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TToo aannsswweerr tthhee pprroobblleemm ooff hhiigghh mmaatteerrnnaall mmoorrttaall iittyy rraattee,, TThhee

GGoovveerrnnmmeenntt ooff IInnddoonneessiiaa llaauunncchheedd ““JJaammiinnaann PPeerrssaall iinnaann //

JJaammppeerrssaall”” ,, aa cchhii llddbbiirrtthh iinnssuurraannccee ffoorr aall ll mmootthheerrss iinn 22001111..

TThhiiss ppooll iiccyy iiss bbaasseedd oonn tthhee vviieeww tthhaatt tthhee ddeeaatthhss ooff mmootthheerrss

aarree cclloosseellyy rreellaatteedd ttoo tthhee lleessss ffiinnaanncciiaall ccaappaacciittyy ttoo aacccceessss hheeaalltthh sseerrvviicceess.. TThhiiss sscchheemmee ggiivvee ffiinnaanncciiaall cceerrttaaiinnttyy aanndd

sseeccuurriittyy ffoorr mmootthheerr bbeeffoorree,, dduurriinngg aanndd aafftteerr cchhii llddbbiirrtthh,,

iinncclluuddiinngg ffoorr tthhee nneewwbboorrnn bbaabbyy..

HHoowweevveerr,, tthhee rreessuullttss ooff oouurr ppaarrttiicciippaattoorryy ggeennddeerr

aauuddiitt iinn PPuurrwwoorreejjoo ((CCeennttrraall JJaavvaa)) aanndd KKuulloonn

PPrrooggoo ((JJooggjjaakkaarrttaa SSppeecciiaall PPrroovviinnccee)) iinnddiiccaatteess

tthhaatt tthhee ddeeaatthhss ooff pprreeggnnaanntt mmootthheerrss iiss nnoott

eennoouugghh ttoo bbee aannsswweerreedd bbyy ssuucchh eeccoonnoommiicc

aapppprrooaacchh.. IInn ffaacctt,, pprreeggnnaanntt wwoommeenn ffaacciinngg

wwiitthh vvaarriioouuss ssoocciiaall iissssuueess lliikkee lliimmiitteedd aacccceessss ttoo iinnffoorrmmaattiioonn,, llaacckk ooff aaddeeqquuaattee hheeaalltthh sseerrvviicceess

aanndd ssuuppppoorrtt ffrroomm hheeaalltthh ssttaaffff iinn tthhee ffiieelldd,, aass

wweell ll aass ggeennddeerr iissssuueess rreellaatteedd ttoo tthhee ddeecciissiioonn

mmaakkiinngg oonn cchhii lldd bbiirrtthh iinn tthhee ssoocciieettyy.. TThhoossee

iissssuueess sshhoouulldd bbee aa ccoonncceerrnn iinn tthhee ffuuttuurree,,

ppaarrttiiccuullaarrllyy ccoonnssiiddeerriinngg tthhaatt mmaatteerrnnaall

mmoorrttaall iittyy rraattee iinnccrreeaasseedd ffrroomm 222244 mmaatteerrnnaall

ddeeaatthhss//110000..000000 ll iivvee bbiirrtthhss iinn 22000077,, ttoo 335599

mmaatteerrnnaall ddeeaatthhss// 110000.. 000000 ll iivvee bbiirrtthhss iinn 22001122

((DDeemmooggrraapphhiicc aanndd HHeeaalltthh SSuurrvveeyy,, 22001122)).. MMoorree tthhaann jjuusstt aann eeccoonnoommiicc pprroobblleemmss,, mmaatteerrnnaall

mmoorrttaall iittyy rraattee rreefflleeccttiinngg wwoommeenn eexxcclluussiioonn iinn

ddeevveellooppmmeenntt aanndd ssoocciieettyy iinn ggeenneerraall.

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THE JAMPERSAL program is a concrete action of the Government of Indonesia to integrate the Millennium Development Goals into the national development programs. The program was launched in

2011 through the Minis try of Health Decision No. 515/Menkes/SK/III/2011 and has i ts aim to reduce the Mother Mortality Rate (AKI) to 102/1000.000 live bi rth and the Infant Mortality Rate (AKB) to 2300/1000 live bi rth. The program has a good scheme since it targets the uninsured women who are in their

pregnancy, maternity and childbed period and neonates up to 28 days . Implemented as a national program, the Jampersal is fully funded using the State Budget. However, the data from fields show

that the AKI and AKB remains high despite of the Jampersal program. The data is presented in table 1.

