HEALTH SECTOR REVIEW
FERTILITY, FAMILY PLANNING AND
REPRODUCTIVE HEALTH
JULY 2014
1
AUTHORS:
GAVIN JONES
SRI MOERTININGSIH ADIOETOMO
2
Acknowledgments
The authors wish to thank Ms Nina Sardjunani, Deputy for Human Resource Development
and Culture at Bappenas, Prof Fasli Jalal, Head of BkkbN, and other resource persons from
the Ministry of Health, BkkbN, Johns Hopkins CCP, and Indonesian Midwives Association
(IBI) who provided valuable inputs, consultations and reviews to improve this report i 1 .
Special thanks goes to Dr Arum Atmawikarta, Mr. Ahmer Akhtar and Dr. Pungkas Bajuri who
coordinated all aspects of this study.
This report would not have materialized without the support of AUSAID (now DFAT) through
AIPHSS.
1
A list of names of resource persons and their affiliation is attached in the annex
3
Table of Contents
Acknowledgments ...................................................................................................................... 3
List of Tables ............................................................................................................................. 6
List of Figures ............................................................................................................................ 7
Abbreviations and Acronyms...................................................................................................... 8
Executive Summary ..................................................................................................................10
1.
2.
3.
Introduction: Population and Fertility Trends ......................................................................17
1.1.
Fertility and Family Planning issues ............................................................................18
1.2.
Fertility and marriage issues .......................................................................................19
Achievement So Far ..........................................................................................................23
2.1.
Fertility ........................................................................................................................23
2.2
Family Planning ..........................................................................................................23
2.3
Unmet need ................................................................................................................24
2.4
Contraceptive method mix ..........................................................................................29
2.5
Abortion rate ...............................................................................................................30
Remaining Challenges .......................................................................................................31
3.1
TFR has stalled since 2003.........................................................................................31
3.2
Regional and socio-economic variation in fertility and in unmet need for family
planning.................................................................................................................................31
4.
5.
3.3
Early marriage and teenage fertility .............................................................................32
3.4
Why is CPR stalling? A situation analysis in 15 Districts .............................................33
3.5
Situation analysis: from a study in 4 provinces and 15 districts. ..................................34
Strategic Issues .................................................................................................................37
4.1
Financing and method mix ..........................................................................................37
4.2
Improvement of equity of access.................................................................................37
4.3
Planning and budgeting: Lack of political commitment among Bupati or Walikota .......37
4.4
Capacity of BkkbN’s human resources........................................................................38
4.5
Family Planning Services ............................................................................................39
4.6
Issues of demand creation ..........................................................................................40
4.7
Contraceptive supply chain management issues ........................................................41
New and Emerging Challenges ..........................................................................................42
5.1
6.
Situation of family planning under the new JKN ..........................................................42
Policy Directions and Strategies.........................................................................................44
6.1
Key policy objectives...................................................................................................44
6.2
Assist the private sector - A bidan-focused strategy ....................................................46
6.3
Demand creation: Reinvigorate specific BkkbN programs ...........................................46
4
6.4
Meeting the unmet need of economically disadvantaged couples ...............................47
6.5
Balancing method mix through increasing long-acting method use .............................47
6.6
Strengthening contraceptive supply chain management .............................................47
6.7
Fostering more effective collaboration at the district level ...........................................48
6.8
Support for later marriage ...........................................................................................48
6.9
Meeting the reproductive health needs of the unmarried .............................................49
6.10 Financing of the family planning program ......................................................................49
7.
2019 Targets......................................................................................................................50
7.1
Fertility – Population Dynamics ...................................................................................50
7.2
Contraceptive Use- Balancing Method Mix .................................................................50
7.3
Reducing unmet need and increase in private sector use ...........................................50
7.4
Increase in quality assurance; Bidan competence and contraceptive supply chain
management .........................................................................................................................51
7.5
Adolescent RH - reducing teenage fertility ..................................................................51
7.6
Coordination among stakeholders and community participation ..................................51
7.7
Equity..........................................................................................................................51
8.
Program and Main Activities ..............................................................................................53
9.
Risks ..................................................................................................................................58
10.
Challenges .....................................................................................................................60
References ...............................................................................................................................61
Appendix Table 1. Changes in Singulate Mean Age at Marriage (SMAM) and in % females
ever married at ages 15-19 between 2005 and 2010, Indonesian provinces .............................63
Appendix Table 2. Projection of TFR 2010-2035 by Province. ..................................................65
Appendix 3 List of Individuals and Organizations Consulted .....................................................66
5
List of Tables
Table 1. Population Growth and Fertility, 2010 - 2014 ....................................................................... 23
Table 2. Family Planning Targets in Mid-Term Review of RPJM, 2010 - 2014.............................. 24
Table 3. Demographic Trends According to the Official Indonesian Population Projection ......... 45
6
List of Figures
Figure 1. Indonesia: Projected Total Population ................................................................................. 18
Figure 2. Indonesia: Dependency Ratio ............................................................................................... 18
Figure 3. Trend in TFR after Reaching 2.6, Various Countries......................................................... 21
Figure 4. Provincial Variations in Total Fertility Rates, 2012 ............................................................. 22
Figure 5. Trends in Unmet Need for Family Planning, 1991 - 2012 ................................................. 25
Figure 6. Percentage of Married Woman with Unmet Need for Family Planning by Age of
Women, IDHS 2012 ............................................................................................................... 25
Figure 7. Percentage of Married Women using Contraceptives by Method and Wealth Index,
IDHS 2012 ............................................................................................................................... 26
Figure 8. Percentage of Married Women who Want to Space or Limit Childbearing but not
using Contraceptives (Unmet Need), by Wealth Index, IDHS 2012............................... 27
Figure 9. Provincial Differences in Use of Modern Contraception and in Unmet Need for
Contraception.......................................................................................................................... 28
Figure 10. Short Term Methods Remain Dominant in Method Mix, 2007 - 2012........................... 29
Figure 11. Increasing Private Sector Services, 1991 - 2012 ............................................................. 30
Figure 12. Percentage of Teenagers Aged 15 - 19 Who Have Begun Childbearing ..................... 33
7
Abbreviations and Acronyms
ALOKON
Alat dan obat kontrasepsi (Contraceptive devices and drugs)
APBD
Anggaran Pendapatan dan Belanja Daerah (Local Revenue and Expenditure
Budget)
APBN
Anggaran Pendapatan dan Belanja Nasional (National Revenue and
Expenditure Budget)
Bappeda
Badan Perencanaan Pembangunan Daerah (Local Development Planning
Agency)
Bappenas
Badan Perencanaan Pembangunan Nasional (National Development
Planning Agency)
BCC
Behaviour Communication Change
BkkbN
Badan Kependudukan dan KB Nasional (National Population and Family
Planning Board)
BPJS
Badan Penyelenggara Jaminan Sosial (Social Security Agency)
BPS
Badan Pusat Statistik – Statistics Indonesia
CBR
Crude Birth Rate
CDR
Crude Death Rate
CPR
Contraceptive Prevalence Rate
CSCM
Contraceptive Supply Chain Management
CTU
Contraceptive Technology Update
DAK
Dana Alokasi Khusus (Special Allocation Fund).
DHS
Demographic and Health Survey
DinDikBud
Dinas Pendidikan dan Kebudayaan (Office of Education and Culture – local
level).
Dinkes
Dinas Kesehatan (Office of Health – local level).
FP
Family Planning
FS
Female Sterilization
GENRE
Generasi Berencana (Generation with Planning)
IBI
Ikatan Bidan Indonesia (Midwives’ Association)
IDHS
Indonesia Demographic and Health Survey
IEC
Information Education and Communication
IUD
Intra Uterine Devices
JKN
Jaminan Kesehatan Nasional (Universal Health Care)
JKN-KB
Jaminan Kesehatan Nasional Keluarga Berencana (Universal Health Care Family Planning)
JNPK
Jaringan Nasional Pelatihan Kesehatan (National Network of Health
Training).
