costs on to patients.

Discussions about transparency and accountability around operational funding are complicated in an

environment where finances seem more cobbled together across delays and gaps than clearly

documented or planned. This study found that certain core services still functioned, despite funding

delays – many (though not all) posyandu were still running despite the lack of funding for transport in

most locations due to BOK delays. Bidan and puskesmas staff were usually in their posts, though often

came late or left early, despite the fact that many are volunteer. It was sometimes more difficult to

understand how services kept running, which is the important point for citizens seeking transparency or

wishing to hold their providers to account. For example, in Manggarai, the head of the puskesmas is

attempting to be more transparent with his use of BOK funding: when he receives it, he posts all BOK

funded activities on the wall, with the budget and the person responsible. When he does not receive

BOK funding, he cannot do this, but can only encourage his staff to continue doing their jobs. Attempts

at citizen engagement through efforts to support kecamatan health committees struggle in this

environment. They may be able to provide input on community needs, but have very little oversight or

advocacy role. Indeed, the one head of a kecamatan health committee interviewed did not even know

what BOK was, 18 and seemed to measure “community engagement” against a metric of how much

citizens were willing to contribute to cost-sharing for activities at the puskesmas.

2.2. Staffing Having the right staff in place is essential for the delivery of quality services, but so is having staff that

can be held accountable for their performance. Staff shortages were only a clear problem in Sumba

Barat, where four bidan (of whom only two were active), were attempting to provide services to citizens

in nine villages. Interestingly, the DHO in Malang also mentioned a problem with shortages of doctors in

“less desirable” locations, even when they were advertised as civil service positions. In other locations,

however, staffing shortages were harder to discern. While many DHO mentioned problems in

recruitment, several local governments have responded by filling (and often overfilling) gaps by

engaging “volunteer” bidan.

Many bidan and doctors are hired on short-term, once-renewable contracts (PTT). If they do not

perform, they can be removed, but it is very difficult to get the replacement position approved from the

national level. As a result, DHO will chose to leave the person in place regardless of performance rather

than lose the position. In addition, doctors in particular tend to leave after one term. If they have been

trained as a PONED doctor, then their expertise leaves with them, and many DHO have stopped training

them for this reason. Since most doctors in NTT are on PTT contracts, it is very difficult to develop and

18

When researchers asked about BOK, they were corrected and told that was for education (referring to BOS- Bantuan Operational Sekolah).

9

then sustain puskesmas PONED. While civil servants generally do not leave, they are often moved in

“mutasi,” which also undermines PONED, breaking up trained teams of two bidan, two nurses and one

doctor. However, the long standing desire of many to be a civil servant also seems under threat by the

private sector in Java. In Malang, the DHO advertised for ten positions for PNS doctors and was unable

to fill a single one. Only seven people applied and none met the basic requirements of the position.

Where districts face staffing gaps, they are increasingly turning to the use of “volunteer” bidan and

nurses. However, the appointment of these individuals often takes place outside of the DHO, and seems

to be driven partly by staffing needs and partly by systems of political patronage. This means that those

accepted are not necessarily the best-qualified nor in line with DHO staffing needs. Volunteer bidan

generally receive small stipends from the district budget or nothing at all. They work in order to “not

lose their skills” and in the hope of securing a more permanent position. Their numbers are hard to

estimate but can be very high. In Dompu, it was estimated that 70% of bidan were volunteers, in

Situbondo roughly 400 of 600 bidan were volunteers. The number in Manggarai was not clear, but they

stopped accepting them at the end of 2014 due to budget concerns.

While problems of quality were present across all types of bidan, they are exacerbated by large numbers

of volunteer bidan. Because they sit at the edge of the formal system, they are generally not eligible for

training, though they are largely younger and less experienced than others. Puskesmas heads in multiple

locations confessed they find it a tremendous burden to find them appropriate positions and manage

them effectively given their limited training and lack of experience. Because they sit at the bottom of the

‘hierarchy’ they are often sent to villages, with positions at the puskesmas going to more senior bidan.

This removes them further from support networks and opportunities to learn. In Dompu, the head of

the puskesmas, a village head and citizens also expressed dislike of volunteers due to their lack of

accountability. While most clearly voiced in that location, it is generally true: since volunteers are barely

paid and not clearly part of the formal system, if they are not at their posts or provider poor care, very

little can be done.

2.3. Bidan incentives Bidan behavior is influenced by a large range of factors, including monetary incentives; availability of

medical tools, medicines and disposables; career opportunities; personal motivation and systems of

support, hierarchy and discrimination. The factors have different meanings and impacts across different

‘types’ of bidan (PNS, PTT or volunteer) and bidan in different locations (East Java vs NTT, more or less

rural locations). Key incentives and constraints are considered below.

2.3.1. Monetary incentives

Monetary incentives for bidan are largely composed of base salaries, claims, and allowances from the

State and any private practice income generated independently. Civil servants in many locations make

less than PTT counterparts, and volunteers are paid little or not at all. In general, the farther east a bidan

works, the more she makes as a PTT, though remuneration for volunteers is variable and not always

clear. In Malang, health department staff made it clear that bidan needed to make ends meet through

private practice.

10

For most bidan outside of Java, claims for deliveries are a crucial part of their income. However, the

implementation of JKN has left many frustrated, as they face increased administrative requirements that

many patients cannot fill. If patient’s paperwork is incomplete (e.g. without family or identity cards),

bidan’s claims will not be paid. The head of one health department explains the tension that this creates

in terms of service delivery:

"The problem is upstream, but those of us who work downstream in the service delivery units are

the ones that get blamed. Citizens say that we are not responsive, that we are unhelpful and

make things worse for them. We are in the wrong either way: if puskesmas staff and village

midwives provide care to patients without identity, then they will not receive their claim from

BPJS. This puts us in a difficult position. If we provide care we don’t get paid, if we don’t provide

care… we are involved in people’s lives (with their souls).

It is important to note that in cases such as the above, very few bidan are working with local

government counterparts to attempt to assist individuals. Only one bidan in Dompu had established a

strong relationship with the village head. She worked with the village government to solve identity

problems. Similarly, village heads did not seek out bidan to try to understand requirements or find out

what was needed to serve their communities. Again, this was not true in all locations: one village head in

Sumba Barat was working hard to ensure that all his constituents had identity documents in order to

receive regional coverage. He did not coordinate closely with a bidan, since there was no longer one

based in the village.

In addition to the real possibility of not being able to meet the requirements, shifting rules and

arrangements further muddy the water, making it unclear what will be accepted for claims. As one bidan

coordinator explained, “information about BPJS is still mixed up- rules about claims for deliveries and

documents that we need are not clear, but if anything is missing, it will be returned to us.”

Even if a bidan is able to meet all the requirements to have her claim accepted, there may be further

problems with getting paid, or paid in full, as discussed above. Important to understand is how this

impacts the services that they are willing to provide. For example, late (or missing) payments have

resulted in some bidan in Situbondo essentially refusing BPJS patients care: “BPJS is just (barely) enough

and there are not that many patients who have it. So, after talking to friends (other bidan) and taking

into account that we don’t get paid, its over. Now, if there are BPJS patients, we just send them to the

puskesmas.” This alludes to a second issue: how much bidan actually get paid. Of the Rp 600,000 that is

meant to be their fee, the amount that actually made it to bidan in the locations studies ranged from Rp

299,500 to Rp 450,000, lower than what can be made in private practice. This was in locations where

bidan could map the payment to the claim. Where claims were paid as lump sum, year end “bonuses,”

bidan were less sure.19

Village bidan are considered in the employ of the State 24 hours a day for the purpose of deliveries. If

patients are not insured, then they must pay for services, and bidan must deposit the (regionally-

mandated) fee with the puskesmas. This interacts with insurance in different ways. In Malang, new

19

This was the case in all locations in Java and in Flores Timur.

11

targets have been set since the end of 2014. Bidan are now required to deposit the fee for one or two

deliveries (dependent on location) to the puskesmas each month. Originally, they could count BPJS

claims toward their targets, but from early 2015, must pay in cash. The regional fee in that location is

actually higher than BPJS at Rp 750,000. Both the need to deposit cash with the puskesmas and the fees

received for referring patients to private hospitals works against bidan encouraging patients to get (or

use) BPJS coverage. While most bidan did discuss BPJS with patients, it was often done at the moment

of delivery, not ahead of time, meaning that patients may or may not be prepared.

In Dompu, confusion around the implementation of the regional program left both bidan and mothers

unclear as to whether health coverage would be continued. However, when bidan asked mothers to

pay, many were simply unwilling, citing years of experience of free service under Jampersal. Bidan are

still responsible for depositing payment (Rp 500,000 per delivery) to the puskesmas. Interestingly, they

suggested births of women unwilling (or unable) to pay be recorded as taking place with the dukun bayi

(traditional birth attendant), even if the bidan assisted. Since this would not be counted as a birth with a

medical professional, they would not need to pay. The puskesmas head disagreed, feeling it would look

worse for the puskesmas to have a high number of non-assisted births than to not deposit money. In

this situation, it is not clear where the blame will fall if it becomes a problem.

2.3.2. Village facilities, medicine, tools and disposables

The importance of state-provided medicine to bidan varies by location, generally driven by what

patients can afford and therefore the strength of the “shadow economy” in drugs. In all locations there

is the perception that medicine provided by the State is likely to be less effective than branded,

purchased medicine, but for some, particularly those who are cash poor, free medicine is essential. For

those in areas that were more cash-poor, they could not hope to make much money selling additional

medicine, while in Java, there was a clear market in private drugs. In Malang, bidan ordered medicine

weekly from agents, either getting money back on the total of their orders or accumulating points for

household items or holidays.

In all locations, there were shortages of essential medicines related to pregnancy. The study checked for

protein sticks for identifying pre-eclampsia, and Oxytocin and Magnesium Sulfate for postpartum

hemorrhage, preeclampsia and eclampsia, and found that many bidan had to purchase one or more on

their own. In locations with many patients who can absorb the costs of the medicine, this was less of a

problem. In locations with fewer patients who could not pay, bidan had less incentive to have drugs on

hand. However, even in those locations, they could buy on their own and claim back to the puskesmas,

sometimes with a large price difference. For example, in one location, Oxytocin which was normally

bought for Rp 8,500/ ampule was sourced from a private practitioner and claimed back to the

puskesmas for Rp 20,000. These systems of buying on the private market or claiming back also mean

that bidan place very little pressure on the puskesmas or the health system to fix the poorly performing

distribution system. This creates problems in particular for medicines that are infrequently used, such as

magnesium sulfate, since no party has much incentive to ensure that the drug is on hand or unexpired,

as was the case in several locations. This can have deadly effects on women suffering from eclampsia.

12

Aside from medicine, many bidan are expected to set up all or some of their practices in the village.

Bidan in locations in East Java have to provide nearly all tools and furniture, including basic items such as

stethoscopes, while in locations farther east, the state provides more basic tools. However, in those

locations, the study found several bidan grappling with more basic problems like water or electricity.

Examples include one village clinic that was denied solar service when it was installed for the rest of the

village, since there was no allocation to pay the monthly fee, and locations given generators but no

petrol to run them, or no money to maintain them. In those cases, small planning failures had large

negative impacts on bidans desire to stay in a village and to provide care. They also impacted patients

who had to pay for their own electricity or deliver in the dark if they gave birth at night.

2.3.3. Careers, hierarchies and discrimination

Given all of the challenges, it is worth asking why bidan enter the profession and what they hope to get

out of it. Many care deeply about providing care to the communities that they work in. Some have

chosen the profession for other reasons, including the (comparatively low) cost of the degree, perceived

availability of jobs etc. Most are aspiring to the security of civil service positions or ensuring that they

keep them.

Civil servants are often frustrated by the fact that they are burdened with increasing administrative

duties which pull them away from patients. As puskesmas step through administrative hoops to achieve

BLUD (Badan Layanan Umum Daerah -Regional Service Delivery Body) status or receive other

certifications, as was the case in Situbondo. There, PNS bidan were consistently pulled out of village

posts to assist with administrative work at the puskesmas. Both patients and bidan complained, since

villagers were without a bidan, and the bidan herself felt overwhelmed. It is likely that she also lost

revenue. Another common complaint from civil servants is that they are often paid less than their PTT

counterparts, though they are asked to shoulder more responsibility. For their part, PTT are often in less

desirable locations, and have limited job security. Volunteers sit at the bottom, hoping only that the

experience they gain and limited money they will make will allow them to get a toe on the ladder.

Regardless of employment status, bidan care about performance in two main ways. They do not want to

have a mother or child die in their care and they generally care about hitting targets, since both keep

them in favor with the puskesmas. However, there are a number of frustrations with targets. First, while

reporting is increasingly based on real numbers, targets are set using population projections, which

often differ wildly from actual populations (usually overstating). This makes it hard for bidan to hit

targets and mean that data paints an inaccurate picture of services provided. Second, targets do not

always match the reality of how patients access care. For example, migrant workers who come home

late in their pregnancies to deliver create a challenge for bidan with targets on women attending their

first ANC visit and attending all four ANC visits. The pressure to meet targets puts providers in a

precarious position where they prioritize demonstrating success of meeting targets rather than the

health of pregnant mothers and newborns. Some bidan do not record services provided to these

patients, so that they will not pull their percentages down. Finally, some targets have been “expanded”,

notably the number of visits for ANC care. The current ANC guideline is to provide at least four ANC

services; however, in many of the study locations the health department was proud to declare that they

had improved services by increasing the number of visits to nine. Unfortunately, while this was more in

13

line with the current mechanism of monthly checks, the volume of patients and repetition leads more

often to a lack of differentiation in each ANC visit, lack of information sharing to high-risk women and no

delivery plan. The impact of this will be discussed in detail in findings in Section 4.

Finally, it is important to note the pervasive hierarchy and frequent discrimination within the medical

system. Hierarchy was pervasive, but in locations outside of Java, bidan were also subjected to being

yelled at, second guessed and insulted when they accompanied patients that they were referring. In one

location, bidan sent volunteers with referred patients so that they would not have to deal with hospital

staff. In another location, when a bidan brought a woman whose hemorrhaging she had managed to

stop to the hospital, she was scolded for not immunizing the baby (understandable since she was

focused on the mother). This type of interaction is serious for several reasons. In that case, while the

bidan had provided poor quality care in a number of ways prior to stopping the hemorrhaging, she may

have ultimately saved the woman’s life. However, when recounting the story, the patient did not

understand (or downplayed) the seriousness of her condition, blaming all problems on the

incompetence of the bidan. This perception was strengthened by the response she saw from hospital

staff. This experience directly undermines trust in local providers and facilities, and by extension patient

desire to use them. Secondly, since the hospital staff yelled at the bidan for something trivial, she is that

much less likely to talk to them about the other more serious problems (in that case, the fact that she

struggled with the administration of magnesium sulfate). If the DHO wants to improve quality of

services, this type of communication and self-assessment is critical. To support quality care, different

levels of actors within the health system need to help each other and share knowledge in a way that is

currently not happening.