Table 1. Table of Absolute Mother Mortality Rate and Absolute Infant Mortality Rate before and after the Jampersal was

launched (Analysis to the Data Bank of the Ministry of Health of the Republic of Indonesia)

This fact sheet is developed based on the research conducted

by Aksara and Posyandu (integrated health post) volunteers in 4 villages , including Purwoharjo, Banjarharjo, Somongari , and Bagelen, in July 2012 to April 2013. The research involved 125 male and 237 female respondents and measured using the Towards the Good Quality Jampersal Cards . The research’s findings are

presented below: First, Information and Service Accessibility

The program is la cking of public awareness measures and this has effect to the people’s perception towards the program, they

are not aware of the program and developing prejudice in terms of additional fees and service quali ty.

Note : These research findings were submitted to the Heads of

Districts and Parliaments of Kulonporogi and Purworejo Districts on their hearing meetings in April 2013

The graph on the right pictures how the people understand the program. Al though 2/3 of the respondents claimed that they

know the program, fewer respondents claimed that they had received detailed information. This finding is acceptable since 65% of the respondents learnt about the program from the TV PSAs .

Aside from the PSA, the program was disseminated through village midwives to the pregnant women when they are having prenatal checks up and the posyandu volunteers when conducting

community meetings . The midwives and volunteers are not equipped with leaflets or guide books .

The Jampersal is available at the Puskesmas (Community Health Centres), midwives and hospitals that have been partnered up with the government. However, not all midwives and hospitals have MoU with the government. Another issue is that the community does not receive sufficient information on the places

where they can access the Jampersal service. Regional hospitals are the only organizations putting a sign showing that they provide the Jampersal service.

This low information access has effect to the service

accessibility. The program’s fund is not used optimally, as i t is

presented below: Table 2. The program’s fund use per region (Source: The Ministry of Health RI, 2013)

Second, Service Quality

As an extension of Jamkesmas (Health Care for the Poor), Jampersal only provides the third class (the lowest) health care s tandards for the users . Meanwhile, hospitals have limited third class wards and they are not able to accommodate all patients . As a result, many maternity women have to share wards with non -

maternity patients . Besides , the Jampersal users claim that the service they receive is not as fast as those not using the Jampersal .

Patient reference mechanism is found to be another factor

contributing to the patients overload. Many women come to hospitals to give bi rth al though they have their pregnancy checks up in the Puskesmas or midwives . The chart on the right shows the people’s preference on the service providers .

Third, Service Scope

The limited information disseminated to the community has resulted to the low quali ty that the Jampersal users receive. Four times Ante-Natal Checks (ANC) are deemed not sufficient by the community. The rules requesting the users to have their checks up following the established schedule have made them miss the service, particularly during the fi rst trimester. I t is i ronic since the service providers frequently complain about the community’s

awareness on the Prenatal Checks .

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To control bi rth and population, the Jampersal users are suggested to wear use Contraception after giving birth for long term. In reality, the numbers of long term Contraception users do

not increase after the Jampersal. Al though the program does not restrict the number of bi rths , the respondents claimed that they are not interested in having many children due to the high living costs (food, clothes and housing), health care costs and education. Other than that, the women who are in childbed period have two

options , i .e. using a good quality IUD but i t is expensive and they have to bear the cost themselves and using the provided IUD with low quality.

Fourth, complain mechanism

The community is reluctant to submit their complain ts in

the complaint box provided in the Puskesmas or hospital. 54.3% of them share their disappointment of using the Jampersal with their

family members or neighbours. 21% claimed that they reported their disappointment to the volunteers , yet their complain ts never go beyond the volunteers . The others prefer to keep silent. The

community is reluctant to submit their complaints di rectly since there is no clear complain me chanism and responses. This leads to the people’s disappointment which is shared among the communities.

“ We went to the

parliament to discuss our problems. But they did not

respond. We are very dissapointed. Maybe a

quote saying that people’s voice is less important

right?’

( YANI , VOLUNTEER)

Fifth, supporting system Voluntary and solidari ty are the factors that will support the

government programs which are implemented at the community

level . Community dues, social fund that is collected through community meetings , women groups at RT / village level are the social fund scheme that has been running well and contributing to

the finance. Desa Siaga (Alert Village) program has considerable potential for strengthening the community’s support to the heal th

interventions , including the Jampersal . Unfortunately, the Desa Siaga, which is a national program, does not receive adequate supports from both provincial and dis trict governments .

Similarly, the health post volunteers , who work voluntarily yet play very important roles , are the front lines of the health programs implementation at the village level . The volunteers , who

also act as intermediation agents , are the ones whom the community trusts to ask and share their problems about the health policy and programs. The volunteers often receive vi tuperation from the community members who are disappointed with the service quali ty that they have received.