KPAI
Komisi Perlindungan Anak Indonesia (National Commission on Child
Protection).
KUA
Kantor Urusan Agama (Office for Religious Affairs)
MOED
Ministry of Education
8
MOH
Ministry of Health
Musrenbang
Musyawarah Perencanaan Pembangunan (Discussions on Development
Planning).
MWRA
Married Women of Reproductive Age
NGO
Non-Government Organization
NRR
Net Reproduction Rate
NTT
Nusa Tenggara Timur
OBGYN
Obstetrics and Gynaecology
P2KP
Jaringan Nasional Pelatihan Kesehatan (Network of Health Training at the
Province level).
P2KS
Jaringan Nasional Pelatihan Kesehatan (Network of Health Training at the
District level).
PBI
Penerima Bayaran Iuran (Recipients of Premium Insurance paid by the
Government)
Pemda
Pemerintah Daerah (Local Office of the Government)
PerPres
Peraturan Pemerintah (Government Regulation).
PLKB
Petugas Lapangan Keluarga Berencana (Family Planning Field Workers).
POGI
Persatuan Ahli Obstetri dan Ginekology (Association of OBGYN)
PPKBD
Pembina Program Keluarga Berencana Daerah (Local Family Planning
Program Officer)
PPM
Pemenuhan Permintaan Masyarakat (Community Demand Fulfillment).
Puskesmas
Pusat Kesehatan Masyarakat (Community Primary Health Care).
RH
Reproductive Health
RPJM2
Rencana Pembangunan Jangka Menengah 2 (Mid-term Development Plan
2).
RPJM3
Rencana Pembangunan Jangka Menengah 3 (Mid-term Development Plan
3).
RPJMN
Rencana Pembangunan Jangka Menengah Nasional (National Mid-term
Development Plan).
SDKI
Survey Demografi dan Kesehatan Indonesia (see IDHS).
SDP
Service Delivery Point
SJSN
Sistem Jaminan Sosial Nasional (National Social Security System)
SK
Surat Keputusan (Letter of decree)
SKPD-KB
Satuan Kerja Perangkat Daerah – Keluarga Berencana (Family Planning
Implementers at the District Level)
SMAM
Singulate Mean Age at Marriage
SUPAS
Survey Penduduk Antar Sensus (Intercensal Population Census)
Susenas
Survey Social Ekonomi Nasional (National Social and Economic Survey)
TFR
Total Fertility Rate
UN
United Nations
9
Executive Summary
Indonesia is benefiting from a slowing of rates of population growth and from the
“demographic window of opportunity”, the change in age structure resulting from earlier
declines in fertility. This window will widen further in the next two decades, especially if the
total fertility rate can be lowered to replacement level, i.e. 2.1. However, Indonesia’s fertility
rate appears to have risen over the latter part of the past decade to its level of a decade ago
– about 2.5. This is because contraceptive prevalence has levelled off at around 62 per cent,
the method mix has shifted toward methods with higher discontinuation, and age at marriage
has fallen, leading to earlier initiation of childbearing.
In the past, Indonesia’s fertility rates fell in tandem with rising levels of economic and social
development (rising income levels, urbanization, educational development, and declining
infant and child mortality), and assisted by a vigorous family planning program. During the
last decade, though, continuing economic and social development has not led to reduced
fertility rates, and the family planning program has found it hard to adapt to new challenges,
including those resulting from regional autonomy.
The key challenges facing revitalization of the family planning program are (1) the need for
effective collaboration between BkkbN, Depkes, and the private sector at the national level,
and between these actors and local government at the kabupaten/kota level; (2) The need to
develop effective mechanisms for the family planning program under the new universal
health care program (JKN).
There is a need to focus on ensuring that the economically disadvantaged are not blocked
from practising contraception through lack of knowledge, lack of access to the methods they
need or inability to pay for contraception. The method mix has been shifting in favour of
short-term methods: the injectable and the pill accounted for 79 per cent of methods used in
2012, compared with 17 per cent for the IUD, implant and sterilization combined. If this ratio
reflected women’s preferences, then these should be respected. However, there is
considerable evidence that it reflects, instead, the preferences of providers. At present, the
private sector is providing 72% of contraceptives, provided mainly by bidan. Many of these
bidan are employed in the government sector, but also operate their private practice. In
private sector practice, there is an emphasis on short-term methods, partly because these
are more remunerative for the provider. Many bidan are also not confident in inserting IUDs
and implants.
The method mix disadvantages many lower-income users. In terms of both demographic
impact and the need to provide users the most effective and acceptable method, effective
promotion of longer-acting methods is needed, and training of bidan to increase their skill in
providing longer-term methods is also urgent. The government must be involved in this, as
the private sector cannot be relied on to play this role.
The implementation of the JKN will provide further challenges, as well as opportunities, for
the family planning program. The key issues are as follows:
1.
The JKN, as a social insurance system which aims to pool risk, benefits from large
numbers of healthy members who do not need to utilize health services. In contrast, the
family planning program focuses on the need to recruit increasing numbers of acceptors
from the ranks of those facing unmet need for contraception. The system of capitation
10
will mean less profit for providers, and hence a disincentive for increasing contraceptive
prevalence rates.
2.
There needs to be a clear explanation of who has to pay for contraceptives and who
gets them free. At present, 72% of contraceptive users pay out of pocket to private
sector providers, while BkkbN provides the contraceptives free for those obtaining them
from public clinics. If BkkbN has to provide free contraceptives for all users, the family
planning program will depend on government funding indefinitely.
3.
The role of the bidan and their remuneration for providing services, and the regulation
that those who provide family planning services as Klinik Pratama have to develop
networking under the coordination of a doctor, needs to be given careful consideration.
Promotion of later marriage is a key task facing the BkkbN, both because of its demographic
implications and its many other dimensions. Early marriage has played an important role in
the stalling of fertility decline in Indonesia, because it brings childbearing forward in time,
thus raising period fertility rates. The high incidence of teenage marriage reflects a situation
in which many such marriages are not desired by those entering the marriage, either
because they result from unintended pregnancies, and marriage appears to be the only
socially acceptable solution; or because they result from pressures to marry from
conservative parents. There is therefore a human rights dimension - nobody should be
forced to marry a partner not chosen by them at an age not chosen by them; and a
reproductive rights dimension – some of those who need reproductive health information
and contraceptive services have restricted access to them because of existing laws and
regulations. The reproductive health issues of adolescents are some of the most serious
issues facing Indonesia.
For population, family planning and reproductive health, the key policy objectives, expressed
very broadly, are as follows:
1.
Lower the fertility rate to replacement level as soon as possible, in the face of still
relatively high desired family size, while respecting the rights of individuals and couples
to have the number of children they desire.
2.
Promotion of a rising age at marriage in the interest of the wellbeing of young people
(especially young girls) whose freedom to choose their partner must be promoted, and
who face health consequences from early childbearing. A rise in age at marriage will
also lead to lower fertility.
3.
Revitalization of the family planning program, in order to meet the reproductive health
needs of the population and lower the level of unmet need for contraception.
With regard to the first objective, it is expected that continuing success in economic and
social development (rapid economic growth, further lowering of mortality rates, urbanization,
further increase in educational enrolment ratios, growth of formal sector employment) will
play a major role in delaying marriage and lowering desired family size. However, crucial as
they may be, planning for these developments lies outside the scope of the present report.
The two key levers for achieving the first objective that are relevant to the present report are
to assist more of the couples with an unmet need for contraception (currently 11% of
couples) to practice contraception, and to promote a rise in the age at marriage.
11
In seeking to raise age at marriage, the main emphasis should be on reducing teenage
marriage, and enforcing the legal minimum age at marriage. In cases where marriage results
from premarital pregnancy, it reflects a need for family planning information and services to
be available to the unmarried. In cases where the marriage occurs when the girl is aged
below 16, it reflects the need to enforce the minimum legal age at marriage. In cases where
the marriage is arranged without the consensus of the bride, it reflects the need to enforce
human rights legislation.