3. Accessing Maternal and Neonatal Care For many Indonesian citizens, the decision to seek care is inextricably linked to whether or not they feel

they can access it. Concepts and feelings about access are multidimensional, and include financial access

(affordability); physical access; administrative access; and equitable access to care. As Indonesia focuses

on shifting health care delivery out of homes (with either a state or informal provider) and into either

state or private facilities, understanding factors that impact access is critical. Effective implementation

of a facility-based policy must address some of the obstacles that patients face in accessing care or it

risks further marginalizing mothers and families that cannot afford to reach services, potentially placing

them at greater risk. Any future policies must also keep these issues in mind, since they are fundamental

in framing how providers and patients interact and shaping perceptions about how services are

delivered.

This section explores these dimensions of access in greater detail, suggesting that a better

understanding of constraints can support more effective policies and actions. It opens with a basic

reflection on how cash poverty and lack of access to credit create financial barriers and impact on other

types of access. It then turns to the two main obstacles to access found in the research: transportation

and insurance. Despite the fact that average distances to health facilities are seen as acceptable,20 they

20

Kementrian PPN/ Bappenas (2014). Health sector review: Consolidated report.

14

hide significant variation between regions, do not take into account road quality and obscure

transportation limitations. While Indonesia is committed to providing universal healthcare in the long

term, immediate policy changes are creating access barriers for many. The dissolution of the Jampersal

program combined with recognized gaps in the national poverty list left many women uncovered who

cannot afford care. For those who do have health insurance, confusion about required documents and

stricter identity requirements are creating barriers to use. This is taking place at a time when the costs of

giving birth at home are rising: particularly outside of Java, sanctions are increasingly being used (legally

or not) to fine women and families or deny them elements of care if they do not use facility-based

services. The last part of this section discusses these approaches and their impact on both access and

accountability. Throughout, it aims to provide examples of how local policies and actors can support (or

obstruct) access to health care services for all Indonesians, but particularly those who may face

additional obstacles in using services. It also notes where national policies assist or constrain local actors

to respond effectively to health care needs.

3.1. Paying for Services: Cash and Credit Across locations, families interviewed still face cash constraints, often because their incomes are linked

to their harvests21 or informal daily work and are therefore seasonal or insecure. In terms of access to

credit, the difference between NTT, NTB and East Java was noticeable, with credit becoming more

available the further west one traveled. At a basic level, this is linked to simply having more or less

developed and diverse local economies, larger or more frequent crops, as well as markets for (and

ownership of) collateral assets.

Lack of cash or access to credit is important as part of a discussion about access to health care for

several reasons. As will be discussed further below, not all “poor” Indonesians have state-sponsored

insurance to defray health costs. If they do not, making monthly payments is difficult. If they do, they

still may have out of pocket costs for transport and medicines. In either case, patients are expected to

pay in cash up front or at the time of service delivery. When families are strapped for cash, delays are

created if they need to borrow more money, usually in referral situations. If they are able to access care,

they may face other problems. In several locations, hospitals refuse to release patients if they had not

paid in full, meaning that costs would increase while the family searched for additional funds. Fearing

escalating costs, patients with limited funds frequently check out (or check out their babies), even if they

are unwell.

In addressing these constraints, the first challenge is identifying and limiting the problem. This has

multiple aspects, from understanding how families try to gather money to what they actually have to

pay for. For example, in East Flores, there seemed to be a gap in the perceptions between providers and

patients as to what was happening prior to referral. Providers described patients needing to make calls

and meet people to conduct adat (traditional law) ceremonies, leading to delays. However, community

members described the same events as a search for money, citing transport costs as their key

21

These findings are consistent with reality check findings in other areas. See “Indonesia reality check main study findings: Listening to poor people’s realities about basic education.” Jakarta: Australia- Indonesia Basic Education Program, 2010.

15

constraint. Adat, they said, could be dealt with on the way, and when they were making phone calls to

family, they were generally trying to secure loans. It is not clear if providers actually understood the

problem, and used “culture” to cover their inability to respond to it, but the fact that they did so

undermined efforts to effectively address the problem. In that location, a typo in a local regulation

meant that everyone had to pay for transportation, even if they had insurance. Because those needing

assistance were presented as bringing the problem on themselves, there was little push for change.

In some instances, cash constraints mean families make decisions to end care to avoid taking on debt

that they cannot afford. The following example shows the impact of cash constraints and costs that led

to the death of a baby in Sumba, as told by the child’s grandfather.

“.... At that time (of year), people generally have no money since the cashew nuts have not

been harvested yet. After gathering the family together we decided to bring the child to

the puskesmas … to the closest clinic. We thought we would only take her there since we

don’t have money. But they said they could not help her, her condition was too serious.

There was a problem with her chest (pointing), they said it was full of mucus. She was only

two months old. So we collected money from the family and took her to the city. In the

city, they asked us to pay Rp 1,000,000. For only three hours… three hours in (the first

hospital). Then we were rejected because we couldn’t pay more. We then went to the

other hospital and she spent three nights there. There, they asked us to pay three million

and eighty thousand. But since we came late on the first day we only paid Rp 2,500,000.

We used the money we had left and were able to borrow more from family in the city. The

next day, we checked the baby out of the hospital. She was home for one night and the

fever began, for four nights. We could not sleep for four nights, the family was together.

Four nights and she fell victim, she died.

Despite these challenges, providers often indicate that what patients lack is not cash, but commitment

to health. Following the death of the baby above, the family slaughtered several pigs. Bidan lament this

practice, saying that the pigs should have been sold for health costs, not to celebrate death. While this

may be true, the family may still face challenges in turning their pigs into cash quickly at a time when no

one in the area has money to buy.

A second challenge is that Puskesmas and bidan have a limited ability to respond patients’ lack of cash.

Some areas have tried to alleviate costs to patients by building waiting houses, so that they can be

closer to facilities. This can address part of the issue, but in the two locations that had them in this

study, they were not being used, in one location because the house did not have a kitchen and in the

other because it had been occupied by puskesmas staff.

As mentioned under bidan incentives, if a bidan provides services to an uninsured patient, she is still

often obligated to deposit the fee for the service with the puskesmas. In one location, state bidan were

encouraging patients to pay off debts incurred for delivery in installments to try to recover money that

they had deposited with the puskesmas. Patients who had worked abroad recommended that Indonesia

consider payment plans, based on their positive experiences with paying in installments in Malaysia. In

16

Situbondo, some patients mentioned that part of their decision to go to a private provider was that they

could pay for services in this way.

Third, while some patients were willing to consider installments, others looked to the Jampersal

program of the recent past and wondered why they are suddenly being asked to pay at all, when until

recently, services were free. This change meant that some patients left the formal system entirely. This

leads to a fourth point: how payments happen within the informal sector. Care provided by traditional

birth attendants is rarely free, but it can often be paid for in kind (chickens, cloth), which makes saving

easier for many people. Several government actors were quick to point out costs in the informal system

as they dismissed arguments that the formal system was too expensive. However, by monetizing

payments, they are overlooking key aspects of how people save, and also assume that assets can quickly

be made liquid, which is often not the case.

3.2 Transport and distance to facilities Transportation costs remain one of the main obstacles in accessing health care for many Indonesians.

Distances, road conditions and time spent traveling can also create barriers. Many patients feel that it

may be safer to stay where they are if they are far from service providers or physical access is poor. For

many women, the fear of giving birth on the road—in the back of a truck, in an unknown house—is one

that is very real. For their husbands, who are also key actors in decisions about where to go, the thought

of putting their wives at risk in this way is equally frightening. Below we consider three key areas

impacted by transport problems and influenced local policies: where to go at the moment of delivery,

making decisions in a referral situation and accessing care at the village level.

3.2.1. Going to a facility

As Indonesia encourages patients to seek care in facilities, it must check the desire to push patients into

facilities “for their own good” with the recognition that it cannot simply shift the transport burden onto

citizens. Patients appreciate providers that respond to local conditions, as the example from Dompu

shows below. Examples from Sumba Barat and Manggarai indicate that if requirements are placed on

patients, providers must also be able to be held accountable.

In Dompu, one village has implemented a village regulation requiring that women give birth at least at

the village clinic. It was developed by the very senior village bidan, in conjunction with the previous

village head. Women not only know it exists, but can also explain reasons why it is better for them to

give birth at a facility. It is also applied “reasonably”: though actually breaking the rules set down in the

regulation, the bidan has reached an agreement with villagers in the farthest dusun (hamlet) that she

will assist with births in their homes if they call her, while all other villagers must give birth at the village

clinic or receive fines. If those in the farthest dusun fail to call her, they also receive a fine. All villagers

are aware of this agreement and see it as fair, since it places responsibility on them but also recognizes

their fears in the dangers of distance. Most importantly, by responding to patient about delivery fears

and needs, the bidan has signaled to patients that the she will make an effort to help them, even if they

do need to be referred on to a facility.

17

In NTT, Revolusi KIA policies require that women give birth at the puskesmas or above. In Sumba Barat,

the implementation of this policy has led to the removal of bidan from villages altogether. To help

patients get to the puskesmas, it has promised that the ambulance is available for free (with insurance)

or at a reasonable price to bring mothers from the village to the puskesmas. Many citizens are more

than willing to use the service, but find it difficult: sometimes the phone is not answered, sometimes the

ambulance simply does not arrive, sometimes it arrives too late, forcing women to give birth at home.

This contributes to a perception that services are arbitrary and unreliable. In this case, challenges

around operational funding and availability of staff contributed to the problem, and need to be

addressed so the service can be offered consistently. While patients may get dispensation if it is clear

that they called for assistance, many still receive sanctions by bidan for giving birth at home.

In Manggarai, birth at village clinics is still largely tolerated. In theory, bidan are allowed to assist at

homes in emergency situations, but with the exception of one village bidan, they were largely unwilling

to do so, pointing to patient proclivity to overstate problems to get home visits. This general lack of trust

and unwillingness to respond to patient requests can have serious consequences. In one case, it likely

contributed to the death of a woman who went into unexpected labor after being terrified by a

landslide near her house. Recognizing she was in trouble, a traditional birth attendant who had been

called to check on her contacted several bidan, but none of them would come to the house. Despite the

fact that the woman was bleeding heavily, the family did ultimately carry her out and get her on a

motorbike in an attempt to get her to the clinic. She died on the road.

While the Revolusi KIA policy starts from wanting to support women to go to facilities to reduce

maternal death, it can become a cover for provider inaction if providers don’t trust patients to identify

emergencies or recognize the barriers patients face. Similarly, patients have a responsibility to try to get

to providers in non-emergency situations. While distances and costs of transports still need to be

addressed, improved communication and trust between providers and patients will also help.

Most government officials present Desa Siaga as the key response to support women to health care

facilities. Desa Siaga consists of several village-level networks aimed at ensuring community readiness

for birth: transport networks, saving schemes, identification of blood donors, etc. Unfortunately, Desa

Siaga seems largely ineffective. Even with commitment from village leadership (which we found in one

village in Sumba Barat), barriers cannot always be overcome at the village level. For example, if

individual savings schemes are within reach of what families can afford, they often don’t add up to

amounts that cover transport costs. This is particularly true in the areas where transport is most

expensive, since those areas also tend to be the most rural and cash poor. Citizens are often unwilling to

contribute to village or collective savings schemes, since they have had too many other experiences of

money disappearing. With additional resources coming to the village under the new village law, there

are possibilities for different village funded solutions to be explored.

Being referred can increase costs significantly, both in terms of transport and care. This is most

dramatically illustrated in Flores Timur, where getting to the hospital involves a boat ride and often an

additional drive. Once a day, in the right season, this costs Rp 30,000/ person on a public ferry. At any

other time, it costs between Rp 700,000 and Rp 2.5 million. For a community operating partially in a

18

barter economy, these costs are astronomical. A father can borrow money from family members (if they

have any cash), but it takes time. At a minimum, he will be admonished by health staff for being

irresponsible and unprepared, but he may also be threatened with fines. However, unless families know

ahead of time that a woman is likely to be referred, they are less likely to prepare for these high costs,

since it often involves making assets liquid- selling goods or animals that would otherwise be used for

“insurance.” If the money is not used, then the asset has essentially been wasted. This is particularly

true off Java. This reinforces the importance of identifying high risk woman and communicating that risk

(and its cost implications) to husbands.

In theory, ambulance services are covered for those insured under JKN in cases of referral from the

puskesmas to the hospital. Reality is mixed. In some locations, particularly in Java, the service seems to

be more often available. Ambulances are often used to transport the puskesmas head to meetings at

the district level, and may also be used for mobile health services, meaning that they are often not

available to patients being referred. However, in two locations, the ambulance was present, but the

driver was absent. In the worst example, a number of patients recounted their anger at being asked to

go and find him in his field if they wanted service. In addition, the cost of the ambulance can be a

barrier, even for those who supposedly should not have to pay. In several locations, those with

insurance coverage were asked to pay, having to negotiate and produce cash before they could leave.

This was worst in NTT.

BPJS rules around referrals can cause additional problems. Since BPJS is pushing harder to ensure that

puskesmas fulfill their roles as gatekeepers, patients are increasingly being told that if they arrive at the

hospital without a referral from a doctor, they may be denied coverage or have to pay. However, due to

kecamatan administrative boundaries, going to the puskesmas can take patients farther from the

hospital and seems like a waste of time, especially in an emergency.

This is clearly demonstrated in one village in Manggarai. Spread across a ridge, citizens drop into the

valley on one side to go to the puskesmas, but dropping off the other side takes them to a main town

with a different puskesmas and a private hospital, on the road heading toward Ruteng and the public

hospital. If they go “their” puskesmas first, it takes them an additional hour to get to the hospital if

needed. Villagers want to be able to go to the hospital in case of emergency, but have heard of friends

or neighbors being turned away from hospitals for not having the right letters. They worry that BPJS

policy is placing them at risk. While bidan are aware that there are exceptions in emergency cases, they

also worry that their claims will be denied if they don’t follow the correct administrative procedures.

The puskesmas head, who until recently had been able to sign off on referral letters if the doctor was

not available (he lives in another town and is often absent), is no longer able to do so and fears delays

for his patients. BPJS points out that any member can request to move to a different puskesmas, and

whole villages can do so collectively. This would be the most obvious solution for the village. However, it

means that the puskesmas loses a percentage of its capitation money, reducing its incentive to share

information on the process. It is somewhat politically sensitive to move resources away from the

puskesmas, so the health department is also not actively advocating change. While there could be huge

19

efficiency gains, and likely improved health outcomes, that could be achieved by mapping citizens to

providers by transport routes (rather than administrative boundaries) it is not clear that it will happen.22

3.2.2. Accessing village level care

Distances and transport within the village is a challenge across locations. At the village level, mothers

need to access posyandu (integrated service post) for regular free ANC visits and the village bidan for

additional check ups (if necessary) and birth. In NTT and NTB, challenges to reaching services within the

village were mostly due to long distances and lack of transport. While posyandu are village institutions in

theory, in practice, timing and location are driven largely by availability of puskesmas staff and the

village bidan. The commitment of the puskesmas to supporting these institutions is critical for both

access and quality. The study showed a wide variety of approaches: in Dompu, there was a strong effort

to ensure that posyandu were close to patients, while in Sumba Barat, posyandu (and posbumil) were

limited, partly due to staffing constraints. In Manggarai, there were tensions between one village and

the puskesmas over the number of posyandu that would be supported.