Sixth, the Jampersal and gender issues

The diagrams above show that pregnancy and birth control are s till deemed as women’s affai rs . Men’s involvement in health

affai rs is very low. This confi rms a s tigma that pregnancy and birth control are the women’s responsibility. Pregnancy, child bearing, birth control and contraception are supposed to be the affai rs of

males and females. The men’s low awareness of bi rth control adds burdens to the women to think of and keep their reproductive health. Gender public awareness and education need to be given to everyone to reduce this inequality.

Besides, the Jampersal claim requires identi ty card and

residential letters . Some pregnant women are not able to access

the Jampersal because their identi ty cards are not issued in the area where they are currently residing and they do not have chance to propose residential letters (the women do not understand the

Jampersal requirements ). This problem was found both in Kulonprogo and Purworejo. The worst case is the teen pregnancy

case that keeps on increasing every year. The identity card requirement has prevented girls with unexpected pregnancy from accessing the Jampersal .

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Midwives have to deal with the limited number of veri fication officials. The Jampersal claims take three months to be disbursed and this has brought financial burden for the midwives

who have heavy workload, including health service provider, the health centre post advisor and an extension of the health department to disseminate their health programs. In addition, village midwives working in community health centres are responsible to manage the health centres .

What to do? Despite breakthroughs that Kulonprogo and Purworejo

districts have made, such as Provincial Health Insurance for

all communities, establishment of hospitals to provide single class service and MoU between the service providers and users on the childbirth cost, problems related to the Jampersal require real actions that the regional government

and the service providers should take, including: First, improvement of the Jampersal Public Awareness: To minimize wrong perceptions of the service providers and users , i t is important to: Provide clear and detailed guide books written in simple and

understandable manner. The books contain information on how

to access the Jampersal, services provided in the program, cost

details, reference mechanism, how the Jampersal relates to

other insurance schemes (Jamkesmas / health, Jamkessos /

social welfare and Jamkesda / health insurance provided by

regional government) including their providers and contact

details. These books are to be distributed to the newly-married

couples, volunteers and village government as the

intermediating agents of the government programs,

particularly health programs;

The public awareness should target wider audience including

pregnant women, men and women and implemented to RT

level;

The use of more appealing media, such as interactive dialogues,

films, leaflets, posters, banners, public signs and their

placement in front of hospitals, clinics, midwives clinics are

important to improve the service accessibility.

Second, improvement of the service accessibility and quality Accessibility to the Jampersal facilities. Medical personnel and

the health centre extensions should be accessible for the

communities to reduce mortality rate due to the delayed helps

for those living in remote areas and to ease transportation fee;

Cooperation with more hospitals, maternity clinics and

midwives should be initiated to allow more pregnant women

access the childbirth service;

Given that most mothers die at hospitals, the mechanism

reference and childbirth SOP need to be reviewed;

Improvement of facilities of the third class health standard or

establishment of single standard service is important to reduce

the refusal of the Jampersal patients. This measure

should be taken along with the improvement of the medical

personnel’ competencies so that they will be trained and

responsive in handling complication cases;

Establishment of the service quality standard without

discriminating the Jampersal patients from non Jampersal ones;

Establishment of costing standard according to the financial

capacity of each region through the Head of District Regulation;

The Jampersal administration mechanism and requirements

should be simplified;

Data update and prediction and analytical skills of the

personnel should be upgraded so that interventions to reduce

the mother mortality rate can be implemented in contextual

and measurable manner.

Third, Improvement of the service coverage Monthly prenatal checks including USG, if necessary. Through

regular pregnancy checks, the pregnancy can be monitored to

reduce mother and infant mortality risks.

Good quality contraception and Birth Control counselling after

the pregnancy should be highlighted so that each of community

members can develop a good family plan.

Targets of the Jampersal should be expanded to cover babies up

to 1 year old (complete immunization) and couples who are

trying to get pregnant.

Fourth, Development of complaint system

Strengthening community control over the Jampersal service quality so that the performance assessment will not be run in one way (not only for adminis trative system) Dissemination of

effective complaint mechanism, including responses to follow up the complaints . Fifth, Improvement of the supportive system

Gender education and awareness by encouraging men to

play roles and share responsibilities of reproductive health and good quali ty family Improve the Desa siaga and independent social mechanism to support the Jampersal program Strengthen roles of the intermediary volunteers and village officials through the improvement of the volunteers ’ capaci ty according to their tasks and responsibilities and rewards for the volunteers and officials.

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