The third objective, revitalization of the family planning program, is aimed at sharply lowering
the level of unmet need for family planning through more focused and efficient provision of
family planning information and services. The strategy should be to clearly delineate the
respective roles of the BkkbN, Kemenkes and local government in (1) providing public sector
family planning/reproductive health information and services, and in advocacy activities
related to such activities; (2) supporting the private sector and community groups involved in
provision of contraceptive supplies and services; (3) promoting contraceptive use by couples
in planning their families (demand creation).
The revitalization of the family planning program will lead to a reduction in the level of unmet
need for family planning, enabling those wishing to avoid births that are unwanted (at
present, or at all) to achieve their objectives. There will be wider benefits as well. A
revitalized family planning program would contribute to lowering the maternal mortality rate
in two ways: avoiding some pregnancies that would have resulted in unsafe induced
abortions, and avoiding some births that would have occurred in circumstances with an
above-average chance of delivery complications that could not be well met by available
health facilities. It would also enable more women to enter the workforce, rather than
bringing up babies they had not wanted.
The demographic targets of the RPJMN 2015-2019 should be modified in light of the latest
understandings of fertility trends and their likely trajectory, for consistency with the recently
issued official population projections and given the policies to be discussed below. The
longer-term target consistent with the population projections would be that in 2025, TFR
would be 2.1, CBR 15.6, CRD 7.4 and the annual rate of population growth would be 0.82
per cent. These targets can be considered conservative; the resumption of fertility decline
could well be faster, and TFR=1 could be reached much sooner if most of the unmet need
for contraception is met; long-term family planning methods are emphasized more;
communication efforts to reduce early marriage succeed; and economic and social
development, especially further increase in educational enrolment rates, continues.
Issues in revitalizing the family planning program include the relative roles of BkkbN,
Depkes, local government, the private sector and NGOs, particularly at the kabupaten level.
The limited availability of suppliers – bidan and doctors – in puskesmas is an issue for the
promotion of longer-term methods. The contraceptive supply chain – from accession to
storage and distribution to the final users - needs to be effectively managed. The role of
NGOs in providing RH/FP services needs to be expanded, and community participation in
family planning/reproductive health promotion revived. There is a role for revived IEC efforts,
for which BkkbN was well known in the past. The basics need to be stressed: the benefits of
delayed marriage and small family size for mother and child health, for children’s
opportunities for continued education, for women’s opportunity for self-development.
Training of staff is needed to use a life cycle approach to providing appropriate messages in
12
promoting contraception for spacing or limiting. An intensive IEC strategy for adolescent
reproductive health is needed, through both formal and non-formal institutions.
In brief, the following strategies for revitalizing the family planning program are
recommended:
1.
Assist the private sector to better meet the needs of the 72% of users it serves
2.
Assist the BkkbN to better serve the needs of the poorer sections of the community for
whom the cost of contraceptives is likely to be an obstacle to use
3.
Reinvigorate BkkbN’s postpartum, post-abortion and workplace-based family planning
programs
4.
Facilitate cooperation between BkkbN, Dinkes and Pemda at the district level
5.
Follow a bidan-focused strategy for ensuring the effective provision of family planning
services of high quality.
6.
Mount a communications program through BkkbN and supportive local government
agencies, workplaces, schools and community groups to foster later marriage
7.
Through a communication program and provision of services, meet the reproductive
health needs of the unmarried
Some more detail on some of these strategies follows:
A Bidan-Focused Strategy
As most private sector services are provided by bidan, strengthening the role of the private
sector should be focused on strengthening the role of bidan. Of the 135,000 midwives in
Indonesia, approximately 40,000 provide family planning services, of whom about 10,000 to
12,000 belong to an elite accredited group called Bidan Delima, who provide a package of
high quality MCH and family planning services in the private sector. The strategy should be
to strengthen and enlarge the group of Bidan Delima and then other licensed midwives to
provide a wide range of contraceptives, including longer-acting methods, by expanding the
range of training opportunities for clinical skills and hands-on experience, including
interpersonal counselling techniques. One of the objectives of this training should be to
eliminate the current evident provider bias favouring injectables.
Fostering Demand
Revitalize understanding of the benefits of having small family size through IEC and BCC,
through the following key messages:
•
Will improve mothers and child’s health
•
With small number of children, parents will be able to meet basic needs of their children,
and invest more in their educational development
•
In the long run, quality of next generation will be better than the previous generations.
•
This will help poverty reduction.
13
The main challenge is the shortage of fieldworkers (PLKB) who were formerly the spearhead
of communication efforts. This problem can be overcome by (1) arranging for bidan who
have completed PTT duties to double up as motivators; (2) Working with the Dinas
Kesehatan to develop health promotion working groups which include family planning
promotion.
Meeting the Unmet Need of Economically Disadvantaged Couples
1.
Communication about use of contraceptives according to life cycle approach (spacing or
limiting). Ensure that information and services relating to long-acting methods are
available.
2.
Reduce side effect or health related problems resulting from contraceptive use, through
more effective counselling and increased availability of trained personnel.
3.
Provide access to contraceptive services which are affordable to the poor
Balancing Method Mix through Increasing Long-Acting Method Use
1.
Counseling on the benefit of using long-acting method, especially for users who plan to
limit family size. Ensure that information and services relating to long-acting methods
are available.
2.
Increasing the number of bidan who are qualified to insert IUD and Implant
Strengthening Contraceptive Supply Chain Management
1.
Improve field data on kinds of contraception needed, supported by recording and
reporting activity, checked against PPM data from BKKBN.
2.
Transparent provision and purchase of contraceptive supplies using e-catalogue. Cease
receiving all products at the central warehouse prior to distribution to provincial level.
3.
Move from target-based to evidence-based methodology to determine contraceptive
requirements; keep accurate records of contraceptive supply availability so that
stockouts do not occur.
4.
Improving storage warehouses consistent with standards needed to maintain the quality
of contraceptives. Consider bypassing district level in delivering contraceptives to SDPs.
5.
Allocate funds for management of the warehouses.
6.
BkkbN allocate funds for ‘handling costs’ and transportation and ensure that
contraceptives reach the clients who need them.
Fostering More Effective Collaboration at the District Level
1.
Comply with the Health Minister’s instruction that Dinkes at the Kabupaten/Kota Level
have to assist SKPD KB in implementation of FP program.
2.
Strengthen advocacy to Bupati and Walikota about the importance of the family
planning program for the future generation, by building a solid team consisting of SKPD-
14
KB, Dinkes, Bidan, Camat, and community leaders to obtain commitment for the family
planning program.
3.
Strengthen the involvement of SKPD-KB in social development planning (education,
health) at the Kabupaten level to include the FP program, and so ensure budget
allocation for family planning activities.
4.
Strengthen capacity of the SKPD-KB at the Kabupaten/Kota level to identify issues, set
priorities, and conduct planning and budgeting for the district family planning program.
Strong and accurate program planning and budgeting with supporting argumentation is
needed to convince the Pemda of the importance of allocating a budget for family
planning.
5.
Guidance and technical support by national and provincial government to increase the
capability of SKPD-KB to carry out their duties.
Support for Later Marriage
1.
Advocacy to executive, religious and community leaders on the reasons to delay
marriage
2.
Activate the enforcement of the minimum marriage age in the marriage law, especially
the minimum age of 16 for girls.
3.
Enforcement of regulations to keep children in school longer and facilitate this through
fellowships for poor students (available through MOED).
4.
IEC to parents and children to delay marriage to benefit fully from educational
opportunities and avoid unintended pregnancies and unsafe abortion that is hazardous
to maternal mortality.
Meeting the Reproductive Health Needs of the Unmarried
1.
Support the GENRE program which assists young people to pursue quality living and
avoid risky behavior including pre-marital sex.
2.
Work with NGOs to meet the reproductive health needs of youth.
3.
Strengthen the coordination between government and partner (NGO).