While transport was less of an issue in Java, timing is a problem. Many women in Situbondo do not go to

posyandu (integrated health posts, held monthly), posbumil (posts specifically for pregnant women, held

monthly in some locations) or the village bidan because they rely on their husbands to take them. There,

many husbands are employed as day laborers, so they can only take their wives for care after they finish

work. In one village, recognizing this challenge, a bidan started a “mother’s class” at night so that both

mothers and fathers could attend. The good attendance levels and participation of the fathers was seen

as a success, but when the activity was replicated, it was once again scheduled during “office hours”

(before 2pm) and attendance dropped again.

3.3. Insurance The current Indonesian health insurance environment is both complex and shifting. The National Health

Insurance program (Jaminan Kesehatan Nasional - JKN) was launched at the beginning of 2014 with the

goal of moving the country toward universal healthcare coverage and has changed the landscape

dramatically. It aims to cover individuals through three main mechanisms: state coverage of health

insurance premiums for poorer individuals, employer payment of premiums and self-payment of

premiums. This report examines the first and third, referring to them as JKN-PBI National (or District, if

the premium is paid from the district budget) and JKN Mandiri, respectively. Those who receive

coverage as JKN-PBI National are included on the 2011 poverty list, which was also used for the previous

primary health care program, Jamkesmas. Both Jamkesmas and Jampersal, which provided universal

free maternal and neonatal care, were both terminated in 2013 with the implementation of JKN.

In terms of ensuring access to health care there are two levels of questions facing both government and

citizens that we explore in this section. First, are the correct people receiving state assistance for health

insurance? While the answer to this question sits primarily with the national government, the study

22

This will does exist in some locations- in Flores Timur, a similar problem was solved by allowing some villagers to go to a village clinic instead of the puskesmas for birth, so that they could be more easily referred if necessary. However, this was observed before the implementation of stricter BPJS referral rules, requiring a doctor to sign of for referral, so it is not clear how the solution has been impacted.

20

found key responses at the district level. Second, can those who need coverage fulfill necessary

requirements to access care? As the sections below highlight, administrative requirements are complex

and information gaps large. Exploring ways in which local actors can work together more effectively to

assist citizens as well as ways in which citizens and providers alike can more effectively access

information will be important to improved implementation. In addition, as considered at the end of the

section, understanding and addressing basic attitudes and perceptions of insurance underpin some

current challenges and should not be overlooked.

3.3.1. Who gets state-assisted coverage?

The Jampersal program was put into place in an attempt to improve maternal and neonatal indicators

by ensuring that cost of services was not a barrier for mothers and families. Its dissolution means that

the list of people that continue to receive state-assisted coverage must be fairly accurate or risk re-

creating barriers to care for those who are neither on the list nor able to pay. Unfortunately, there is

significant evidence that the list is poorly targeted and has potentially significant inclusion and exclusion

errors.23 For those concerned about the ability of poorer Indonesians to access maternal and neonatal

care, this is a serious concern as it means that there are potentially significant numbers of poorer

mothers who both cannot afford maternal and neonatal care, nor access state-assisted coverage. This

research finds that concern is valid.

Local governments and health departments at the frontlines receive the most complaints about the list

and have often responded with district health programs aimed at covering those who have been missed

on the national list. Management of the list at the local level is handled by the social department, in

coordination with national actors. According to regulations, local officials can adjust the list by replacing

members that have died or moved from the district with new members, but to the frustration of many

local governments there continue to be significant challenges in doing this.24 This inflexibility makes the

district programs all the more important in delivering flexible and responsive assistance to those in

need. Districts studied took a variety of approaches to the provision of district health care, some which

utilize BPJS and others which do not. The ability of these programs to both “fill the gap” on maternal and

neonatal care going forward is critical and they deserve attention to determine both which models are

more effective and which can successfully operate using BPJS, as is required by 2016. District health

plans are summarized and discussed further in Annex A.

23

Harimurti, et. al. (2013). The Nuts & Bolts of Jamkesmas, Indonesia’s Government-Financed Health Coverage Program; Tim Nasional percepatan penanggulangan kemiskinan (TNP2K); Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K) (2014). Finding the poor vs Measuring their poverty: Exploring the driver of targeting Effectiveness in Indonesia. TNP2K Working paper 20-2014. Jakarta, Indonesia. Indonesia’s Government-Financed Health Coverage Program for the Poor and Near-Poor which finds the extent of the mistargeting could be up to 50% of the list. See World Bank (2012). Targeting poor and vulnerable household In Indonesia. Public expenditure review (PER). Washington, DC: World Bank. 24

In particular, poor death and moving records.

21

3.3.2. Citizen perceptions of insurance

Aside from the rules and processes around ensuring coverage, there are a number of perceptions about

insurance as a concept and what a patient will get when they choose to use that coverage. Three key

perceptions are: discrimination, poor quality care and care that is still not actually free.

Some patients did not want to use JKN-PBI National because they worried they would be discriminated

against. Many of these feelings stem from bad experiences using Jamkesmas, which clearly identified

users as poor and has been identified elsewhere.25 In one research location, patients had adopted their

own practices to attempt to avoid being identified in this way: they would initially say that they were

“public” patients, and then produce their insurance cards only at the end when they had to pay.

Feelings of discrimination included members having to wait longer and not being “respected” in the

same way as other patients, or not getting the same quality care as those who can afford to pay. One

woman explained: “BPJS patients have to wait in line. It takes a long time for them to be served and then

they are considered insignificant (disepelekan)” There were also quite strong perceptions that the

quality of medicines used for those covered by state insurance were poor, and that as a result people

did not get better. “It also takes a long time for BPJS patients to get well. There was a patient near my

child, even after two months there seems to be no difference. I am afraid my child will be ill for a long

time if I use BPJS.”

Feelings of discrimination, while present in all locations, were stronger in Java and less so further east.

In NTT, most people, used the public health system, and district health staff planned to serve the whole

population. At the village level, since the majority of citizens lacked extra cash, bidan did not

differentiate services as much, though it certainly happened. Threats and sanctions (discussed below)

were more common and while discriminatory in a different way (as discussed below), they were mainly

equally applied.

In addition to the problems above, while JKN and regional programs have the goal of providing free

coverage for members, in reality, this is very rarely the case. There are several things that those with

insurance have to pay for. The most common is medicine, followed closely by disposables. There are

complex factors behind this, including poor distribution of drugs, and incentives for doctors and bidan to

make money by selling them, as discussed above. Additional expenses for medicines and disposables

were more common in Java and less common in NTT, largely due to the lower economic capacity of

patients farther east.26 Patients resent hidden costs, which contribute to their distrust of the system.

There are a number of other perceptions that shape citizen’s decision around coverage. The idea of

paying every month, even while healthy, is an anathema for many. This seems particularly strong in East

Java, where it is underpinned by a cultural belief that being prepared is to invite illness. On the other

hand, people dealing with recurring illnesses such as malaria were able to understand the concept of

25

UGM, UNAIR, UNDANA, (2014). Health Seeking Behaviour Study in East Java and East Nusa Tenggara: A Collaborative Study through the Indonesian Health Policy Network, 2012-2014. 26

The differences were described by one bidan who had moved from Java to NTT and was comparing the two, complaining that she could not sell as much in her new location because citizens there simply could not afford it.

22

capitation through that lens, as explained in Sumba Barat. Despite this, many still leaned toward a one-

off payment instead of seeking insurance, sometimes with disastrous results.

These perceptions, as well as the range of challenges explained above, are understood by some in

government, but dismissed by others. Some are fighting very hard to facilitate coverage, such as the

head of the health department in Dompu. Others, unfortunately, describe citizens as lazy or simply

backward. Or, in the case of this puskesmas head, the problems that they face are just excuses: “Ya.. all

the classic excuses are trotted out- they have no money, they have no motorbike, then there is no one to

take care of the kids. All kinds of things…” These perceptions of the poor are particularly destructive

within local government, since it means that the people who are in a position to provide information or

seek solutions are unlikely to help citizens in need to overcome barriers that they face in seeking care.

Indeed, institutionalization of negative attitudes about the poor creates greater obstacles for their

access.

3.3.3. Accessing insurance for mothers: choices and complexity

The diagram below lays out options that a woman faces if she becomes pregnant and wants insurance

coverage.

23

The most dominant challenge illustrated by the diagram above is complexity. Nearly every question

must be answered “yes” or coverage will (or may) be denied, or patients need to attempt to switch

systems. They may or may not have enough information about how to fulfill each requirement or what

their insurance options are. If they do, satisfying all conditions can be expensive, confusing and

frustrating as citizens generally need to go to the district level multiple times and navigate opaque

administrative systems. The key issues are discussed below, but it is important to remember that the

large number of “little rules” mean that multiple challenges need to be overcome by patients (or

multiple obstacles reduced by local government) to ensure effective coverage. It is generally the poorest

and most marginalized who are least able to fulfil multiple requirements and are thus at the greatest

disadvantage. This quote from a bidan trying to help a patient in this situation shows the multiple

challenges that patients can face and how it impacts providers:

She (the patient) didn’t finish primary school, so she doesn’t have a diploma (ijazah terakhir). She

also didn’t have an ID card, so I asked for her certificate of baptism, but that was still being sorted

out at the church. Actually, she is planning to get married, maybe on Saturday she will have the

marriage documents. If I want to use her family card, it is impossible since she is not married yet,

but she might be able to use a letter of domicile. I asked the village head about that, and it turns

out that her Jamkesmas is actually registered (in a different location) so she is not yet really a

citizen here. I am completely confused about how to claim this.

3.3.3.1. Jamkesmas card vs BPJS letter

As JKN-PBI National covered individuals are the same as those who were previously covered under

Jamkesmas, most locations began with accepting the Jamkesmas card as proof of JKN. BPJS also issued a

letter to each covered family at the beginning of 2014, confirming their coverage and listing the names

of the covered individuals in the family.

There have been at least two problems with these documents: those with cards and those with letters

do not fully overlap and there is confusion and inconsistency between these two documents as to which

constitutes proof of coverage. Poor correspondence between those who received a Jamkesmas card and

those who received a letter seemed particularly large in Manggarai, but also came up in other study

locations. As one village head explains, “here, a lot of people have Jamkesmas, but not a lot have BPJS…

see if they could just make BPJS match the number of people who have Jamkesmas!” Depending on

which documents are accepted (or not) patients may be denied coverage.

In addition, information about which document was valid varied between and within locations. For

example, when one woman was referred to the hospital in Manggarai, she was told to take her BPJS

letter. She used this for her first check up, but when she went back two days later was refused care

because she did not have her Jamkesmas card. Her husband was able to return home (at some expense)

and get it before she gave birth the following day. She was lucky in that she had both documents, but

the experience was highly stressful for her, since she was unsure if she would actually be covered. In

East Java, there was also basic confusion about the purpose of the letter.

24

3.3.3.2. Legal Identity (KK and KTP)

Those wishing to access insurance provided under JKN now need to also provide both their family cards

(KK) and their identity cards (KTP) as forms of identity. This marks a departure from Jamkesmas, where

they either did not need to show identity or they could use a letter of identity from their village head.

Bidan are also impacted by this change, as copies of these documents are required to be included with

claims for them to be paid.

This research confirms the findings of other work indicating that a significant proportion of the

population does not have one or both documents, and those levels rise among the poor and in Eastern

Indonesia.27 Partly due to the recent nation-wide effort to provide citizens with e-KTP, more people have

identity cards than have KK. However, following the e-KTP rollout, it is actually now more difficult to get

an identity card, since citizens have to go to the district to apply for them instead of the sub-district

where they were previously processed. Both KK and KTP require other legal documents such as birth and

marriage certificates, but are often processed without these criteria being met. The study corroborates

other work in identifying many of the key obstacles faced by individuals in getting these documents:

multiple trips to district offices are expensive (both due to transport costs and lost time/ wages) and

engaging with a largely opaque bureaucratic system can be at best frustrating and at worst frightening

and discriminatory. In addition, this study identified some challenges that are either unique to the health

care environment or deserve highlighting in that context. These include:

Inconsistencies between documents are frequent and can result in denial of coverage. Many

respondents showed researchers differences in names, ages, addresses etc between Jamkesmas/ JKN,

KK, KTP and other documents. While previously these differences had little impact, when used to

validate health care coverage, they become critically important. These problems can be corrected (or

more worked around), but it takes time, effort and money. For example, to get a letter clarifying his

wife’s name (different between two documents), to allow her to use her JKN PBI National coverage, it

took one man in Java a day of effort and cost him Rp 1.8 million. 28

Citizen mobility creates obstacles in securing identity and accessing care. A very large percentage of

Indonesian women and/or families travel and live either domestically or internationally for employment.

Of the women that we interviewed, nearly a third had lived outside of their area for work. 29 Many of

them come back to their villages to give birth. They can face problems both if they move and if they

come back depending on where they are registered and where they have started maternal care. First,

individuals moving permanently need “moving letters” (surat pindah), and should register in each new

27

DFAT, PEKKA and PUSKAPA UI (2014) Baseline Study on legal identity: Indonesia’s Missing Millions. Universitas

Indonesia: Jakarta 28

It is worth noting that this effort got his wife two days and two nights of not seeing a doctor, and he finally pulled her out of the clinic in search of further/ actual care. 29

Based on n= 113, the number varied between locations, up to 40% in Manggarai and over 50% in Dompu and Lombok. A further 23% can be considered “pendatang” or (internal) immigrants who have moved to a new location for work or due to marriage. Coding decisions were made by the research team. In some cases, “pendatang” self-identify as such. In others, the code was applied by the researcher to those that came from other kabupaten, and were considered “outsiders” in the village.

25

place of relocation in Indonesia. These seem particularly problematic to get and use, leaving some

individuals unable to officially register in their new location. This may make them ineligible for primary

coverage. JKN members have the same benefits for in-patient care in any location, but they can only

receive out-patient benefits at the primary care provider where they are registered. It is not clear how

registration outside the area of one’s legal domicile is handled. The problem is the same for women who

return home to give birth. In theory, if they are already registered, primary providers can be changed,

but requires a trip to the district and a waiting period before the information is updated. Some women

also did not go to local providers since they expect to be rejected or treated poorly simply due to the

fact that they were from somewhere else. Since bidan performance is linked to delivery of a full set of

ANC visits, some are reluctant to provide only later visits. Women who return home to give birth may be

less likely to give birth with a provider.

Lack of a marriage certificate may be an obstacle to getting a KK. Legally, a marriage certificate is

required to get a KK, but this rule is inconsistently applied. Challenges in getting marriage certificates

need to be highlighted with respect to access to health care for pregnant women. Some young women

choose to marry young (still common among the Sasak populations of Lombok and Bima), or become

pregnant, either willingly or accidentally. Some get pregnant as a result of rape or incest. In these cases,

women can often use KK of their families to access care, but this may be complicated by strict marriage

requirements (Lombok) or denial of use of the family KK if they were not supportive of her situation.

