Maternal deaths continue despite all the pledges<\/p>\n
Meiwita Budiharsana, Program Officer, Ford Foundation, Jakarta Office<\/p>\n
In two years, Indonesia must report the results of a decade of
\nthe implementation of an action program agreed upon at the 1994
\nConference on Population and Development in Cairo. Do the current
\nhealth programs reflect the government's seriousness in realizing
\nits international commitment? Has the fairly large Indonesian
\ndelegation that attended that conference consistently implemented
\nthe declaration that they signed?<\/p>\n
The fact is, there have been many programs here -- but no real
\nchanges.<\/p>\n
The basic system for monitoring and reporting births,
\nmarriages and mortality rates in Indonesia has yet to produce
\ncomprehensive vital registration data. Without well processed
\ndata or accurate estimates for the annual program planning, the
\npolicies drafted from one year to the next are based on
\n\"guesstimates\" alone.<\/p>\n
Since the 1994 Household Survey (SKRT), which came up with an
\nestimated maternal mortality rate (AKI) of about 340 per 100,000
\nlive births, a decline has never been reported. Yet it has
\nrepeatedly been stated at every seminar and workshop that
\ncompared to other Southeast Asian countries, Indonesia has the
\nworst AKI.<\/p>\n
Unfortunately, statistics alone are not sufficient in bringing
\nabout significant changes. There is no sense of urgency to
\nallocate an adequate health budget (at least 5 percent to 10
\npercent of a total regional budget), so that 15 percent of this
\namount can be concentrated on programs to lower maternal and
\nneonatal mortality rates (in the latter case a newborn is
\nexpected to survive the first 28 days).<\/p>\n
It is not surprising that the situation in the central
\ngovernment is replicated in the regions. As we embarking on the
\nera of decentralization with missing accurate data, predictably,
\nthe hope of obtaining a commitment from regional legislative
\ncouncils and regents to allocate adequate funds to lower the
\nmaternal mortality rate is grim.<\/p>\n
\"A high maternal mortality rate\" remains an expression that
\nfails to move anybody reading or hearing it. It also has failed
\nto introduce changes such as integrating the \"usual\" vertical
\nhealth planning and programming.<\/p>\n
Who should be responsible to change this situation? Is it
\nsupposed to be a shared responsibility? Whose responsibility is
\nit to guarantee that the basic human rights to life and equitable
\naccess to quality health care is fulfilled?<\/p>\n
Sharing of responsibility among ministries, complete with
\nsystematic monitoring and evaluation of costly programs, is
\nneeded. This is the greatest challenge to the Office of the State
\nMinister for Women's Empowerment and women's non-governmental
\norganizations (NGOs).<\/p>\n
A genuine partnership between both parties is fundamental to
\ntake control of maternal and neonatal deaths.<\/p>\n
A genuine partnership means listening with great concern and
\nattention to NGOs who recognize the right of women to access
\nequitable information and comprehensive reproductive health
\nservices -- not fragmented as in the current health system.<\/p>\n
The current health system consists of vertical programs that
\nseparate the planning and budgeting processes of the four
\nessential components of reproductive health care for over 30
\nyears. Maternal and child health has been delivered separately
\nfrom family planning, and does not pay attention to barriers to
\naccess to proper detection and treatment of sexually transmitted
\ninfection. Not to mention that adolescent services
\nmerely focus on primary school-age children, leaving out the out-
\nof-school youth who comprise almost half of the adolescents above
\n15 years old in this country.<\/p>\n
In the near future we will see the impact of decentralization,
\nin which the allocated health budget will shrink at the district
\nand lower levels. There is no longer such a thing as absolute
\ntop-down directives from Jakarta. With no convincing advocacy to
\nthe district and subdistrict heads and local legislative
\ncouncils, almost certainly the use of the annual development
\nbudget will concentrate around the construction of physical
\nfacilities -- instead of human resources development focusing on
\nreducing the risk of maternal and neonatal deaths.<\/p>\n
The Office of the State Minister for Women's Empowerment must
\ntake firmer action in convincing relevant ministries that a
\nfaster reduction in the maternal mortality rate requires not only
\npublic participation but, more importantly, also changes in
\nprogram strategy.<\/p>\n
A \"shared responsibility\" campaign will not be effective
\nunless there is unity in planning and implementing a program
\nstrategy. Shared responsibility can be demanded only when the
\nwomen's rights to participate in planning, priorities setting,
\nmonitoring and evaluation are guaranteed.<\/p>\n
NGOs have written a lot about women's need and rights to
\nobtain information and effective reproductive health services. A
\nbook published last year titled Sketsa Kesehatan Reproduksi
\nPerempuan Desa (Sketches of the Reproductive Health of Rural
\nWomen) was written NGO staff who daily assist rural women
\nfarmers. The book reflects years of work which established a
\nbonding trust among women farmers that is conducive to the
\nsharing of feelings and experiences, including sexual and
\nreproductive experiences.<\/p>\n
This book, edited by Sri Hadipranoto and Heru Santoso,
\ncompiles true stories reflecting the factors contributing to the
\nhigh maternal and neonatal mortality rates. The book includes
\nstories of sexual harassment, the fear of unwanted pregnancy due
\nto expensive and scarce contraceptives, the experience of going
\nthrough unsafe abortions, the enduring of stigmatized infertility
\nowing to sexually transmitted diseases, and poor participation
\nand empathy of husbands of women who face the risk of death
\ncarried by unsafe abortions.<\/p>\n
Strategic changes must be targeted at a series of direct and
\nindirect causes of maternal mortality voiced by people at the
\ngrassroots level. In line with the general principles of
\npreventive health, early diagnosis and proper treatment are only
\npromising when the causalities are known.<\/p>\n
The success measures of a \"shared responsibility\" campaign
\ndepends on whether we can include the voice of the grassroots
\nNGOS in the planning and changing strategies, for a program
\naiming to speed up the decline in maternal death risks.<\/p>\n
The above is based on a presentation the writer gave at a
\nseminar on maternal mortality on March 12 in Jakarta.<\/p>",
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