Financing of the Family Planning Program
1.
Need for MOU between BkkbN and Ministry of Interior about financing of the family
planning program at the regional level
2.
Consideration should be given to disbursing APBN funds directly to the kabupaten/kota
level. This would require appropriate monitoring and evaluation mechanism, and
technical support for SKPD-KB to develop regular program planning and budgeting.
3.
The DAK (special allocation budget) - a central government contribution to fund specific
priority activities at kabupaten/kota level, gives priority to lagging regions with relatively
poor fiscal capacity, but with good potential to carry out the programs. The budget is
usually used for infrastructure such as buildings, vehicles, IUD kits, etc. The utilization is
15
often not optimal because of lack of operational funds or diversion to other uses;
moreover, program needs are often not for infrastructure, but for operational expenses.
The Pemda has to put aside counterpart funds amounting to 10 percent of the total
DAK. This reduces the funds which should be able to be used for operational expenses
of the family planning program.
4.
It is recommended that for the kabupaten/kota where infrastructure needs have been
met, the DAK budget could be used for operational aspects of the family planning
program including for training of bidan, contraceptive supply etc.
16
1. Introduction: Population and Fertility Trends
Indonesia has profited greatly from the reduction in fertility rates that was achieved over the
1970s, 1980s and 1990s. This decline led to a near-cessation of growth of the school-age
population, thus facilitating the considerable increase achieved in educational enrolment
rates, slowing the increase in the burden of numbers on the health care system, and slowing
overall population growth, thus ameliorating the environmental pressures that have
accompanied Indonesia’s economic development.
A popular way of conceptualizing the impact of changing age structures that result from
steady declines in fertility is through the term “demographic bonus” or “demographic window
of opportunity” – meaning the favourable trends in the proportion of working age population
in the total population. Such trends facilitate, but do not ensure, more rapid economic
development through improvements in human capital and higher levels of per capita
production. Indonesia made fairly effective use of its demographic window of opportunity,
which happily is expected to continue widening over the coming two decades.
There is, however, one factor marring this generally favourable picture: namely, the stalling
of fertility decline over the past decade. Whereas in 1985, Indonesia’s fertility was well below
that in Malaysia, India, Bangladesh and Vietnam, by 2010 all those countries had lower
fertility than Indonesia. The stalling of Indonesia’s TFR at 2.6 (half a child per woman higher
than replacement level fertility) means that total population is growing more rapidly than had
been expected, the school-age population is increasing, thus providing greater challenges in
achieving 9 years compulsory education and moving to 12 years’ compulsory education, and
the larger numbers of births increases the challenge in providing for the health care needs of
the population.
The exact trend of fertility since 2000 is a matter of considerable controversy. The reference
to a stalling of TFR at about 2.6 compares the estimated figure from the 2002 Demographic
and Health Survey (DHS) with the estimated figure for the 2012 DHS. However, careful
analysis of what happened since the 1990s suggests that TFR may have actually reached a
low of about 2.2 in 2002 and risen to about 2.5 in 2011 (Hull, forthcoming). The data are not
robust enough to be totally sure about this. What is clear, however, is that the fertility decline
experienced during the 1990s has not continued in the present century; fertility in 2012 was
barely different from its level in 2002.
If fertility decline can be resumed quickly, the scenario for future total population and its age
structure (reflected in dependency ratios) will be greatly affected. Figures 1 and 2 compare
trends in the official population projections released in January 2014 with those derived from
the latest - 2012 - United Nations projections. The United Nations projections show the
alternative paths of total population and of dependency rates depending on whether fertility
increases slightly from its present levels (the assumption in the high projection), declines to
replacement level by the early 2020s (the medium projection) or declines rapidly to levels
well below replacement level (the low projection). The official Indonesian projection is close
to the UN medium projection. Comparing the high and medium projections, the trajectory of
fertility could make a difference of about 49 million in the total population by 2050, and the
difference between a dependency ratio rising from a low of 0.47 in 2020 and one reaching a
low of 0.45 in 2025and remaining low for two decades after that.
17
Figure 1. Indonesia: Projected Total Population
Thousands
Total Population ('000) - Indonesia
400
Historical
Official
Indonesian
Projection
350
United Nations
Population
Projection:
300
250
High Variant
200
Medium Variant
150
2050
2045
2040
2035
2030
2025
2020
2015
2010
2005
2000
1995
1990
1985
1980
100
Low Variant
Figure 2. Indonesia: Dependency Ratio
1,20
Indonesia - Dependency Ratio
(0-14 + 65+)/(15-64)
1,00
0,80
0,60
Historical
Official
Indonesian
Projection
United Nations
Population
Projection:
High Variant
0,40
0,20
Medium
Variant
Low Variant
0,00
1.1. Fertility and Family Planning issues
Indonesia has a valid interest in achieving replacement level fertility. Even if this is achieved
by the early 2020s, Indonesia’s population will still increase by about 86 million, or 36 per
cent, from its 2010 figure before levelling off well past mid-century,
mid century, as a result
res of population
momentum.2 The key issue for population planning and family planning in Indonesia is to
ensure that this macro goal of lowering the fertility rate is consistent with the goal of enabling
couples to achieve their desired family size and ensure
ensure their reproductive health. The fertility
goal should not be allowed to override these other goals. Are the two goals consistent?
2
This is based on the United Nations medium population projection; the official Indonesian population
projection does not go beyond 2035, in which year the population is expected to be still growing.
g
18
From one perspective, there may seem to be a conflict between them. After all, the average
expressed desired family size of Indonesian women is 2.8 children (married women) or 2.6
(all women) (DHS 2012), which if attained by all women would result in fertility above the
nationally desired level. However, it must be kept in mind that some women do not marry,
and some are unable to achieve their fertility desires because of marital dissolution,
infecundity or sub-fecundity. Therefore an average desired family size of 2.8 among married
women will not lead to a fertility level as high as TFR of 2.8. Moreover, as infant and child
mortality declines further, the “replacement” and “insurance” motives for having more
children will weaken. Desired family size can change, and could be expected to decline
somewhat as Indonesia reaches higher levels of economic development; social science
literature suggests that in general, socio-economic development is strongly related to fertility
decline, though institutional and cultural factors also play a role, as can a well structured
family planning program (Bryant, 2007; Robinson and Ross (eds), 2007). It is not
unreasonable to expect that if average age at marriage in Indonesia can be raised from its
current levels, and those couples with an unmet need for contraception can be enabled to
use contraception, fertility can be brought down to replacement level without any violation of
reproductive rights.
1.2. Fertility and marriage issues
It has to be conceded, however, that Indonesian fertility trends over the past decade suggest
that there are factors influencing Indonesian marriage and fertility that are working against
the usual relationship between fertility and socio-economic development. Rising school
enrolments have led to increasing enrolment rates in Indonesia for both males and females,
and the proportion of the Indonesian population living in urban areas has risen considerably.
Such trends are usually associated with delays in marriage and declines in fertility. But this
has not been the case in Indonesia in recent years. The factors leading to declining marriage
and a rise in fertility are not well understood. Therefore the fact that international experience
suggests that further improvement in Indonesia’s socio-economic indicators should lead to
increases in age at marriage and declines in fertility cannot be taken as evidence that these
associations will necessarily hold in Indonesia as well.
While in most Asian countries, average age at marriage for both women and men has been
steadily rising, in Indonesia, as noted above, there has been a surprising trend toward earlier
age at marriage since 2005 (Hull, forthcoming). Early marriage has played a very important
role in the stalling of fertility decline in Indonesia, because it brings childbearing forward in
time, thus raising period fertility rates. This effect on fertility rates occurs even if the couple
do not end up having any more children than if they had married later.
The trend to earlier marriage in Indonesia is not easy to explain. However, many observers
think a key element may be increased religiosity and participation by more young people in
religion-based social groups which foster early marriage with co-religionists, and the
prevalence of messages favouring early marriage and family formation in popular media
programs. If so, the trend is unlikely to continue unabated, particularly in the face of
continuing extension of average years of schooling. But much will depend on whether
alternative, convincing messages favouring delays in marriage are competing in the
marketplace of ideas.