Many young women are still forced to marry the father if they become pregnant, and some do so legally

by securing the assistance of a local official to change their date of birth. Since young pregnancies carry

higher risks, it is critical that these women not be blocked from health care coverage if they become

pregnant below the age of marriage.

Those who have required documents may still face challenges in accessing coverage. There are several

reasons for this. Many, particularly in Java, remain listed under their parents KK as part of a large

extended family. These may need to be split to afford coverage. Family cards may also be the wrong

“version”: the format was changed in 2013, and in some locations only new KK are accepted.

3.3.3.3. Additional costs related to JKN Mandiri

The largest barrier to JKN Mandiri coverage for those who are struggling to make ends meet is cost. As

one BPJS staff member explains: “Citizens have a pretty high level of motivation (anemo) to sign up for

BPJS Mandiri. Its just as I mentioned before- (they are stopped by) their ability to pay the premium, since

they have to pay Rp 25,000 every month… Here, Rp 25,000 is the salary of a construction worker for a

day, so people have to think- ‘do I pay the insurance premium or do I think about my cost of living?’”

Costs are increased by the policy, starting in 2015, which requires whole families to be covered. 30 This

policy of “gotong royong” or “self-help” protects the organization from having to bear the cost of only

sick individuals, but as a result, ends up being too expensive for many rural families.

30

BPJS, (2014). “Petunujuk Teknis Pendaftaran dan Penjaminan Peserta Perorangan Badan Penyelenggara Jaminan Kesehatan,” Peraturan Direksi BPJS No. 211 Tahun 2014, pasal 5. Note this contradicts earlier policy which allowed individuals to be covered.

26

To sign up as a member of JKN Mandiri, each family needs to have a bank account. The head of the

health department in Dompu captures reality31 and the feeling that many have about the requirement:

“BPJS is crazy- what villager has a bank account?!” If an individual can get an account, they will still have

to go to the bank or BPJS office every month to pay for coverage, since auto-debit payments, though

frequently mentioned, were not actually available in any location. Even in Java, citizens in one village

have to travel more than 30 km to a bank. In other locations the distances were greater and travel costs

higher, effectively increasing monthly premiums. In some locations, there have been efforts to make it

easier for JKN members to pay, but these are limited. Notably, in Malang, the health department has

proposed “collectors” be allowed to gather premium payments at the village level and deposit with

BPJS. However, BPJS remains uncomfortable with the idea. The extent to which work with banks is

happening is unclear, though the benefits to accessing a bank account have the potential to extend far

beyond securing health insurance coverage.

To sign up for coverage, most individuals must go to the BPJS office at the district level, which also

deters potential members, though some locations were attempting to make access for registration

easier. Regional health programs in Lombok and Dompu (run through BPJS), allowed women to register

through their village bidan. In Malang, the puskesmas opened a registration table, and is processing BPJS

applications in coordination with BPJS. Finally, rules have recently been changed regarding effective

dates, now requiring a waiting period of 1- 30+ days for coverage to be active.32 While there are ways

around this in emergency situations, they are complicated and often not communicated to the patients.

These have particular impact on the coverage of newborns, discussed below.

3.3.4. Covering newborns

According to BPJS governing regulations, newborns born to mothers covered by JKN PBI National are

eligible for “automatic” coverage.33 Unfortunately, there is nothing “automatic” about getting coverage

for newborns. Individuals who want their newborns covered must file a request to the social

department, which checks to see if a space is available (if someone has died or moved), and make a

recommendation to BPJS. In most locations, it was estimated that this process takes at least six months,

and is unlikely to be successful. It is not a realistic option, particularly for unhealthy newborns. To secure

coverage, families must pay for JKN Mandiri.

Processes for getting coverage of newborns are complicated, as described below. In all locations, the

main problem faced by parents (and to some extent bidan) was getting information regarding when and

how to cover their newborns and babies. In several locations, researchers heard stories of newborns

being taken out of hospital either at birth or when ill because the parents could not cover the costs. This

31

Based on 2014 data, the World Banks estimates that just 36% of Indonesians have a bank account, and that number drops dramatically in rural areas and among the poor. See http://datatopics.worldbank.org/financialinclusion/country/indonesia This does not break data by rural or poorer households, but based on talking with both BPJS offices and members of the communities where we did research, very few individuals have bank accounts. Note that based on this data, 0% of Indonesians (or at least below 1%) have mobile accounts, so opportunities to pay remotely are literally nil. 32

More detail is provided in Annex A. 33

Kementrian Kesehatan RI, (2014). “Pedoman Pelaksanaan Program Jaminan Kesehatan Nasional,” PMK, No 28 Tahun 2014.

27

results in infant death in some cases, as described in the case in section 3.1. In that case, though both

parents are on the national poverty list, and have JKN coverage, coverage was not automatic for their

baby. The removed her from hospital when they could no longer afford costs and she subsequently died.

The story is particularly heartbreaking because no one in the village, at the puskesmas or at the two

hospitals that they visited told them that they could sign up for BPJS, or that there was a district

program being implemented to help them pay the premium. They found out about it shortly after the

child died.

For non-emergency coverage after birth, parents need to bring their KK, KTP and the birth declaration

letter (surat keterangan lahir) to the BPJS office.34 To secure coverage before birth, they need to bring

the above plus a doctor’s letter or USG scan stating the sex of the baby.35 If they need emergency

coverage (ie waived waiting period) they need to bring all of the above plus an emergency letter from

the hospital. JKN PBI members may need to bring any of the following: a letter from the social

department, a letter from the health department, and a poverty letter from their village head (endorsed

by the camat (sub-district head), and usually the social department). They still need to pay for between

one and three months of coverage up front. To secure emergency coverage and waive waiting periods,

this generally needs to be completed in no more than 3x 24 hrs from the moment that the newborn is

born so that coverage can be retroactive. It is important to note that the people seeking this coverage

had newborns requiring incubators, ventilators or other specialized care.

3.3.5. Information about insurance options: why so many gaps?

As is clear from above, BPJS policies change frequently, and successful implementation of the program

depends to a large extent on key actors knowing what they are. Current socialization approaches are

unsuccessful in this regard. Part of the problem is structural, particularly for JKN-PBI National members:

BPJS manages the program, the social department manages the list of members, and the health

department interfaces with patients on care. There is a great deal of finger pointing as to who has

socialization responsibilities. While those within the health department who interface with BPJS have

information about updated policies, those who are focused on implementation of health programs (ie

bidan coordinators) often do not, since they see understanding insurance rules and regulations as

outside of their job description and a distraction from the focus on health programming. This means

that information often does not even get shared to bidan. However, when the information does make it

to them, it often goes no further. For example, when BPJS provided information to one puskesmas, in

NTT, health actors explained that they did not feel it was their job to socialize the information further.

34

This represents a change, since the child now does not need to have an identity number (NIK), which was previously the case. See Peraturan Direksi Nomor 211 Tahun 2014 tentang Petunjuk Teknis Pendaftaran dan Penjaminan Peserta Perorangan BPJS 35

Note that USG scans are not covered by BPJS unless they are ordered by a bidan in light of an identified risk to the mother and newborn. The mother must get a referral and travel to a hospital to get the scan, since USG are part of the services covered only at a referral health center (FKTL). This means that pre-birth coverage is effectively limited to high risk women. It excludes women that do not have obvious risk signs but whose newborns nonetheless have problems and women with pre-term births who may not have been sent for a USG (since they are generally ordered later in pregnancy).

28

In other locations BPJS provided information to local government actors, but those actors still expressed

limited to low levels of information about JKN, though with some variation.36 Information that is

provided to lower levels seemed strong on what needs to be done (“get coverage!!!”), but weak on

exactly how to do it. As one village head explains “Socialization of BPJS in the field is not much (begitu

saja). People from the district talk at the village office, at most it’s a hot issue for a moment, but it is

hard to put into practice. It is not clear what I am supposed to take to citizens. They (district officials) just

make appeals, but if there is no follow-up, how am I supposed to explain things to citizens? They will

surely have lots of questions.” The perceived arbitrariness of those who received coverage (and social

tensions that it caused in many villages) also means that local officials are wary of being associated with

it, so they do not always seek or share information.

3.4. Sanctions, threats and discrimination Increasingly, there is a focus on “sanctions” to promote a wide range of health behaviors designed to

support improved health outcomes. They cover a wide range of actions which include completing the

full set of ANC visits; saving for birth costs; delivering at a facility; breastfeeding; planting vegetables,

etc. While they vary, they are generally also applied to a wide range of actors: mothers, fathers and

communities (cadre and dukun bayi) as well as bidan and village government actors. However, they are

most strictly applied to women who give birth at home and any dukun bayi who support them, and

potentially any cadre who fail to bring them to a facility.

Formal sanctions are normally written into village regulations. These are being promoted, particularly in

NTT (under Revolusi KIA, which requires birth at a puskesmas), but also in NTB, under the guise of Desa

Siaga. Indeed, in NTT, respondents within district government highlighted these regulations as the key

element of the program needing to be implemented to ensure that communities and families are

prepare themselves for birth and raise healthy children.

Only one village in the study sample had a written regulation. Bidan, however, used various sanctions

and threats in all locations. These included:

- Fines for giving birth at home. Applied in one village per regulation in Dompu, threats of fines

were also made NTT. These included fines for the mother and for any dukun bayi that helped a

mother to give birth at home, and ranged from Rp 500,000 to Rp 2 million.

- Withholding of birth declaration letters. This happened in all locations. Women giving birth at

home may be able to get a letter from the village head (rather than the bidan), but it is not clear

if village heads are issuing them, or if mothers face challenges using them at the civil registry.

36

Local government actors in E Java had the lowest levels of information about the program, since it was less important to their populations. Lombok government actors also seemed to have low levels of information, but potentially for a different reason: that the government above them seemed particularly disengaged. Dompu is explained in the box. Village actors in NTT had slightly more knowledge, but it was also inconsistent: of the four village heads, one was a temporary “acting” village head, and though he would help people who came to him, he had little incentive to seek information. A second was fairly knowledgable, but did not actually live in the village he was governing, so there were broader problems regarding the flow of information. The third had limited information, and did not seem to be seeking more and the last was very active, advocating for his community.

29

- Denial of postnatal care, particularly the first immunization. This took place in all districts,

though not all villages. Some bidan are still willing to check newborns and provide initial

immunizations.

- Denial of birth control. In NTT, some bidan were threatening to deny birth control to women

after they had given birth if they did so at home.

Local government actors seem generally supportive of harsh sanctions. One respondent in BPMD (the

division responsible for promoting Desa Siaga), encourages village heads to cut off benefits to mothers

who have given birth at home, refusing them Raskin, BLSM, PKH etc.37. Newly drafted regulations in the

area included a very general clause allowing the village head to apply sanctions as he saw fit.

These sanctions have a number of impacts on both perceptions of service delivery and on the lives of

the families to whom they are applied. First, threats of withholding services exploit the power imbalance

between families and providers. It indicates that the State is uninterested in some of the very real

problems facing many families, and is willing to exacerbate them. In some cases, though, by “stepping

over the line” providers do get push back from community members who are more willing to be clear

about their expectations. In one location, a bidan who tried to deny a woman birth control for giving

birth at home was pointedly told that had she been at her post, the woman would have given birth at

the facility. The woman received birth control.

Second, these sanctions can have lasting impacts on the lives of mothers and children. Children without

birth certificates are likely to find it harder to enter school, impacting their entire adult lives. Awareness

and dismissal of this displayed by one sub-district secretary was chilling, as he was aware of the impact

but mainly concerned about whether bidan were really applying the sanction: “These days, birth

certificates are required, and those certificates can only be made (if citizens have) a birth declaration

letter from the bidan. People need a birth certificate to go to school, so if you give birth at home but have

a birth certificate, what is going on? Are bidans willing to tell the truth or not??” Women denied birth

control are stripped of their ability to make their own decisions about their fertility, increasing

pregnancy risks, the chances for more children and higher poverty. Refusal to immunize children

impacts not only the family being sanctioned, but the entire community. All of these impacts run

counter to the goals of the health system and the State more generally.

While many of these sanctions and threats are unhelpful, it should be noted that the study did find an

example of a well-implemented village regulation, described above. In addition to responsibilities for

patients, there were requirements for the bidan, and at least one respondent felt that they had

contributed to her being more frequently at her post.

37

Technically, PKH incentive payments are stopped if a participant fails to complete her ANC visits. However, it is interesting to note how the language about PKH benefits has shifted from reward for positive actions to punishment, doled out at the discretion of the village head, potentially expanding to all social protection programs Note these threats were echoed by other respondents in across locations in NTT. For further reading see Hutagalung S, Arif , (2009). Problems and challenges for the Indonesian Conditional-Cash Transfer Programme-Program Keluarga Harapan (PKH). Jakarta.

30

Sanctions and threats run borderline to discrimination, and indeed are rooted in the same ground: the

idea that villagers are “backward” or “primitive” and, given their lack of capacity to reason their way

through health decisions or their general laziness, must be scared into taking action. Unfortunately,

these perceptions were all shared in various forms by respondents ranging from village heads to those

sitting at the district level. This discrimination comes across in a number of ways. Bidans admonish

parents for being irresponsible: mothers must eat better and rest more (even if they can’t afford it) and

fathers are told that they “only know how to make babies” but are unaware of how to take care of their

wives and children. One cadre, trying to help get care for a family where the mother had died in

childbirth, was told by a puskesmas staff member that if she had just done more for the mother, she

wouldn’t need to be helping with the baby. These repeated admonitions, insults and snide comments

push people away from the formal system and create a barrier to access in their own right.

Even when bidan don’t yell at patients, perceptions that villagers are uneducated or a bit simple mean

that bidan often focus on directives, but not explanations, since they think patients won’t understand.

This type of discrimination is difficult to separate from the way bidan themselves are generally trained.

The impact of a lack of information is discussed further under quality of care. Here we note only that the

basis for the discrimination is largely unfounded. In particular, education does not have much

correlation to understanding of health concepts: some women who had barely completed primary

school understood quite a lot, while some who had completed school held traditional (and sometimes

unhelpful) beliefs about pregnancy. Both deserve explanations about their bodies.

4. Perceptions and expectations of maternal and neonatal care This section examines how both patients and providers perceive health needs and develop expectations

about the quality of care that they should receive or provide. To gather this information, the study

focused on key moments in maternal and neonatal care, focusing on important elements of the patient-

provider interaction and “tracer issues” at each step. Specifically, we focused on the beginning and end

of antenatal care (ANC), identifying if relationships were being developed between women and their

providers in early visits and if key risks were being identified and communicated and delivery plans

made in later visits. We used the “tracer issues” as a lens into quality of services. For example,

researchers asked questions around routine blood pressure checks and use of protein urine sticks as

part of the early identification of hypertensive disorders, including eclampsia and preeclampsia. In

looking at delivery, we identified whether plans were made and information available, and noted any

delays. Our examination of postnatal care (PNC) focused largely on whether it happened or not.

