IMPACT OF DECENTRALISATION ON THE DELIVERY OF SRH SERVICES

1. IMPACT OF DECENTRALISATION ON THE DELIVERY OF SRH SERVICES • AtashendartiniHabsjah, MA • Women’s Health Foundation • & CEDAW Working Group Indonesia (CWGI) • Indonesia • Satellite Session on Advocacy for Resource Mobilisation in Asia & the Pacific • Berlin, September 2009

2. Indonesia (Bogor District/West Java) The largest archipelago with 17,500 islands 33 Provinces, 370 Districts, Population : 225 million (2007) Pregnant women: 4.8 million MMR: 228/100,000 (2007) IMR: 34/1000 (2007) The CPR in research area is lower (57%) than the national CPR (60.3%).

3. RESEARCH QUESTIONS I Does decentralisation really: • Make the health system responsive to local SRH needs, particularly the fulfillment of the contraceptive needs of the poor women • Develop service delivery innovation and local adaptation of services • Improve inter-sectoral coordination and fewer levels of bureaucracy • Increase technical efficiency and improve quality of services from the user’s perspective • Promote greater accountability II How far the process of privatization of the Health sector (started in the early 1990s) undermine the public health system in the Bogor District? III What type of mechanism is provided for having free implants and IUDs? Did women who faced failure in implants and IUDs get “ back-up services” from the government?

4. FINDINGS (Survey) • Median age at first marriage is 19 years, but many were forced to be child marriage • Teenage married mothers: 35% • Low contraceptive prevalence rate: 57% (National 60.3%) • High drop-out rate: high transportation cost made no FP access • Poor households, poor FP access • Married adolescent’s knowledge about SRH is still low • Total reported deliveries: 107.989 (highest in West Java) • Deliveries helped by Midwives 51.1% and helped by TBAs 38.0% • Women helped by Midwives during delivery chose midwives for FP matters

5. Demographic Approach still used in the Decentralisation Era, NOT human rights approach as mandated by ICPD FINDINGS 1I • Although Decentralisation was introduced 5 years ago, no holistic SRHR framework has been developed • Decentralisation as a means to enhance the health system’s responsiveness to local needs, particularly the needs for contraception, was not fulfilled • Decentralisation has not improved access to SRH care and services, since no outreach to FP/contraceptive services were set up to serve the isolated and poor communities • Ad hoc mobilisation by some elite women/men during recruitment of potential acceptors to join the mass campaign for inserting implants or IUDs or tubectomy still used regularly (sweeping) • Coercion during recruitment of potential family acceptors still applied • There is no quality assurance during this mass campaign since in one day 300 clients are provided the services performance by 4 general physicians; without prior information on the procedure; not following medical procedures made several women suffer from complications

6. Access to contraceptive services and IEC in SRHR was not seen as development strategy FINDINGS 1II • During decentralisation, government FP fieldworkers decreased by half (1 person for 3 villages). As local government civil servants, they were asked to move to other departments. • No facility support (motorcycle and transportation fee for FP fieldworkers). • 1 public health for 3 villages • No institution is responsible for conducting women’s empowerment and SRHR program in the community so that they can make informed choices and good decisions • No capacity building in counseling skills for health • Most midwives, physicians and FP fieldworkers do not promote emergency contraceptive pills

7. FINDINGS 1V Privatisation of the health sector weakened the needed teamwork for effective service delivery • The humanpower at the lowest level of public health care still highly problematic: midwives and physicians who worked there in the morning have their own practices in the afternoon/evening. Many women who can pay out of the pocket preferred the private practice which provided better service. • No good referral system and coordination between public and private health facilities was established: many poor women who were in critical condition died in public transportation since they were sent from one hospital to another • The local poor women could only rely on those contraceptive methods which were free of charge, but only available on certain period time. No private practice would give FP service free of charge. • There is almost no inter-sectoral coordination

8. RECOMMENDATIONS • FP/contraceptive services should be provided in an SRHR framework and not using the targets to reach the 70% CPR. • Rebuild an understanding on FP/contraceptive services based on human rights by conducting capacity building training for politicians, parliamentarians and policymakers, and health providers in order to stop with the mass FP campaign. Promote patient rights charters and awareness raising on the rights of public to SRH information and services . • Fees for services is not appropriate in a district wherein more than 30% of the families are very poor. The high transportation cost to the public health centre should be anticipated by outreach activities by the staff. • Males in the community should not only support their wives to be acceptors, but they should themselves be acceptors too!!

9. RECOMMENDATIONS • As part of government accountability, monitoring and evaluation, as well as a complaints mechanisms, should be in place and conducted regularly. The community should be more involved in planning and implementation. E.g., holding public hearings, inviting public inputs on policies and programs. • Policy advocacy should be conducted to influence the more conservative politicians, parliamentarians and policymakers in order to prioritise family planning/contraceptive services in their development agenda and allocate budget in a more gender-sensitive manner • High-quality and sustained FP/contraceptive services should be integrated in the existing district health regulation on reducing maternal mortality rate