19
The concerns about continuing high levels of teenage marriage in Indonesia relate not only
to their effect in fostering high fertility; there are also other major issues associated with such
marriages: human rights issues in the case of marriages where the girl had no say in the
choice of husband; issues of implementation of law in the case of marriages below the legal
age of 16; issues about the need for reproductive health education and provision of
contraception to sexually active adolescents in the case of marriages resulting from teenage
pregnancy (see Utomo and McDonald, 2009).
The health risks of early childbearing are faced both by those becoming pregnant outside of
marriage and by those married at an early age for other reasons, who are likely to have their
first child at an early age. These multi-faceted implications of early marriage pose
considerable challenges to policymakers in Indonesia
The key planning issues relating to fertility in Indonesia, then, include the uncertainty about
future trends in fertility if no major interventions to affect it are planned; and the likely efficacy
of different interventions. Briefly, on the first of these, the experience of other countries after
reaching a TFR of 2.6 illustrates the dilemma of predicting what will happen to fertility in
Indonesia. Figure 3 shows the trends in fertility in a number of comparator countries up to 10
or 20 years after fertility in these countries had fallen to 2.6, compared with what has
happened in Indonesia to date, and the projections of what will happen in Indonesia
according to the official Indonesia population projection. Clearly, Indonesian trends differ
greatly from most of these countries, which include some of Indonesia’s neighbours as well
as some other Muslim-majority countries. In many of them, the decline from a TFR of 2.6 to
replacement level occurred in less than 10 years, and in some cases fertility continued to
decline thereafter to well below replacement level 15 years after TFR of 2.6 was first
reached. Only in Sri Lanka was TFR after 15 years as high as it is assumed to be in
Indonesia (around 2.3). In the others, the TFR ranged from 1.5 to 2.1. The official Indonesian
population projections (as well as the United Nations medium projection) assume a very
slow decline in fertility toward replacement level, which in the official projections will not be
attained until 2027. While this may well be the case, there is a real possibility that fertility will
turn down much more rapidly as a result of socio-economic development trends, along with
revitalization of the Indonesian family planning program.
There are considerable regional variations in fertility (see Figure 4). Contrary to the situation
a decade ago, no Indonesian provinces have fertility below replacement level. Ten provinces
have a TFR of 3.0 or higher. These are mainly less populous provinces, seven of them with
a population below 3 million, and among them only Sumatra Utara has a population
exceeding 5 million. Their total population of 34 million is 14 per cent of the Indonesian
population. Thus the contribution of these higher fertility provinces to Indonesia’s population
growth is only modest.
20
Figure 3.. Trend in TFR after Reaching 2.6, Various Countries
ountries
2,6
Indonesia
2,4
Sri Lanka
2,2
Myanmar
2
TFR
Malaysia
1,8
Tunisia
1,6
Iran
1,4
Thailand
1,2
Vietnam
1
South Korea
0
5
10
15
20
Years
Source:
ource: Derived from United Nations, Department of Economic and Social Affairs, Population Division
(2013), World Population Prospects: The 2012 Revision,, DVD Edition. For Indonesia, after 10 years
beyond reaching 2.6, the trend is based on the official population projections.
The stalling of Indonesia’s fertility decline discussed earlier has resulted in the population
growth rate increasing from 1.44 percent per annum during 1990-2000
1990 2000 to 1.49 percent per
annum during 2000-2010
2010 (BPS, 20113). The RPJMN target for fertility (TFR) in 2019 is 2.3,
and Bappenas envisages achievement of a TFR of 2.1 (NRR=1, or replacement level) in
2025. In considering what policies are needed in order to lower fertility, the proximate
determinants of fertility must be kept in mind (see Bongaarts, 1978), as any policy can only
influence fertility through these proximate determinants. They are:
a) Proportion married
b) Contraceptive use
c) Abortion
3
BPS, 2011, Pertumbuhan dan Persebaran Penduduk Indonesia, Hasil Sensus Penduduk 2010,
2010 page 8.
21
Figure 4. Provincial Variations in Total Fertility Rates, 2012
Papua Barat
Sulawesi Barat
Papua
NTT
Maluku
Sulawesi Tengah
Maluku Utara
Kalimantan Barat
Sulawesi Tenggara
Sumatera Utara
Riau
Kalimantan Timur
Kalimantan Tengah
NTB
Sumatera Selatan
Sumatera Barat
Aceh
Lampung
Indonesia
Gorontalo
Sulawesi Selatan
Sulawesi Utara
Kepulauan Riau
Bangka Belitung
Kalimantan Selatan
Banten
Jawa Tengah
Jawa Barat
Bali
Jawa Timur
DKI Jakarta
Jambi
Bengkulu
DI Yogyakarta
3,7
3,6
3,5
3,3
3,2
3,2
3,1
3,1
3,0
3,0
2,9
2,8
2,8
2,8
2,8
2,8
2,8
2,7
2.6
2,6
2,6
2,6
2,6
2,6
2,5
2,5
2,5
2,5
2,3
2,3
2,3
2,3
2,2
2,1
0,0
1,0
2,0
3,0
4,0
5,0
Source: Indonesian Demographic and Health Survey 2012
TFR by province from the official projections are shown in Appendix Table 2
22
2. Achievement So Far
2.1. Fertility
The targets set in the RPJM 2009-2014 were to reduce the TFR from an estimated 2.6 in
2009 to 2.1 in 2014, and the population growth rate from 1.3% per annum to 1.1 per annum
over the same period. Teenage fertility indicated by Age Specific Fertility Rate at age 15-19
was to be reduced from 51 to 30 in 2014, and the median age at marriage was to be
increased from 19.8 to 21. It was noted that regional variation remained high. Given the
trends in teenage marriage that have become clearer since these targets were set, none of
the targets are likely to be achieved. Table 1 shows the conditions in 2007 and 2012, the
target for 2014, and Bappenas’ comment at the time of the mid-term evaluation of RPJM.
Table 1. Population Growth and Fertility, 2010 - 2014
Population
growth rate
Condition
2007
1.3 a)
Condition Target
2012
2014
1.49 c)
1.1
TFR
per 2.6 b)
2.6 d)
woman 15-49
Teenage
Correction
48 d)
Fertility (ASFR 51 (author)
15-19)
per
1000
teenagers
Median Age at 19.8 b)
20.4 d)
marriage- (yrs)
SMAM
22.5
22.2
(Singulate
Mean Age at
Marriage (yrs)
Regional variations remains high
• 2000-2005 (a) Supas 2005, b) IDHS
d) IDHS 2012
2.1
30
21
Need to do
Work
hard,
strategy
new
Work
hard,
new
strategy
Efforts should be
continued to increase
Age at marriage
Efforts should be
continued
Focus on increasing
SMAM
through
increase in education
2007; c) 2000-2010, Census, 2010
Source: Bappenas, 2013. Evaluasi Paruh Waktu (Midterm Evaluation) of RPJM 2009-2014.
2.2 Family Planning
The contraceptive prevalence rate has risen little since it reached a level of 60% (any
method) and 56.7% (modern methods) in 2002. In 2007 it was 57.4% if only modern
methods are considered, and 61.4% if traditional methods are included, and in 2012 57.9%
for modern methods or 61.9% for all methods including traditional methods. The method mix
has been shifting in favour of short-term methods: 23.5% of users are using the pill and
55.1% the injectable. In terms of both demographic impact and the need to provide users the
most effective and acceptable method, it would be desirable to have a greater proportion of
long-acting methods such as the IUD, implants and sterilization.
The targets for family planning in the midterm review of RPJM are shown in Table 2. The
final column presents the comments included in the mid-term review about strategies and
degree of difficulty faced in achieving these targets.