Discussions around family planning included use and availability.

The goal of this research was not to assess the quality of medical care provided (though it certainly

comes through and is presented below where relevant), but to understand how communities and

providers can best work together to understand, demand and provide high quality services. As part of

that dynamic, we explored to what extent a patient’s level of and access to information about their

health is important in driving expectations about the care that they should receive. We also examined

how previous health care experiences shape perceptions and expectations of future care. On the

provider side, we aimed to understand how incentives and supply-side constraints (described in

31

previous sections) impact bidan behavior and shape their own practices of interacting with patients. The

sections below explore these themes in each of the key moments around pregnancy and childbirth.

Across the key moments, the role of choice (or the lack thereof) shapes the patient provider relationship

before, during and after childbirth. The farther east one travels, the fewer formal providers there are.

For villagers in NTT, they may only be able to access a village bidan (or bidan at posyandu) and perhaps

the local puskesmas. If they do not feel that they are getting quality care, there is very little that they

can do, especially in an environment which punishes them for electing to opt out (with sanctions as

described in the previous section). Because patients are essentially “non-voluntary,” bidan have very

little to lose by providing poor care. While they may seek to minimize complaints, they ultimately cannot

be disciplined by patients.38 For example, one puskesmas head, after receiving numerous complaints

about bidan being “mean and rude,” cross-checked with bidan who said the distances between villages,

poor transport and long hours made them tired. The puskesmas head responded to citizens that they

should simply be more understanding. Villagers can opt out to informal systems or (primarily n Java)

private providers, but both come at a cost.

Similarly, a number of fears weave through pregnancy. Women fear for the health of their child and

themselves, but they also fear costs of transportation and care. The prospect of referral, for many, raises

fears of increased expense as well as those of giving birth in an unknown location, with unknown

providers, and likely ending in an operation. Without information about their condition and clarity on

how the medical system can help, many women are afraid of bad outcomes for their newborns or

themselves.

4.1. Antenatal care The antenatal care package intends to prepare the woman for a safe birth within the health care system.

Through antenatal visits, providers should confirm pregnancy, monitor its progress, inoculate mothers

for preventable disease, provide nutrition information and vitamins important to fetal growth, and

support mothers to develop delivery plans. 39 In addition, providers should identify women with risks of

pregnancy complication and develop plans for remediation and safe delivery. The consistent thread

running through high quality ANC is the patient-provider relationship. The key to a good patient-

provider relationship is trust built from having ones needs met both as a patient and a person having

those opinions considered in the clinical decision making process.40

For nearly all women interviewed, antenatal care involved both “formal” (bidan, doctor) and “informal”

providers (dukun bayi). Acknowledging this plurality is critical to understanding how women and families

shape perceptions and expectations of care across providers and how those providers adapt behaviors

to recognize each other. While both providers are valued seen as giving “medical” assistance, bidan are

38

Lipsky, M. (2010) Street-level bureaucracy: Dilemmas of the individual in public services (30th

anniversary edition). New York: Russell Sage Foundation 39

World Health Organization: Antenatal care. http://www.who.int/gho/maternal_health/reproductive_health/antenatal_care_text/en/ 40

Mayberry RM et al. Improving quality and reducing inequities: a challenge in achieving best care. Baylor University Medical Center Proceedings. Volume 19, Number 2.

32

seen as bringing formal knowledge and education to their services while dukun bayi bring tradition,

experience and often a spiritual dimension to care.

Across locations, the first person that most women visited if she thought that she was pregnant was the

dukun bayi in her area. Dukun bayi are generally respected figures within the community, and are

trusted by pregnant women and their families. They provide care in privacy of the home, responding to

women’s needs and values. For example, in NTT, women were more comfortable with dukun bayi

because they did not have to “deliver naked, like animals,” which they had heard was the practice at the

puskesmas. Women describe liking that the dukun bayi touch them and feel the position of their baby,

that they can move the baby to help it grow41 and help alleviate mother’s discomfort, particularly later

in pregnancy. Dukun bayi also often tell mothers the sex of the baby and a due date. They may also

provide traditional medicines- either along the way or to induce. In some locations, they will provide

nutritional and activity advice in line with cultural norms.

In NTT and NTB, some women continue their ANC care with an private examination from the bidan,

though some seek care directly at the posyandu. Of women that go to the bidan directly for their first

examination, some go alone, though many choose to be accompanied by the dukun bayi or a posyandu

cadre, who often receive an incentive for bringing the mother to the bidan. Care generally continues

with the bidan at the monthly posyandu, though some go to their village bidan or the puskesmas, a

decision generally based on distance. Care at the posyandu is particularly important for women who live

far away and cannot reach a clinic. Those women who receive care from bidan value access to

medication and vitamins, and opportunities to hear their baby’s heartbeat. Bidan also provide advice on

what to eat or do, though in some locations, women found it either vague (“eat healthy!”) or out of

touch with local living conditions or the family’s economic capacity (“buy meat!”). Increasingly, bidan

are encouraging women to get ultrasounds. However, since they rarely share the reason for the

ultrasound, women can be frightened – both about the cost and that something is wrong with their

baby.42

Unlike women in NTB and NTT, women in East Java have the option of receiving their monthly ANC from

a state bidan (from their own or a neighboring village), at the puskesmas or with a private bidan. Some

pregnant women in East Java were reluctant to receive ANC prior to the fourth month of gestation

period because of the cultural belief that others knowing of their pregnancy could result in a

miscarriage. For women who sought ANC, some opted to pay to receive ANC services from a private

bidan whom they perceived to be more experienced in their clinical knowledge and as a result provide

better care. Women also considered cost, availability, reputation and previous experiences in choosing a

provider.

41

Many women said that the dukun would “kumpul darah” or gather blood for the baby, which gets spread out through work in the fields. 42

There were a noticeable number of cases where women were being asked to get ultrasounds at around six to seven months to determine if a baby was in a breach position, despite it being too early to tell. This lead to misidentification of risk and potentially unnecessary referral.

33

Women use their experiences and move across providers to evaluate the quality of their ANC care. For

example, bidan are increasingly encouraging women to get USG to check the position of their babies

prior to birth. While many mothers like being able to see their baby, others questioned the time and

expense of traveling to another location to learn the position of the baby, when the dukun bayi could

provide them with the same information at their home. Often, women were given conflicting due dates

from bidan and dukun bayi, and had to determine which they thought was more accurate for their

preparations. These differences also contribute to questions about bidan competence. The reverse is

true for dukun bayi, though to a more limited extent.

With this context as backdrop, we turn to an examination of key gaps in the current ANC approach and

consider some opportunities for improvement.

4.1.1. Access and quantity vs quality and accountability in antenatal care

Current Indonesia obstetric guidelines are in accordance with the World Health Organization’s (WHO)

recommendations, which promote four ANC visits during pregnancy, each with discrete objectives.43 At

the same time, the monthly posyandu is (rightly) viewed as a cornerstone of ANC provision, leading

some DHO to target the provision of nine visits rather than four. This goal contributes to the finding that

health providers contextualized ANC more in terms of meeting performance targets rather than

opportunities to prevent, detect, alleviate, or manage different types of health problems faced by

pregnant mothers. Posyandu cadres and bidan urge patients to attend monthly ANC but do not explain

the purpose and significance of the visits.

Posyandu themselves are often crowded, meaning bidan have little time to conduct examinations or

answer questions. Women in NTT and NTB often describe their ANC checks at posyandu as rushed and

not private. Knowing that there are others waiting, or having conversations that others can hear makes

it difficult to establish a relationship with the bidan, much less ask questions or talk about concerning

symptoms. Bidan are aware of this problem. In Dompu, one bidan uses posyandu more as a screening

exercise to catch initial problems, and then suggests that women follow up with her at the village clinic.

This is effective, since the village is relatively small, so it is easy for women to follow up. Since bidan are

often trying to hurry through a group of ANC examinations, they tend routinize them, varying exams

little if at all in response to where the patient is in her pregnancy. This homogeneity often continues

outside of posyandu as well, as even women who went to village clinics or even private providers

similarly struggled to describe differences between visits or key moments within their pregnancy. This

lack of differentiation has consequences for the effective identification of pregnancy risk and

development of delivery plans. It also indicates that information about the purpose of checks at various

points in pregnancy is not being shared.

While the posyandu experience was fairly consistent, there was variation in the effectiveness of the

institution to improve patient access to care. Despite the fact that posyandu are village institutions, their

schedule remains largely driven by the willingness and capacity of the puskesmas to send staff to

support them, including village bidan who should otherwise be at their posts. The ability of the village to

43

Kementerian Kesehatan RI Midwifery Service Standard (2010). Pedoman Pemantauan Wilayah Setempat Kesehatan Ibu dan anak (PWS- KIA).

34

demand more or better posyandu seems limited. In both Manggarai and Sumba Barat there were

tensions between villages and the puskesmas over the posyandu. In one village in Manggarai, several

women had stopped going to posyandu since they were being held at the village clinic rather than at the

dusun level, as they had been previously. If they had to walk to the clinic for a private visit or to wait to

be seen at a crowded posyandu, many chose to go on their own time, even though it involved a small

fee (Rp 5,000). While this worked for some, it had the effect of pushing at least one woman out of care

altogether, as she followed her friends out of posyandu, but couldn’t actually afford to pay for the

private visits. In Sumba Barat, staffing shortages made posyandu implementation difficult, and there

were complaints of odd consolidation (in one village one posbumil had 24 mothers, while the other had

one), and bidan often failing to show, which made mothers less likely to come. In neither location was

village government involved in a discussion about how to make improvements. In Dompu, on the other

hand, the puskesmas was highly committed to holding posyandu, and was able to ensure that there was

one close to most mothers. However, to do this, they often had to hold two to three a day, making

services particularly rushed.

4.1.2. Poor communication and missing information

The section above touches on some of the physical circumstances that lead to poor communication

between patient and provider. Here we turn to the heart of the biggest gap in ANC care: lack of

information, particularly about danger signs in pregnancy, risk factors and delivery plans.

All pregnant women should understand potential signs of danger (tanda bahaya) during pregnancy.

Examples include bleeding during pregnancy or excessive vaginal discharge, among others. These are

covered in the buku KIA (mother and child health book) that in theory all pregnant women receive at the

beginning of their pregnancies. Women’s understanding of danger signs was mixed. More importantly, if

they did experience what they regarded as a problem and went to the bidan, a significant number were

told “tidak apa-apa,” (no problem) often without being physically examined. This emerged as a theme

across locations. Women’s understanding of their own bodies seems to be considered “lay knowledge”

and not always taken seriously as a medical concern. Bidan sometimes dismiss women, particularly

those in their first pregnancy, as just being worried or nervous. However, when patient concerns are

dismissed, it can undermine women’s confidence in themselves to identify problems and trust in the

bidan to listen to them and take them seriously. In some cases, it also had disastrous results for women

or their children.

Bidan approaches to sharing information about pregnancy risks fell into roughly three categories: 1)

those who provide a complete explanation of risk, including the impact of the problem on the health of

the mother and baby 2) bidan who shared partial information about the risk and 3) bidan who shared no

information about the risk, often telling mothers that they were fine, or discounting risks as not a

problem (“tidak apa-apa!”). Sadly, the first category was by far the smallest. It did happen, however,

and when it did made an important difference in a number of ways. At best, information not only

reached at risk patients, but was discussed and shared. The wife of one village head in Sumba Barat

suffered from high blood pressure during her last pregnancy. She received good information about the

problem, as did her husband. Both became active in talking to women in the village from their positions

of relative power about not only the risks involved, but how the health system could help. On a smaller

35

scale, risks communicated to one father in a different location let him plan ahead to cover what he knew

would be more expensive transport and hospital costs. Women who understood risks well were more

likely to prepare for and agree to referral, since they understood the challenges that they were facing.

Bidan were much more likely to take the second approach. “Explaining” a risk to a woman generally

involved telling her that she had a problem and what she should do about it. For example, many women

who had high blood pressure were told simply that they should eat less salt. Some were also told that

they would need to give birth at the puskesmas and perhaps referred. Most bidan do provide

information about administrative processes. One bidan in Malang, explains: “as soon as I know that a

mother is high risk, I immediately tell her to take care of BPJS and that she should not worry about cost.”

Listening to the bidan it is evident that many do not know how to discuss pregnancy risks in a way that is

understood by their patients. This is important, since many bidan genuinely feel that they are providing

sufficient information and quality care to the women they see. Internationally, recognition is growing

that providers struggle to talk to patients about risk effectively.44 Difficulties in communication are hard

to untangle from bidan’s own educational backgrounds and a work environment which also tends to be

based on directives rather than explanations. However, there were also indications that some bidan felt

that patients would be unable to understand information, or that even if they did, would be too lazy to

take action. This came through in some of the discussions about sanctions, where some bidan and other

health workers indicated that information was not useful and the only way to motivate villagers was to

threaten or scare them.

Finally, there were many cases of bidan (and doctors) not communicating risk to patients, either

because they themselves did not understand it, because they did not consider it serious, or because

they didn’t want to lose the woman as a patient, among other things. In examining women’s buku KIA,

researchers found examples of women with high blood pressure who had never been told they had a

problem. In one case, they found that a woman had tested positive on a protein urine test (indicative of

hypertensive disorder, and generally a follow up to high blood pressure), but when asked about it the (+)

notation, she said that she had been asked to take another pregnancy test and was still pregnant. While

issues of bidan quality are only tangentially addressed as part of this study (see above under staffing and

bidan incentives), it did uncover at least one key reason why bidan are actively withholding information.

Particularly in East Java, where patients have multiple choices of provider, many bidan are afraid of

being labeled as “quick to refer.” Faced with a declining clientele, one bidan from Situbondo explains her

dilemma: “I wanted to know why people were no longer coming to me to be checked. I asked the cadre,

and apparently people were saying that I would refer them for any little thing, so now I am more

careful”.

This hints at the two-sided nature of communication: how mothers and families perceive, understand

and act on the information that they receive and whether they choose seek more is also critical.

Mothers take different approaches to seeking and processing information, which impact on their desire

and ability to care and advocate for themselves and their families. In general, women prioritize health of

44

Much of this discussion has focused on old-age care, but would be equally applicable to this area. See Gawande, A. (2014) Being Mortal: Medicine and What Matters in the End. Metropolitan Books: New York

36

their unborn child over their own – a common approach.45 When they go to the bidan, they want to

know that their baby is healthy and that they are as well (generally in that order). If they are told that all

is well (and they feel fine), then most do not seek further information. Different approaches arise if they

a) have questions or feel that something is wrong, but are told they are fine or b) told that they have a

pregnancy risk.