23
Table 2. Family Planning Targets in Mid-Term Review of RPJM, 2010 - 2014
Condition 2007
Estimated
Actual 2012
Target 2014
What to do
CPR, Modern
Method
57.4 b)
57.9 d)
65.5
Hard to achieve
Unmet Need
9.1 b)
Revised 13
(author)
73.6% use short
term method
11.4 d)
5.0
Continue the
hard work
Very slight
increase in FS*
and implant
73% private d)
23% public
Balanced method
mix
Hard to achieve
Balancing
Method Mix
Source of Supply
•
69% private
22% public
Empower private
sector?
2000-2005 - b) IDHS 2007, c) 2000-2010 – Census 2010, d) IDHS 2012
*FS –Female Sterilization
Source: Bappenas, 2013. Evaluasi Paruh Waktu (Midterm Evaluation) of RPJM 2009-2014.
2.3 Unmet need
Unmet need for contraception in Indonesia has been declining over time (see Figure 5). It is
not particularly high compared with many other countries (Jones, 2012). However, it is high
enough so that it can be considered a major reproductive health issue, as some of those
whose needs are not met are likely to have unwanted pregnancies, to practice unsafe
abortion, or to give birth to children who are likely to be neglected or abused. Reducing
unmet need by half, from the 2012 figure of 11% to 5%, would have important benefits in
these respects, as well as making a substantial contribution to lowering the fertility rate
towards the target replacement level. Unmet need means that the demand for contraception
is there, but information and services are lacking, or perhaps the cost of known methods is
considered too high. In theory, universal access to contraceptives means zero unmet need,
although in practice unmet need can never be totally eliminated. However, the aim of
reducing unmet need to 5% within a short time period is not unrealistic, even if it does not
quite meet the MDG5b: “achieve, by 2015, universal access to reproductive health”.
24
Figure 5. Trends in Unmet Need for Family Planning, 1991 - 2012
18
16
17
15
Percentage
14
14
12
13
13
11
10
8
6
4
2
0
1991
1994
1997
2002/3
2007
2012
Source: IDHS, 2012
Note: Figures in the above chart use the revised definition of unmet need (IDHS, 2012, page 96).
As shown in Figure 6, among the younger age groups, unmet need is mainly for spacing,
whereas among women from age 35 and up, it is mainly for limiting; in other words, their
desired family size has been reached, but they are not practising contraception. The fact that
unmet need for spacing is dominated by young couples below 30-34 years may reflect the
effect of early marriage and lack of awareness about the importance of family planning.
Figure 6. Percentage of Married Woman with Unmet Need for Family Planning by Age of
Women, IDHS 2012
18
16
15,3
14
Percentage
12
10
For Spacing
8
6
For Limiting
6,3
4
2
0
0,9
0,4
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Source: IDHS, 2012
Other information from the IDHS is very important in indicating inequities in access to family
planning. Figure 7 shows the percentage of married women using different contraceptive
methods by wealth index (from the lowest to the highest wealth quintiles). The lowest wealth
quintile is notably underrepresented in use of two of the long-acting contraceptive methods –
female sterilization and IUD – though they have higher proportions using the other longacting method – implants. Adding together the use of the three long-acting methods, the use
of implants by the poor does not make up for their low use of the other methods; overall, the
25
use of long-term
term methods by the highest wealth quintile (29.8%) is double that by the lowest
wealth quintile (14.7%).
%). This seems to reflect an inequity in access to different methods of
contraception; it is hard to imagine that the poor really want to rely on short-term
short
methods to
a much greater extent
tent than the wealthy.
Percentage
Figure 7. Percentage of Married Women using Contraceptives by Method and Wealth Index,
IDHS 2012
70,0
60,0
50,0
40,0
30,0
20,0
10,0
0,0
Sterilizati
on
Sterilizati
on
Lowest
Female
2,8
Male
0,2
Pill
23,6
IUD
2,8
Injectables
60,9
Implants
9,1
Condom
0,6
Second
4,2
0,2
23,5
3,8
60,2
6,9
1,3
Middle
5,1
0,3
23,1
4,5
58,4
6,1
2,5
Fourth
5,1
0,3
25,1
7,3
54,4
3,9
3,8
Highest
10,5
0,2
22,8
15,7
43,6
3,6
3,6
Figure 8 focuses directly on unmet need by wealth index. While the unmet need for limiting
does not vary much by wealth quintile, unmet need for spacing is a different story; here the
poor have much higher unmet need than the other wealth quintiles.
26
Percentage
Figure 8.. Percentage of Married Women who Want to Space or Limit Childbearing but not
using Contraceptives (Unmet Need), by Wealth Index, IDHS 2012
8
7
6
5
4
3
2
1
0
for spacing
Lowest
6,7
Second
3,8
Middle
3,9
Fourth
3,9
Highest
4,3
for limiting
6,7
6,4
6,4
6,9
7,9
Figure 9 provides information on the proportion using a modern method of contraception,
and the proportion with unmet need, by province. This information reflects differential access
to contraception by geographical area. It is very clear that the lowest proportions
proportio
using
modern contraception, and the highest proportions of unmet need, are concentrated in the
poorest provinces of Eastern Indonesia, where issues of widely dispersed population across
scattered islands or inaccessible, mountainous areas make it very difficult
d
to provide
adequate health and family planning services. But there is considerable variation in unmet
need across
cross other provinces as well.
Importantly, there are two other kinds of unmet need that are not covered at all in Figures 5
to 9. The firstt is the unmet need for contraception by sexually active unmarried women (who
are not included in the DHS surveys). The second is unmet need for more appropriate family
planning methods for women who do not have access to the full range of methods. When
these
ese two additional categories of unmet need are considered, the task ahead of the family
planning program appears considerably more daunting.
27
Central Kalimantan
Jambi
Lampung
South Sumatra
South Kalimantan
Bengkulu
Bali
Bangka Belitung
West Kalimantan
East Java
Banten
Central Java
North Sulawesi
West Java
Indonesia
Jogyakarta
Riau
East kalimantan
Jakarta
North Sumatra
Gorontalo
West Sumatra
Aceh
North Maluku
West Sulawesi
South Sulawesi
Riau Islands
Central Sulawesi
West Nusatenggara
East Nusatenggara
Sutheast Sulawesi
Maluku
West Papua
Papua
South Kalimantan
Lampung
Bangka Belitung
Central Kalimantan
South Sumatra
West Kalimantan
North Sulawesi
East Java
Jambi
Central Java
Gorontalo
Banten
Bengkulu
West Java
Bali
Jogyakarta
Indonesia
West Nusatenggara
East kalimantan
Riau
Jakarta
Central Sulawesi
North Maluku
West Sumatra
Sutheast Sulawesi
Riau Islands
West Sulawesi
South Sulawesi
Aceh
North Sumatra
West Papua
Maluku
East Nusatenggara
Papua
Figure 9. Provincial Differences in Use of Modern Contraception and in Unmet Need for
Contraception
Percentage of married women using modern method of contraception, by
province IDHS 2012
70,0
60,0
50,0
40,0
30,0
20,0
10,0
0,0
Percentage of married women with unmet need for contraception, by
province, IDHS 2012
25,0
20,0
15,0
10,0
5,0
0,0
28
2.4 Contraceptive method mix
Two other related aspects of the current situation in regard to family planning are crucial.
The first is that the method mix has shifted steadily towards short-term
short term methods. The
injectable and the pill accounted for 79 per cent of methods used in 2012, compared
co
with 12
per cent for the IUD and implant combined. If this ratio reflected women’s preferences, then
these should be respected. However, there is considerable evidence that it reflects, instead,
the preferences of providers. Currently, 72 per cent of
of women access their family planning
services from the private sector, provided mainly by bidan. Many of these bidan are
employed in the government sector, but also operate their private practice. In private sector
practice, there is an emphasis on short-term
short erm methods, partly because these are more
remunerative for the provider. The public sector is more oriented to providing longer acting
methods, and free services through campaigns organized by the provincial representatives
of the BKKBN in coordination with
with local officials from Districts or Municipalities. The
sustainability of these official programs is a key issue. In addition there are also issues on
referral system in case of complications or side effects, and contraceptive resupply.
The Mid-term review
ew notes the method mix in family planning, with short-term
short
methods
dominating and little change between 2007 and 2012 (see Figure 10).
). Particularly notable is
the ratio between injectables and pills, on the one hand, and longer-term
longer term implants and IUDs,
on the other, which remains extremely high.
Figure 10.. Short Term Methods Remain Dominant in Method Mix, 2007 - 2012
No significant change in method mix 2007-2012
2007
60,0
Percentages
50,0
40,0
30,0
20,0
10,0
0,0
Female Male
Steriliza Steriliza
tion
tion
2007
4,9
0,3
pill
iud
inject
implant
s
condo
m
traditio
nal
21,6
8,0
52,0
4,6
2,1
6,5
2012
22,0
6,3
51,5
5,3
2,9
6,5
5,2
0,3
Figure 11 shows the trend in the proportion of contraceptive supplied by the public sector,
the private sector, and
d other sources, between 1991 and 2012. The public sector has
reached the point where it supplies less than a quarter of the contraceptives in Indonesia.
This new situation has major implications for policy.
29
Figure 11. Increasing Private Sector Services, 1991 - 2012
Increasing Private Sector FP Services, IDHS 1991-2012
80
70
Percentage
60
50
40
30
20
10
0
1991
1994
1997
2002/3
2007
2012
Private sector
22
28
42
63
69
73
Public sector
76
49
43
28
22
23
Other
2
23
15
8
8
4
2.5 Abortion rate
The level of the abortion rate in Indonesia is unclear, since data are very unreliable and
estimates can only be based on assumptions with a wide range of uncertainty. An estimate
of about 1.3 million induced abortions in 2000 was made by Utomo et al (2001); when
combined with an estimated 0.7 million unintended births, this means that at least 2 million
pregnancies were unintended (Hull and Mosley, 2009: 31-2). Since then, no credible
estimates of induced abortions have been made. The available studies, however, suggest
that women who obtain abortions in clinics or hospitals tend to be married and educated. But
in rural areas, traditional birth attendants are estimated to perform more than four fifths of
abortions. “Altogether, nearly half of all women seeking abortion in Indonesia turn to
traditional birth attendants, traditional healers or masseurs to terminate their pregnancy.
(Women who induce their own abortions are not included in these estimates)” (Sedgh and
Ball, 2008) The issue urgently needs further study, both because abortion is believed to be
widespread among married women facing an unmet need for contraception and those
suffering from contraceptive failure, and because it is believed to be widespread in the case
of pregnancies to unmarried teenagers. The need to lower abortion rates is urgent, as so
many abortions are conducted in unsafe conditions and are hazardous for maternal
morbidity and mortality.
30
3.
Remaining Challenges
3.1 TFR has stalled since 2003
What are the possible reasons for the TFR remaining stagnant over the past decade?
According to the mid-term review of RPJM2, the target to increase the number of new
acceptors had been met, but the fact that contraceptive prevalence had not increased
suggests relatively high dropout rates, perhaps related to the “churning” across methods
which is commonly found in family planning programs emphasizing short-term methods.
There is a need to look more carefully at the characteristics of new acceptors. For example,
if they tended to be women using for the first time after having more than three children, this
might have little impact on fertility.
The long-term development plan of Bappenas 2005-2025 emphasizes the control of
population quantity and growth in the 2010-2014 period, and the achievement of a stable
population in the 2015-2019 period. This plan now requires modification, to be consistent
with the official population projections developed on the basis of the 2010 Population
Census results. These show that population growth is unlikely to be controlled in the 20102014 period; rather, the rate of population growth is likely to still be as high as 1.3 per cent
per annum in 2015. Also, the slow decline in the CBR but no decline in the CDR envisaged
in these projections does not meet the conditions of a stable population, which are a
constant birth and death rate. In any case, there is no particular reason for setting a goal of
reaching a stable population. A more realistic goal would be to reduce the fertility rate to
somewhat below replacement level, recognizing that because of population momentum, the
population will continue to grow for decades after replacement level fertility is reached.
The official Indonesian population projection has been arrived at after considerable
discussion among the experts involved. It envisages a very slow decline in fertility, with
replacement level fertility being reached only in the 2025-2030 period. While this assumption
is understandable, given the stalling of fertility decline over the past decade, it is also
possible that fertility decline could be resumed at a faster pace than envisaged in the
projections. This will need to be monitored carefully because of the important implications of
an alternative trend for all aspects of development planning.
3.2 Regional and socio-economic variation in fertility and in unmet need for family
planning
As shown in Figure 4, fertility ranges widely between Indonesian provinces. It ranges even
more widely between districts. The provinces where the total fertility rate is above 3 are all
provinces with large areas that are relatively inaccessible. These provide particular
challenges in providing family planning and reproductive health services to their populations,
as evidenced by their higher levels of unmet need for family planning (Figure 9).
Socio-economic variation in fertility is also high, with higher fertility among the poorer and
lower-educated groups. According to 2012 DHS data, the TFR decreases from 3.2 children
among women in the lowest wealth quintile to 2.2 children among women in the highest
wealth quintile, and the mean number of children ever born declines from 3.9 among women
age 40-49 in the lowest quintile to 2.7 among women in the highest quintile4. It is unlikely
4
IDHS 2012: Table 5.2, page 52
31
that these differences in actual fertility fully reflect differences in desired fertility. As already
shown in Figures 8 unmet need for family planning is greater among women in the lowest
wealth quintiles.
3.3 Early marriage and teenage fertility
In Indonesia, little childbearing takes place outside marriage (or at least outside relationships
recognized as marriages by the community), though pregnancy is sometimes the
precipitating factor for marriage. Thus trends in marriage are very important in influencing
fertility. Teenage marriage and childbearing is one of the key factors keeping fertility above
replacement level in Indonesia, though equally important are the many issues it raises about
the welfare of the teenagers involved. Recent marriage trends in Indonesia have caused
surprise. After rising over a number of decades, the average age at first marriage (SMAM)
declined between 2005 and 2010 (see Appendix Table 1). Moreover, the proportion of
teenagers aged 15-19 who are married rose substantially, from 9.2 per cent to 14.4 per cent.
India had almost twice as high a proportion of teenagers married as Indonesia in 1990, but
the figures in 2010 were identical, because India had made considerable progress in
reducing teenage marriage, while Indonesia had not.
In Indonesia, marriage usually is followed rather quickly by childbearing, so it is no surprise
that many young women in their late teens have begun childbearing. The figures from
successive DHS surveys are shown in Figure 12. The proportions have not changed very
much over the past decade, except for a worrying rise at age 16; almost 5 per cent of girls
this age have started childbearing, reflecting marriages below the legal minimum age of 16.
At age 19, almost 25 per cent of young Indonesian women have begun childbearing. Overall,
10 per cent of adolescent women age 15-19 are already mothers or pregnant with their first
child. Childbearing at ages 15-19 is heavily concentrated among the poorest young women;
the percentages fall from 16.7 per cent in the lowest wealth quintile and 13.7 per cent in the
second lowest quintile to 6.6 per cent in the second highest wealth quintile and 2.6 per cent
in the highest5. Importantly, early childbearing exacerbates the other disadvantages faced by
the poor.
5
IDHS 2012, page 61 Table 5.12
32
Figure 12. Percentage of Teenagers Aged 15 - 19 Who Have Begun Childbearing
30
Percentage
25
20
2002/3
15
2007
10
2012
5
0
15
16
17 Age 18
19
Source: IDHS, 2002/3, 2007, 2012.
The age specific fertility rate at age 15-19 has actually declined slightly over the decade
between the 2002/3 DHS and the 2012 DHS – from 51 to 48, though this is still quite a high
rate, much higher than in Thailand or Malaysia, for example. For women aged 20-34, the
rate has increased between 2002/3, 2007 and 20126.