A key challenge for women who have questions or feel that they are experiencing a problem in their

pregnancy is that they do not feel “brave enough” (berani) to ask the bidan questions about their

condition or to challenge her assertion that all is well. In NTB, bidan desa frequently gave pregnant

women an injection during their ANC visit; however, they did not provide any information on the

function of the injection. One mother experienced headache and nausea after receiving the injection

and feared it could harm her unborn baby, but was afraid to express her fears to the bidan desa who

was frequently temperamental and “judis (bitchy)” in her disposition. In NTT, another mother was upset

by poor information from the bidan: “ after every posyandu I would come home worn out and in tears.

One time (the bidan) told me I had twins, but that my stomach was still small. Another time she said my

baby had no head. I came home and was crying in my room and my mother-in-law asked me what was

wrong. I kept crying and told her that I had been told my baby had no head. My mother-in-law asked if

the baby was still moving. I said yes, and was no longer sad.” These feelings, coupled with a bad delivery

experience, have led her to stop attending posyandu entirely.

Women’s inability or unwillingness to ask questions of the bidan stem from several factors. In particular,

perceptions of hierarchy, in which comparatively well-educated bidan sit “above” most of their patients,

keep many women from speaking up. These are reinforced when bidan use (or abuse) their positions of

power, as some did when threatening or applying illegal sanctions. Even if they are not directed at her, a

mother will be careful not to challenge the authority of a bidan that has indicated she will punish

patients. This is particularly the case when women lack a choice of provider and are likely to depend on

the bidan in the future for care for themselves or their babies and children.

Women receive information about risk in different ways. In some cases, providers indicate that risks will

likely lead to referral. More often, women make the connection themselves and interpret information

about risk as tantamount to referral. They are often not wrong to do so, given the low capacity of both

bidan and village and district facilities to handle pregnancy complications, and therefore the frequency

with which at risk women are referred. Some will seek a second opinion, given the costs involved (and

based on their level of trust in their provider). This happened most frequently in Situbondo, where many

bidan referred to the practice of “shopping”- where at-risk women went to multiple providers until they

found one that told them they (and their unborn child) would not have a problem. The distinction

between “shopping” and seeking more information is fine. Poor explanations, potentially high costs of

transport and care, and fear all factor in to women’s desire to seek assurance and avoid costs. Finally,

some women reject information about risk, either because they have been told by another provider

(formal or informal) that they will be fine or because they feel that they simply cannot bear the costs of

transport and care. These factors are not always difficult to disentangle. In some cases, fathers

45

Brody, E.M. (2004). Women in the middle. Second Edition.

37

struggling to pull together savings expressed nostalgia for days when the dukun bayi dealt with

everything at the village level and there was no stress around referral, just prayers for health.

4.1.3. Ineffective collaboration with village actors: dukun bayi and posyandu cadre

Dukun bayi remain critical sources of support and information for pregnant mothers. While some of

them see their skills as inherited or spiritually gifted, many were trained by the state, and see

themselves as a key part of frontline service provision.46 While trying to limit their engagement in

delivery, the Ministry of Health has recognized the value of the dukun bayi, by articulating the

importance of their partnership with bidan and including it in a national framework.47 However, this

“partnership” is weak, and often extends efforts to reduce or end the involvement of the dukun bayi in

delivery to the entire pregnancy and childbirth process. “Trainings” for dukun bayi, which were once a

source of prestige, are now merely meetings where dukun bayi are told the rules of what they are and

are not allowed to do. In most locations, the “partnership” extends to only certain dukun bayi. The

identification of “partner” dukun bayi (dukun bermitra) has been used to limit the number of dukun bayi

who are considered legitimate partners of the bidan, or to replace them with women who are not

considered dukun bayi by the community, in order to ensure that they will only bring women to the

bidan, and not provide care themselves. Younger bidan in particular are less interested in collaborating

with dukun bayi. This approach has drawn the anger of many dukun bayi, who feel they have worked

hard for the health of their communities for decades, only to be now treated as a threat. As one dukun

bayi in NTT explains: “They just pushed us out. They didn’t need to throw us away. There was no

farewell or gratitude from the government. They just kind of dumped us out like rubbish.”

This is a lost opportunity. We found that most women turn to the dukun bayi for information,

particularly because they may not feel comfortable with the bidan or because the bidan is not available.

Partnership between the bidan and dukun bayi can ensure consistent and complementary messaging. If

a mother cannot access formal care for any number of reasons, including emergency situations, physical

or financial access issues, or because the bidan is not at her post, the dukun bayi remains the first and

only provider for pregnant women. They therefore need support in order to provide quality care.

Finally, many bidan are overworked, responsible for a large catchment area with minimum assistance.

They are often perceived as young and inexperienced. A true partnership with the dukun bayi could help

the bidan share information, build trust and ultimately provide better care.

In one of our study sites in Dompu, NTB, we did find a strong partnership between bidan desa and

dukun bayi where the bidan desa was deliberate in engaging the dukun bayi. She allowed her to give

women “blessed water” in the village clinic and stay with them during childbirth, since she saw that it

made women calmer and helped delivery. She also engaged the children of the dukun bayi as posyandu

cadre, pulling the family into the formal system. She also engaged both cadre and dukun bayi as

partners, talking through key health issues in the village and sharing new medical information. There

46

McLaughlin, K. (2014). Indonesian village health institutions: A diagnostic. Jakarta: PNPM Support Facility. 47

Kementerian Kesehatan RI, (2011). Pedoman Pelaksanaan Kemitraan Bidan dan Dukun. Accessed through http://www.kesehatanibu.depkes.go.id/wp-content/uploads/downloads/2011/12/PEDOMAN-KEMITRAAN-BIDAN-DUKUN.pdf

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was an impact on mothers as well- many in the village had a clearer understanding of risks and reasons

to use the formal medical system, while simultaneously indicating that dukun bayi provided a spiritual

aspect to care that was important in being “fully well.”

The role of posyandu cadres with respect to pregnant women is to identify new mothers and ensure

that they start their antenatal visits, to encourage pregnant women to attend monthly posyandu and, in

many locations, accompany women in labor to the provider, assisting with transport arrangements and

communication as necessary. Posyandu cadres are theoretically the link between the community where

they live to medical providers. However, reality is more nuanced. Where cadre posyandu are

particularly active, they are seen as helpful individuals in positions of semi-authority. However, bidan do

not always coordinate well with cadre, and cadre often lack opportunities to learn, even if they want to.

Many cadre in NTT expressed the desire to know basic health information so that they could serve

communities better. While cadre can potentially make effective patient advocates, it must be

recognized that they are also part of their communities, which can be gossipy, discriminatory and

exclusive just as much as they can be supportive. The research found several examples of cadre

dismissing certain women for being “uneducated” or for being from certain ethnic groups. While there

are certainly opportunities to provide cadre with more information, they cannot be a complete

substitute for a neutral actors that can help all women access care.

4.2. Delivery Ultimately, mothers, fathers and bidan alike want mothers and their newborn children to be healthy.

For all, the birth can be stressful and frightening as well as beautiful. How they navigate the delivery

experience depends on their perceptions of what will or does happen against their expectations of what

should happen or what they hope for. While there are many overlaps between bidan and families, there

are also some key differences.

Women’s expectations of what will happen in delivery are influenced by her perception of the facility

where she is expected to give birth and the availability and quality of providers that will receive her.

Most women know that village clinics have limitations, but want to feel safe at the puskesmas. However,

both women and providers know that they are usually working with limited resources. Lack of

medicines, tools and shortages of human resources all impact care. Perceptions of the extent of those

limitations influence decisions to access care.

While women can understand that bidan cannot always be on call, there is an expectation that bidan

should make an effort to be available, or at least not punish women who can’t reach them. However,

many women feel that services are limited or non-existent on Sundays and around holidays, and limited

at night or early in the morning. This seems particularly the case in NTT. In Manggarai, one mother’s

child was born at home on a Sunday. She had called her provider, but knew that all the bidan went to a

savings group that day. Subsequently, the bidan attempted to deny her birth control for giving birth at

home, but she successfully fought back, pointing out that she had tried to contact the bidan but she was

not available. Her relative was not so lucky when her baby fell ill. Because that family called the bidan at

five in the morning, and went to the puskesmas at 6:30, they were too early, and the baby died. Many

patients perceive that care is worse or lacking entirely if they need it near a holiday, on a Sunday, too

39

late at night or too early in the morning. Bidan, for their part, resist the idea that they should be on call

24 hours a day, and often complain that patients abuse their time. Finding the balance likely comes

down to the ability to communicate, trust each other and find options for patients in emergency

situations.

Women hope that the provider will listen to them while they are in labor and respond to their problems.

Many draw on previous experiences with dukun bayi who come at the beginning of labor and stay with

the woman and her newborn until several hours after birth, then return on a daily basis. By contrast,

women across locations described their experience with the bidan as having their dilation checked and

then being given a time when they should be checked again or an estimated time of birth. Many of

those women’s labor proceeded faster than estimated, but they frequently struggled to get the bidan to

listen to them. Some women described trying to “hold in” their babies while waiting for the bidan. Many

of the cases when women had to wait did not result in medical problems for the mother or newborn,

but they terrified and angered women and generally made them feel that the provider was

unresponsive. For example, a mother from NTB had to be transferred to a hospital, which was

approximately two hours away from her village. When she arrived at the hospital, she was told to return

home because it was not time to deliver. The hospital bidan said, “just go home first, it’s not time to

deliver because your stomach is small. If you want to go home tomorrow that is fine, but you need to

leave here.” The mother emphasized that she was feeling contractions, but the bidan became angry and

said, “but your stomach is small, it’s not time.” Her response to the bidan was one of outrage: “I was so

mad. Why does she tell me to return home when I am telling that I am having contractions. But I didn’t

dare to put up a fight.” She was waiting to be discharged when her contractions became stronger and

she gave birth to her baby.

Where women have a choice of provider, as is the case in East Java, many women choose to pay out of

pocket and even take out loans to deliver with a private practice bidan whom they perceive to be more

experienced, knowledgeable and attentive. A woman in East Java explained her preference: “Although

the private practice bidan is more expensive, her services are good and everything is included in the cost

such as food and medication. The service is good. The private bidan checks every hour, which is different

from the bidan desa who only checks (dilation) the woman when she is in extreme pain and close to her

delivery time.” For their part, bidan generally expressed surprise when women gave birth more quickly

than expected, though many had experienced it. Their medical training equipped them with a timeframe

for the labor process that not all women follow, but many stick to it strictly since it fits definitions of

“good practice.”

Women also do not want to be referred needlessly. Perceptions of what is “needless” vary dramatically

and can be fairly strongly linked to a woman’s understanding (or lack thereof) of pregnancy risk. Women

who did not feel that they were in danger felt that providers were unnecessarily burdening them with

costs and being incompetent or lazy if they referred them without good cause. Across locations, there

were examples of women who were referred to a hospital and then sent home because it “wasn’t time.”

When it genuinely was not time, as in the case below, it did not create a medical problem, but did

generate anger from families about the waste of time and money, and led to women thinking that

40

providers did not know what they were doing. In addition, these problems can overshadow real referral

needs.

A case from Manggarai illustrates the frustration women feel in being referred unnecessarily, as well as

demonstrating why women do not speak out. There, one woman was referred because she had passed

her due date. She also had other risks: it was her eleventh child and she had high blood pressure. Many

bidan were planning to be away for the approaching Easter holiday, which seemed to also be a factor in

their decision to send her to the district hospital. However, when she arrived, she was sent back home.

When one of her children shared dissatisfaction with her care and perceived lack of competence of

puskesmas bidan on Facebook, it became a major problem. Both the family and the staff of the

puskesmas were called into the Camat’s office, forcing the puskesmas to close early more than once.

Ultimately the family was fined Rp 500,000 and a dog for the insult to their providers.

If women are referred, in addition to costs, women fear operation, since they often see the hospital as

synonymous with surgery. This was particularly the case in Java.

Wherever they give birth, women do not want to be alone. Both mothers and fathers were mixed on

whether fathers should be part of the delivery experience, but many who had done it found it

important. Universally, women wanted their mothers or mothers in law and often the dukun bayi

present at their birth. However, not all women wanted the whole community to know that they were in

labor and disliked what they saw as public act of going to the village clinic, in comparison to giving birth

in the privacy of their home.

Finally, if anything does go wrong, women and their families want information as to what they should

do. They also often want information about the problem, but do not always expect it, given patterns of

information sharing. In East Java, one mother had a successful birth after being induced at the hospital,

where she had been referred due to leaking amniotic fluid. However, she was not allowed to hold her

baby after birth. For three days, the hospital staff kept the baby from her, but were not clear about what

the problem was. She explains “I wanted to breastfeed but they wouldn’t let me. I wasn’t even allowed

to see him. When I finally did see him in I asked if I could hold him and was allowed to. Then a different

staff member came along and told me I had to lay him down, I was not allowed to hold him.” The baby’s

problem was never clear to the family, and finally they fought to check out. They were asked to sign a

declaration that they had done so of their own volition and against the advice of health staff. The family

perceived this as just another part of the hospital staff not taking responsibility. While there are good

reasons to have such a document, it must be accompanied by clear information about the medical

problem so patients can make an informed decision.

4.2.1 Delays: Seeking, Reaching and Receiving Care

The perceptions and challenges in service delivery above, in addition to barriers to access discussed in

the previous section, combine to put women at risk in a number of ways. Here we consider risks through

the framework of three delays: delays in seeking care, delays in reaching care and delays in receiving

quality care.

41

Cost considerations, time of day, physical access, poor perceptions of facilities or bad experiences with

providers can all prevent or delay decisions to seek care. In addition, many women will try to minimize

time at facilities by pushing the limits of their waiting time before heading the puskesmas. Echoing the

experiences of several other women, one mother in NTT described waiting several hours after her water

broke until she felt it was time for delivery. She then drank an herbal extract, believed to accelerate

childbirth before taking a long, bumpy 20-minute motorbike ride to the puskesmas. Bidan support this

approach in several locations, preferring to allow contractions to advance in the comfort of the home

before requesting women come to the facility, or accompanying them to the puskesmas. In East Java,

more than one bidan sent women home when they were at the beginning of contractions, telling them

to come back in several hours.

For those that choose to wait, they face both the risk of home birth and, particularly where they are

required to go to the puskesmas, the wrath of the bidan. One bidan recalls a situation when she forced a

mother who was on the brink of giving birth to take a motorbike to the puskesmas to ensure that she

was in compliance with the Revolusi KIA regulation. She explains: “I forced the mother to race down the

motorbike with her husband. She was close to giving birth.”

Delay in reaching care can be influenced by availability and cost of transport, physical access and

problems related to referral such as the frontline provider not being clear when to refer or complicated

referral rules that increase the time it takes to get to a secondary provider. Many of these issues are

discussed in Section 3.

To address referral problems, different locations use different tools. Locations in NTT have a referral

manual which groups women into different risk groups and sets out referral procedures for each. In East

Java, bidan tended to use a scoring system to determine the extent of risk. Unfortunately, it did not

appear that guidelines were being used. The first reason for their lack of use was that they were

developed based on functioning Puskesmas PONED, which could support normal puskesmas in

responding to less severe problems. Lack of staff generally meant that these facilities were no longer

functioning in this capacity, so all women had to be referred to a hospital. Second, for women with

clearly identified risks, the manual laid out a pre-referral process. However, referral letters from the

puskesmas could not be issued before the day of delivery, since they needed to follow a daily numbering

system. Some patients, knowing that they needed to continue to the hospital, were still forced to go to

the puskesmas for the referral letter, wasting critical time.

In addition, in NTB and NTT, multiple referrals were a problem. In Situbondo, it was clear that the

OBGYN did not work on the weekend, so patients were referred to other hospitals. If he was not

available, patients could find themselves bouncing around in search of a qualified provider. Similar

problems emerged if women needed specialized medical tools. In Malang, one woman was referred to

three different hospitals before she found the tool that she needed. The bidan worked hard at each

location to find the necessary equipment, but it would have been more effective if she had been able to

just call each location and determine if it had the necessary equipment.

42

Finally, even if a woman is able to make the decision to seek care and reach a health facility, she may

experience delay in receiving appropriate care. This generally comes down to the quality of providers,

their willingness to listen to mothers and the capacity of the facility. One mother in East Java was

referred to deliver at a hospital because of leakage in her amniotic fluid. When it came time for her

delivery, she went to the hospital, stayed overnight but the health staff could not help her. Her husband

Hasan explains: “I was mad at the nurse at the general hospital. We arrived at the hospital and I was told

that her opening was at three so we needed to wait so we waited until the next afternoon. By evening,

no one came to explain what was happening so I asked another nurse to examine my wife who told me

that my wife was not dilated.” Her husband demanded his wife be transferred to a private hospital,

where she had a safe delivery. He explained that he was irate by the misdiagnosis and misinformation at

the general hospital and the money spent for their one night stay there and the transportation.

4.3. Postpartum and postnatal care In several of the study locations, neonatal and baby death was rising. The postpartum period is a critical

period in the lives of mothers and newborns. 48 Per Indonesian guidelines, at least three postnatal

examinations should be conducted, one between 6 hrs of birth – and the third day following birth, the

second between days four and 28 and the last before 42 days following birth.49 While most DHO and

puskesmas indicated that they still encouraged bidan to conduct home visits, this generally did not

happen. Indeed, across locations postnatal care was being carried out sporadically or not at all.

Reasons for the lack of PNC varied, but were related to the fact that bidan did not want to go to the

patients home, and patients, having just given birth, did not want to leave their homes with new babies.

There are compounding factors on both sides. Bidan cite a lack of time, transport money and the dismay

of other patients if they are doing home visits instead of at their post. Mothers are uncomfortable taking

their children out, as in many locations there are cultural taboos about newborns leaving the house.

Many women are simply afraid to take transport, often a motorbike or truck, after just giving birth and

with such a young child. Across locations, dukun bayi support in the provision of PNC, in some locations

coming every day until the child loses his or her umbilical cord, in others up to 40 days after birth. The

dukun bayi assists with washing the child and mother and seeing if they have any complaints. When the

bidan did provide PNC, most women described not a physical examination of themselves or their babies,

but answering a brief set of questions.

There are a few regional variations worth mentioning. In NTT, many (but not all) bidan refused PNC to

women who gave birth at home. Women were somewhat aware of the punitive nature of this approach

because they wanted the immunization that is included in the first visit for their child. They were

generally unaware of the other reasons for the PNC visits. In one location, bidan were only suggesting

PNC visits for those women who were “high risk” either due to risks in pregnancy or problems in

delivery. In Situbondo, many women did not complete PNC if they gave birth with a private provider. To

do the PNC visit at home, the private provider would have to come into the “area” of the village bidan,

which is not accepted. Women therefore need to go to their clinic for PNC examinations. However, for

48

World Health Organization, United Nations Population Fund, UNICEF, The World Bank.(2006). Pregnancy, childbirth, postpartum and newborn care. A guide of essential practice. 49

Kementerian Kesehatan RI. Midwifery Service Standard (2010).

43

the reasons above, many do not. Some providers indicated that PNC care should be undertaken by the

village bidan, but it is also difficult for her to know about the birth and take over care effectively.

4.4 Contraceptive use Across locations, many women preferred to use injections as their form of birth control. In NTB and East

Java, women prefer injection. Women make this decision based on information from family, least

amount of weight gain, duration of contraception, and cost. In NTT, there was slightly less choice. There

were some reports of trouble with respect to access to birth control, due in one area to poor

coordination between the family planning office and bidan, and in another to poor supply chains for

medicine. In that location, one father expressed his frustration with a system that pushes women to use

birth control, but then is out when they go for their next shot.

In NTT, more women used IUD, but women related a number of stories of problems with the devices

which required medical assistance. One woman described her experience with an IUD that “came

loose.” When the she went to her village bidan for help, the woman said she didn’t have the skills to

help. The woman ultimately had it removed by a dukun bayi in a neighboring village. IUD was not used in

NTB and East Java because the process of inserting the device is viewed as a taboo given the intimate

nature of the process. In Sumba Barat, most respondents chose sterilization over other forms of birth

control.

Across locations, there were a surprising number of birth control failures. Some happened as women

switched birth control methods. For example, a mother from East Java became pregnant with her

second child when she was in her transition period of returning to depo shots after experiencing

negative side effects of birth control pills. She tried the pills but felt nauseous and started vomiting and

decided to stop. Her plan was to return to depo once her vomiting and dizziness subsided and it was

during this period that she became pregnant with her second child. Other methods simply failed:

another woman in East Java used birth control pills successfully for over five years, and then suddenly

became pregnant. When she asked the doctor how it could have happened, she was told that the pills

were ineffective if they were not taken exactly 24hr apart. A delay of even five minutes could render the

pill ineffective. Finally, a number of women who fell pregnant unintentionally continued to use birth

control (mainly injections), and were deeply upset when they discovered their pregnancies, fearing that

ongoing use of birth control would harm their babies. Information about risks and effectiveness of birth

control are not effectively communicated.

5. Recommendations These recommendations start from the lowest level, examining opportunities for improved interaction

between informed patients and quality providers.

5.1. Strengthen patient – provider engagement Patients want service providers to be flexible and helpful, who treat them as individuals and help people

in need. These acts of compassion have a greater societal benefit as they “redeem the state” allowing

44

community values to find expression alongside bureaucratic rules50 and, in the context of this study,

changing concepts of health and medicine. As the Indonesian state increasingly pushes toward a more

facilities based approach, this understanding and flexibility is important to build trust in providers and

service provision generally. Unfortunately, in many locations, approaches to service delivery seem to be

headed in the other, more punitive direction, increasing provider power and decreasing patient voice.

This should be addressed at a national level, but can also start at the local level, as described in

recommendations below.

At the national level, adopt clear values and dimensions for quality in health services that include a

focus on patient-centered care. Make them public with clear plans to evaluate them. Already

recommended in the Health Sector Review, this study agrees that a re-orientation to patient centered

care needs to start from the top. Service standards that are responsive to patient needs are more likely

to support patient use of medical services.

At the district and village levels:

Reconsider support for sanctions around maternal and neonatal health care. While the research found

an example of a village regulation working well, it found far more examples where the developing

culture of threats and sanctions meant that providers did not have to “work with” patients thus

undermining the development of local solutions to challenges in accessing and delivering health care.

These regulations theoretically contain ways for citizens to hold providers accountable, but structural

constrains and power dynamics make this unrealistic.

Use moments such as the development of citizen charters or standard operating procedures to open

broader discussions about patient medical experiences and hopes as well as provider constraints.

Citizen charters and similar accountability tools can be effective in addressing key elements of service

delivery, such as attendance of bidan. Increasingly, accountability agreements address the patient-

provider interface by providing guidelines on the interaction. For example, they encourage reduction of

waiting times, smiling, etc. However, they generally do not enter the “medical” space. This should be

questioned, since the way medical processes are carried out shape patient perceptions. A key example

from the research is the way that labor estimations are made: bidan measure dilation, estimate a birth

time and then often tell the patient to just wait. Women want to be able to express changes that they

feel, and want more frequent checking-in by the bidan (even if not a full examination). Similarly, fathers

should be allowed in delivery rooms. This supports other elements of Indonesian policies to engage

fathers in maternal and neonatal care, but is inconsistently applied.

Make the partnership between bidan and dukun bayi an actual partnership. This is likely to need

support from the national level, but it can be (and in some locations has) started locally. It can be

expanded by:

- Using training to provide information on ANC goals, pregnancy danger signs and risks. Many

dukun bayi were very proud of training that they had previously received, since education is

prestigious. Providing information to dukun bayi would help it reach women, help the dukun

50

Lipsky, M. (2010) Street-level bureaucracy: Dilemmas of the individual in public services

45

bayi better understand emergency situations, and move toward re-establishing a more

productive partnership between informal and state providers.

- Seek input from dukun bayi in developing ANC recommendations and communication

strategies. Understanding local context helps bidan provide better care. It can help them both

tailor recommendations, as well as explain why some practices are not in the best interest of the

mother. This dialogue should take place with informal providers.

Support a more meaningful partnership between bidan and posyandu cadre, leading to more

substantive role for cadre. In the location where there was a strong relationship between bidan and

cadre, mothers also had more information. Funding meetings for posyandu preparation or debrief

would be valuable, and providing a clearer focus on maternal care useful. They could also receive

information through text messages since they are more likely to have phones. Assigning a single cadre to

each pregnant woman to provide some basic information on ANC and potentially insurance would also

be valuable in preparing mothers for ANC visits.51

Be aware of constraints to accountability and use external actors where necessary. Many patients who

fear discrimination are “non-voluntary” in the sense that they access services at the mercy of limited

state providers and dependent upon state assistance. Chances for the success of citizen charters, MOUs

etc., should be understood in this context. If those who complain are reprimanded and fined (as in

Manggarai), opportunities for accountability are limited. External actors such as NGOs may be better

placed to advocate for change without fear of retribution at the local level, and may need to start by

documenting routine problems. Increased attention to patient’s rights may help women advocate for

medical privacy and freedom of choice in their medical decisions. DFAT-funded programs such as

MAMPU should examine how sanctions impinge on women’s rights, and organizations such as KOMNAS

Perempuan should continue to be engaged on this issue.

5.2. Support bidan to provide quality, patient centered care In his work looking at frontline health services internationally, Atul Gawande notes “the overwhelming

message to the people who work at the frontlines of care around the world is that no one notices

excellence and no one cares.”52 To this, we would add that in addition to not recognizing excellence,

when the Indonesian health system does mention it, it is defined only in terms of medical steps or

standards. While these are important, they need to be balanced by patient experience, and bidan need

support and encouragement to think in this way. Recommendations here do not replace the need for

ongoing standardized training, but are rather aimed at efforts that can be undertaken by DHO or

puskesmas to adjust performance targets and provide support for bidan to develop professionally in

ways that improve both their medical capability and their ability to communicate and interact effectively

with patients. They include:

Provide more opportunities for on the job support and learning. In two locations, puskesmas were

adding discussions and mini-training sessions to their monthly staff meetings. Bidan found these useful,

51

This is being trialed by the USAID program EMAS, and deserves to be monitored. 52

Gawande, A (2014) “The Idea of Wellbeing”. Reith Lecture 2014: The Future of Medicine.

46

and they have the advantage of providing support to all bidan (including volunteers). They can be

expanded beyond strictly “medical” topics, such as:

- Assessment of routine events, such as seeking care or referrals. While many DHO are

conducting maternal death audits, these are focused on identifying failures and gaps. An

assessment of difficult but successful events would help to identify and acknowledge positive

behaviors as well as recognizing challenges in a less threatening context. These may require

external facilitation, but would be useful if undertaken in two different ways:

o Between village/ puskesmas staff and hospital staff. Developing more supportive and

positive relationships between bidan and hospital staff was badly needed in many

locations. These discussions could help set expectations, help identifying positive

behaviors, and build trust.

o Between village/ puskesmas staff and citizens. If patient perspectives are included, it

could be an opportunity for a more productive discussion about challenges and

responses, applying a “positive deviation” approach for engaging citizens. A focus on

information and patient understanding would be particularly useful.

- Conduct discussions on communicating with patients. This can be done through the

assessment of routine events, but needs to support increased sharing of information with

patients and approaches for communicating effectively.

- Establish and moderate discussion forums between bidan. Many bidan turn to the internet or

existing local groups on Whatsapp or BBM for information. Many use these groups to

communicate locally. Using these forums as spaces to share information about quality of care or

good practices could be useful.

In addition, the study found some areas where performance targets need to be changed, more closely

monitored or adjusted for better quality care. Recommendations include:

Focus on quality over quantity of ANC. Indonesian guidelines around ANC are clear, stipulating four

visits with clear objectives. Relaxing local targets for more ANC visits will not necessarily improve quality,

but it will at least open space for providers to provide better care. Wider socialization of ANC goals

(though cadre and dukun bayi) may support pressure to improve quality.

More actively monitor PNC. In many locations, neonatal and baby deaths are actually on the rise, but

PNC is being increasingly overlooked. This needs more attention by DHO as they oversee puskesmas and

bidan.

Consider linking delivery and PNC payments. Many bidan are willing to simply not claim PNC fees, since

the amount that they receive is small, especially if they front money for a home visit. Bidan could be

further incentivized if delivery and PNC payments are linked, paid on acceptance of PNC by the mother.

This would need to be piloted and monitored so it does not just become a new requirement for women

to pay more in travel costs, but actually results in care for patients at their homes.

Develop and implement more functional referral plans and guidelines. Locations in NTT had referral

guidelines and classified conditions for referral. Adjustments that need to be made are:

47

- Plans that are not bound by administrative boundaries. BPJS insistence that puskesmas fulfill

gatekeeper requirements should not result in delays in care. Individuals should be mapped to

locations that get them closer to second level services if they need it. DHO should undertake

mapping exercises to evaluate most effective referral routes so patients can be assigned and

providers resourced appropriately.

- Plans that recognize (lack of) capacity of PONED due to staffing changes. Most PONED were no

longer functional as such, but were a core part of referral plans.

- Pre-referral processes and referral processes need to be clearer. Pre-referral appears to be

blocked by the need for puskesmas to maintain the order of their referral letter numbers. This

requirement should be examined and addressed so those who need to can go to hospital

directly. Ongoing guidance to bidan on when to refer, and checklists for patient preparation are

still needed.

5.3. Improve access to identity documents Lack of identity documents is a key barrier to accessing insurance. Efforts to lower costs and improve

access to these documents can be effectively made by district governments. However, national reforms

will have larger impacts and should be simultaneously pursued. Key recommendations for district and

village governments include:

Move KK and KTP service provision to the kecamatan level. Efforts at this were initiated under the

DFAT LOGIC program and should be continued for national scale up.

Continue to support mass registration and integrated services that cover marriage, divorce and birth

certificates as well, but improve quality control. Some individuals are avoiding mass registration

because there are so many typos and inconsistencies, which then create even bigger problems for

patients. If these problems can be reduced, mass registration can be extremely beneficial.53

Support local government record keeping of death certificates and citizens who have moved. Local

governments face pressure to more flexibly allocate health insurance benefits. They are stymied by

fragmented administration (health department for death certificates, civil registry for registration of

those that have moved, social department for the poverty list). Helping Bupati to get a better handle on

the problem could help them push harder for solutions from the departments that they oversee with

the political return of being able to provide coverage to more citizens in their district.

Encourage better coordination between bidan and village heads on identity documents. While it is in

the interest of the bidan to coordinate with the village head on identity documents (reducing their work

load and helping ensure that they gets paid), it rarely happens. Many village heads see health as outside

of their realm of control, but they need to have a clearer understanding of (and be held responsible for)

their role in ensuring citizen access. There could be a role for districts to more clearly articulate village

head responsibilities in this space.

At the national level, recommendations include

53

PUSKAPA UI (2014) Exit Survey Integrated Mobile Services for Legal Identity “Yandu” Universitas Indonesia: Jakarta

48

Streamline identity documents and processes. Given the huge barriers to access created by Indonesia’s

legal identity requirements, the government should consider whether all are necessary. Specifically:

- Evaluate the value of family cards. These are a legacy of a different approach to government,

and may not be a necessary part of the modern Indonesian state.

- Evaluate requirements for registration in a new location. While individuals should certainly

register in a new location if they move, increasingly linked national databases should be heading

toward a point where that registration could strike them from the rolls of the location of their

previous residence. “Moving letters” should be phased out.

5.4. Improve access to insurance Reduce costs around registration with BPJS, both for pregnant mothers and newborns. In Malang,

patients are able to register at the puskesmas. In Dompu and Lombok Utara, women can register for the

regional program (run through BPJS) with their bidan. Either of these approaches could be replicated

and should be extended to the registration of newborns.

Ensure that the lack of a marriage certificates does not create a barrier to care for young mothers.

Pregnant women below the age of marriage face higher pregnancy risks, but will struggle to get their

own KK if they cannot use that of their family. They should not have to consider marrying to access care,

and may need special consideration by BPJS.

Improve information flows about the program across local level actors, including bidan, cadre and

members of village government. Fragmented socialization approaches mean that information is both

poor and confusing.

Explore mobile banking options. Explore more flexible systems for payment of insurance premiums.

Mobile or hand phone mediated payment systems can reduce cash complexity and overcome distance

and transport barriers. These types of services, and greater access to banking services generally, have

broader benefits for rural families.

Support district governments to implement effective regional health plans. All district health plans

must run through BPJS by 2016. This change can be used as an opportunity to help district governments

learn from each other and explore ways to ensure the coverage that they provide is effectively targeted

and flexible. This study provides some initial information about the range of options in locations studied,

but a broader study may be useful, combined with opportunities for local governments (both district

and provincial) to learn from each other.

Support local governments to effectively regulate service delivery costs and meet procurement

regulations. Inconsistencies between local regulations and BPJS and fears of audit are blocking access to

a significant amount of BPJS funding. These problems vary considerably by location, indicating that local

governments could benefit from significantly clearer implementation guidelines or need more support

to fix or navigate local regulatory frameworks. Districts may need technical assistance and opportunities

to learn from each other.

At the national level, the key recommendation is to update the national poverty list. In doing so,

actuarial calculations should be made to make coverage of children of those receiving state-assisted

49

coverage truly automatic. At a minimum this should cover the PNC period (42 days), though would be

better targeted to cover children through the full period of risk (five years, matching period of posyandu

coverage), or it could include coverage later into life.

5.5. Additional opportunities for village and district governments Explore options for village government to help defray transport costs. BPMD oversees both the

implementation of the new village law (which increases village budgets considerably) and Desa Siaga.

They should work to ensure that rules for use of village funds are flexible enough to support village level

solutions to transport problems. Some village heads are already considering “village ambulances,” which

requires buying a vehicle. Other options for reimbursing villagers who have existing vehicles for

transport at pre-negotiated prices should also be considered.

In addition to the above, national and local government could work together more effectively to

evaluate existing programs. This could also be supported by donors. These efforts are perennially

underfunded but are necessary to determine if very limited district money is being well spent.

5.6. Key constraints in the health system The aim of this study was not to identify national level constraints, but here we mention those that

impacted most heavily on frontline care.

Continue to take steps to ensure bidan quality. Training budgets sit with the district, but evaluation of

the quality of bidan education and certification is a national matter and needs attention.

Fix problems in distribution of drugs and disposables. Addressing procurement and logistics barriers as

well as strong external incentives against reform (ie the current shadow economy) will be important for

change, which is critical to reduce patient costs and improve trust in the quality of Indonesian health

care

Adapt the health system to the reality of patient mobility. Current targets and service delivery

approaches are based on the assumption that patients access all care from their village bidan. In reality,

pregnant mothers and families move between villages, and will access private providers if they feel they

are better quality. Specific recommendations to address mobility include:

Adjust targets, reporting and incentives to recognize patient mobility. Pregnant women can

and should use their “buku KIA” to allow bidan care to continue if they move during pregnancy.

Incentives should be linked to individual visits, and bidan and districts not penalized for not

hitting ANC targets (for all four visits) if women move to the area late in their pregnancy.

Extend reporting requirements on private providers. Currently these seem to sit with the

village bidan, who has to guess at where women in her village are seeking care.

Improve disbursement of BOK and timely release of BOK guidelines. Delays impact service provision

and undermine transparency.

Improve the flexibility of recruitment systems so that poor performing providers can be more

effectively disciplined or fired. This will remain difficult in areas where scarcity of providers is a problem

50

(Sumba Barat), but scarcity is increasingly less of a problem. It will also remain difficult for civil servants,

but in the short run could be applied to PTT.

Further investigate the use of volunteer bidan. While this study highlights the frequency with which

these staff are employed (and the challenges they represent for accountable service delivery), a better

understanding as to why they are so pervasive. It is likely to be a mix of political patronage and inflexible

recruitment systems, but deserves further examination in order to formulate an adequate response.

51

Annex A. Insurance Coverage and Health Costs

A.1. Insurance programs

Table A1: JKN Coverage in study locations

Province District District Population JKN PBI Natl* JKN BPI District

NTT Manggarai 332,560 194,997* -

Sumba Barat 117,787 79,000 11,500

NTB Dompu 225,937 102,286 4,411**

Lombok Utara 205,064 122,000 14,500**

E Java Sitobondo 660,760 224,667* -

Malang 2,506,102 708,058* -

*In some locations there were differences in the number of covered individuals provided by the health department and BPJS. In

that case, we present data provided by BPJS.

** Funded jointly by the district and the province.

At the beginning of 2015, BPJS introduced a seven day waiting period for coverage to become effective

in an attempt to encourage people to seek coverage before illness struck.54 Initially, this was applied

without exception, but was revised to allow patients to get a Member Eligibility Letter (Surat Elijibilitas

Peserta (SEP)) which eliminates the waiting period for a card to be released by the social department.

This was often called a “recommendation letter” from the social department, and often had to be

organized within 3 days of birth or emergency to be retroactive.

Table A2 Waiting periods for coverage eligibility: regional variation

Manggarai Sumba Barat Dompu Lombok Utara Sitobondo Malang

Class I 7 days immediate 7 days 7 days 7 days 7 days

Class II 7 days 7 days 7 days 7 days 1 day 7 days

Class III 7 days 6-37 days55 immediate 30 days 1 day 7 days

54

Peraturan Direksi BPJS No 211/ 2014 pasal 6 which revised the previous regulation Peraturan BPJS No 4 /2014 pasal 11. 55

If received on or before the 25th

of the month, then available on the 1st

of the following month, if between 26th

-31

st, then available on the 1

st two months later. Note that this was for coverage paid through the regional health

program, but generally anyone who was applying for third class coverage was considered “kurang mampu” and put in this group. (Surat Edaran, Waikabubak No BU.422.1/283/63.L/VII/2014)

52

TABLE A3 A summary of Jamkesda programs

Prov District Jamkesda

NTT Manggarai General (including maternal/ neonatal care): Can use poverty letter at public hospital, but

not at private hospital or at primary health care provider.

Paid 100% by district (?)

Sumba

Barat

General (including maternal/ neonatal care): District covering JKN premiums for 11,500

people (potentially being increased to 13,000 during mid-year budget revision),

application with poverty letter or through collective application from village head.

Paid 100% by district (?)

NTB Dompu General: for in-patient care only, using a poverty letter, paid 100% by district

Maternal/ neonatal care: “Jampersal NTB”:

Registration: through bidan, covered under JKN from registration until the end of the

calendar year (31 Dec, 2014), babies covered with poverty letter from village head.

Quota: 3,197 women, 1,214 babies

Paid 50% by district, 50% by province

Contested for 2015 at time of research

Lombok

Utara

General: for in-patient care only, prioritizing pregnant women, babies and emergency

care using a poverty letter (though with strict ID requirements)

Paid 100% by district

Maternal/ neonatal care: “Jampersal NTB”

Registration: through bidan, covered under JKN from registration until the end of the

calendar year (31 Dec, 2014), babies covered with poverty letter from village head

Quota: 14,500 individuals across both categories (general and pregnant)

Paid: 4,500 pregnant women by province, 10,000 by district (general)

Contested for 2015 at time of research

E Java Sitobondo General (A): 4,352 individuals given cards to access care, paid 50% by district, 50% by

province

General (B): care provided for free at both health clinic and hospital with a poverty letter

(issued on recommendation of district secretary, valid six months)

Malang General: 6,213 individuals identified, given cards to access care, paid 50% by district, 50%

by province (not clear)

A.1.1. Utilization of BPJS in regional programs

Both Sumba Barat and both locations in NTB run their regional health programs through BPJS, but they

do so in very different ways. Understanding their experiences is important, as all districts must run their

regional programs through BPJS by 2016.

NTB has an explicit focus on maternal and neonatal care. From an access perspective, it has dramatically

reduced barriers for mother by running registration though the bidan and puskesmas. While helpful for

mothers, it places some additional burden on midwives, and it does not necessarily ensure coverage for

mothers. “Ketika ada BPJS gratis dari pemerintah dompu untuk ibu hamil, juga masih banyak yang tidak

bisa mendapat BPJS karena kendala tidak punya kartu keluarga, nah orang lombok kan jarang yang

53

punya kartu keluarga cepat. Buku nikahnya juga tidak ada karena mereka menikah dibawah umur”.

However, in one village, the bidan was working with the village head to ensure that patients could meet

administrative requirements for coverage.

Districts in NTB have negotiated with BPJS to allow for pregnant women and babies that need additional

assistance to be covered for a calendar year (until Dec 31, 2014). This has some clear drawbacks for

women who give birth at the end of the year, since their coverage ends nearly immediately.56 They have

also managed to get the family registration rule waived for pregnant women or at-risk babies covered

under the regional program.

Unfortunately, there have been some problems with these arrangements. In particular, there was

disagreement as to whether women and babies who had been provided coverage under the program

could be dropped at the end of 2014 to make space for another year’s worth of women and children.

BPJS indicated that they could not leave the program, and so would have to be covered by the regional

government or shifted to JKN Mandiri. As such, they were considering the quota “full” while the health

department was ready to add a new group of women. For the women who received coverage in 2014, it

was not clear if they would be allowed to exit the program or be expected to take over the premiums.57

Confusion around whether or not the program would continue meant that both bidan and mothers

were unsure if they would be able to be paid or have to pay for delivery.

Sumba Barat is focused less specifically on maternal and neonatal care, and more on ensuring that those

who cannot pay can still recive coverage. They have budgeted to cover 11,500 individuals in 2015,

though at the end of February, over 13,000 had already registered. 58 Registration takes place

collectively via the village head, or individually (per family) directly to the kabupaten. Families need a

poverty letter, which they (or their village head) take to the health department, which then issues a

recommendation letter for their coverage under the regional program. They take this letter to BPJS for

coverage.

Access to the program is limited largely by information and the level of village head commitment to

covering his constituents. Only one village head in Sumba Barat had taken the initiative to register

uncovered families in his village at the time of research. The location was chosen as a study site. Some

observers commented that the village head was politically motivated, since he is standing for re-

election. He also seemed to have been personally influenced by the death of a woman in childbirth in

2009 (prior to his election) and the fact that his own wife had a pregnancy risk (high blood pressure)

shortly thereafter. Either way, the outcome is positive for citizens, though increasing demand across the

district has slowed the process of actually getting cover, and even the village head has to wait when he

helps families process their KK and KTP (which needs to be done first). By contrast, in the neighboring

56

In a side note about communication, it was also very confusing when coverage ended, since most DHO staff said that coverage lasted “for a year” but meant “for the calendar year.” 57

This is important for if they are expected to pay, it must be clearly communicated. Otherwise, they will face a fine and have to pay for all previous months if they want to access care in the future. 58

Further funding may be available in the mid-year budget revision, but will still remain a serious constraint. This is discussed further under Health Care Financing.

54

village, knowledge of the program was mixed, and individuals applied on their own via the village head if

they found out about it and wanted to apply. One family whose baby died after they took it out of the

hospital because they could not meet costs discovered only after her death that they could have applied

for coverage.

A.1.2. Poverty letters

In Manggarai, Sitobondo and Dompu, individuals can still use poverty letters to secure fee waivers for

care, but the level at which that care is covered varies: in Maggarai expenses are only covered at the

hospital, while in Sitobondo and Dompu poverty letters can also be used at the puskesmas. Malang

allowed the use of poverty letters until the end of 2013, but incurred so much debt with its hospitals

that it has subsequently canceled the program, effectively having no local insurance program.

Poverty letters are worth highlighting because of their impact on the uptake and perception of JKN. In

Sitobondo in particular, there was a very low focus on JKN, both because there are many private sector

options for care, and because individuals could use poverty letters. Interestingly, however, the

requirements for poverty letters have also been tightened, requiring KK, KTP and buku nikah, and going

from village head to Camat, to Sekda who issues a recommendation before the letter can be finalized. It

takes two to three days and can exclude individuals in the same ways that JKN does. In Manggarai, there

was more focus on ensuring JKN coverage, because expenses at the puskesmas (for normal births) were

not covered by the regional program. However, in the case that families without health insurance

needed to go to the hospital, they had a way to seek coverage. Generally, a letter from their village

head, agreed by the Camat, was sufficient.

A.2. Costs without insurance Following the dissolution of Jampersal at the end of 2013, all women who do not have health insurance

have to pay to give birth at a medical facility. The costs range fairly widely by location.

Table A4: Delivery costs for public patients in research locations

Manggarai Sumba Barat Dompu Lombok Utara Sitobondo Malang

Rp 600,000 Rp 350,000 Rp 600,000 Rp 300,000 Rp 700,000 Rp 750,000

In Manggarai, women without health insurance also had to pay (Rp 5,000) for prenatal care at posyandu.

In all other locations it was free for all women at posyandu, but women without insurance generally

needed to pay if they went to the bidan at a different time. In some locations the registration fee

(applied at puskesmas and village clinics) had been waived through regional programs, but women still

needed to pay for medicines. In other locations registration fees ranged from Rp 5,000- 20,000 plus

medicine.

55

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