3.4 Why is CPR stalling? A situation analysis in 15 Districts
There are many factors limiting contraceptive use in the current Indonesian situation,
especially those related to delivery mechanism, such as institutional arrangements, financing
of the family planning (FP) program and regulations which are hampering FP program
implementation. Most issues of institutional arrangements have arisen after decentralization.
The role of the BkkbN, which in its heyday was an efficient, centrally run agency reaching to
the far corners of the country, has changed significantly since regional autonomy, and the
BkkbN has been struggling to define its role and devise productive ways of operating. The
balance of responsibilities between BkkbN and MOH in provision of contraceptive services
was constantly an issue pre-dating regional autonomy, but it continues to pose difficult
questions, especially at the grass roots level. After decentralization, the issue of lack of
political commitment among local executives and legislatives has also emerged, resulting in
a low percentage of budget allocated for the FP program at District or Municipal level. The
third issue is regulation, as Law number 52 of 2009 on Population and Family Planning has
not been adequately supported by Presidential Regulation (PerPres) which should
strengthen the FP program.
In dot point form, a more detailed list of factors associated with contraceptive use includes:
1.
The significant role of the private sector, which includes providers’ readiness.
2.
The bidan is the spearhead of FP services at the grass roots level, but the role of PLKB,
which was significant in motivating couples to use contraceptives, is disappearing.
3.
Contraceptive supply chain management and delivery.
6
IDHS 2012, page 54, Table 5.4
33
4.
Unbalanced method mix
5.
The long-standing and unresolved issue: services for the unmarried? Especially the
youth?
3.5 Situation analysis: from a study in 4 provinces and 15 districts.
The following section provides a more concrete analysis of issues and problems in the
delivery mechanism presented in the previous paragraph, based on a study, conducted in
2012 (Febriani 2012), which helped provide a clearer picture of the situation in the local
areas including political commitment on financing, human resources and partnership; as well
as challenges in revitalizing the FP program at district and municipal level. The study was
conducted in the following provinces:
1.
West Java (large population with early marriage)
2.
West NusaTenggara (high TFR, low CPR and high Unmet Need)
3.
West Kalimantan (Low CPR, high unmet need)
4.
North Sumatra (low CPR and high unmet need).
The in-depth study was conducted in 15 kabupaten/kota in the following provinces which
were included in BkkbN’s KB Kencana initiative: NTT, North Sumatra, West Sulawesi, West
Papua, West Kalimantan and West Java. In general, the key finding from the 15 kabupaten
and kota under study is that there is a lack of activity in the FP program, except in providing
contraceptive supplies. Outreach activity in the form of providing information and motivation
is not being conducted. This might be due to inexperienced human resources, and lack of
technical support (facilitation) from the Central or Provincial level of BkkbN.
Payment for FP services by the client, and regulatory aspects:
Cost of services is not a problem for most clients, because the price is relatively inexpensive,
most clients are willing to pay for FP services and have shown this by moving to the private
sector during the last 15 years.
In any case, althoughThe GOI provided contraceptives for free, in most cases clients have to
pay. Both private and public service delivery points (SDPs) apply tariff for services which
varies among kabupaten/kota or among SDPs. There are no standardized tariffs for FP
services, no official regulations from local government, Bupati or Walikota, no memorandum
of understanding between the local family planning workers and the local health authorities.
All the family planning implementing units at the kabupaten/kota level (SKPD-KB) distribute
to public SDPs, and some also distribute to private SDPs-KB. But most health facilities as
well as the health staff have to buy contraceptives or the particular brands needed or
preferred by most clients.
Some Puskesmas apply a fee for services. Puskesmas in several kabupaten stated they
were experiencing contraceptive stock-out, pill almost expired and unsuitable/inappropriate
size of injectable.
34
Planning and Budgeting
This varies among kabupaten/kota due to the absence of national guidelines or budget
allocation for the FP program at the local level. Kabupaten and Kota have different budget
allocation in terms of APBD. In general among the 15 kabupaten under study, the budget
allocated for the FP program ranges between 0.04-0.2% of APBD compared to 6-17%
allocated for health – in other words, only somewhere between 0.2 per cent and 3.3 per cent
of the health budget. There is no standard format of the allocated budget, for example cases
were found of 54% for building renovation, and 94% for family data collection.
There are certain minimum standards of services (Standard Pelayanan Minimal), designed
at the Central Office, as follows:
1.
SKPD_KB/Kota should allocate 30% of contraceptive supplies from the local budget
(APBD) but in reality, this is not happening, so the central BKKBN has to provide all the
contraceptive supplies, for free. Only some kab/kota under study was able to provide the
30 % of contraceptives, showing that these Bupati have a commitment to implement the
FP program. In addition, the FP program obtains DAK (Dana Alokasi Khusus, or Special
Funds) but the regulation stated that this money is mainly for equipment and
infrastructure. This is a problem since the FP program is more about activities than
infrastructure. If it is used for mobile clinics (operational car, speakers etc), there should
be funds to cover operational cost.
2.
There is a requirement set by the central government that local government has to
provide 10% of the DAK money in order to receive this DAK. This reduces the local
budget that is supposedly for the FP program
3.
SKPD-KBs are not actively involved in planning and budgeting of programs or activities
at the village level. Most often proposals from the village level are only for infrastructure.
SKPD-KB should be involved in the development planning discussions
(MUSRENBANG) at the district and sub-district level to advocate the need for FP to be
included in the planning and budgeting.
4.
SKPD-KB has to compete with other local programs - education, health etc, KB is not a
priority, and there is no monitoring and evaluation of SKPD-KB performance.
5.
Budgeting refers to past years performance and there is no guidance on the budget
ceiling for the FP program.
Technical capacity of SKPD-KB
The capacity of SKPD-KB to advocate the need for and benefit of FP program is weak.
Staffs lack experience, management capability and technical competence. The assignment
of SKPD-KB is related to the political situation at the local area, and available budget is
sometimes used for operations related to local elections. Not surprisingly, there is a high
turnover of SKPD-KB. The key need is for capacity building, technical support for basic
planning, budgeting, program implementation, monitoring and evaluation and supervision, as
well as conducting IEC about the benefit of FP. The planning process needs to be integrated
with related sectors (Dinas Kesehatan, and Ministry of Women’s Empowerment and Child
35
Protection). Communication or relations between the SKPD-KB and Puskesmas or other
SDPs tends to happen only at the time of contraceptive distribution by SKPDs.
The BkkbN Provincial office determines the target for demand fulfilment (PPM). If the
kabupaten/Kota is able to meet the target, this is considered good performance. This
procedure appears to be “business as usual”, harking back to a much earlier period in the
program.
The kabupaten/kota do not have strategic planning for KB. There is no monitoring or
evaluation of the family planning efforts by local executives at the province level or by the
Central BkkbN office. There is little use of data in planning – but this is related to the lack of
suitable data. Data about clients who obtained contraceptives from SKPD-KB are not
available at the time of planning, and there are no data from the private sector SDP or KB
mandiri.
Family planning services
PLKBs (family planning field workers) were responsible for motivating clients to become
acceptors. But since decentralization the availability of PLKB and their activities has been
limited. Five of the kabupaten (30 percent) do not have PLKB, and in one kabupaten there is
only one PLKB covering 100 couples. PLKB performance is limited due to very limited
training; high turnover, especially of experienced PLKB (there are no incentive
remunerations for PPKBD (supervisor of PLKB) and Sub-PPKBD; geographical and
topographical barriers, with no support for operational cost; and sometimes lack of social
support from religious and community leaders.
The availability of bidan
There is an unevendistribution of bidan in the villages. In some kabupaten, bidan are more
concentrated in the kabupaten capital than in the villages, no doubt related to the preference
of bidan to work in urban areas. This increases problems of accessibility by the users. The
overall performance of bidan is low due to the lack of trained bidan, lack of technical skills
(only 14% have technical skills in inserting IUD and implant, and only 2% have counselling
skills), no supervision mechanism to ensure quality performance of bidan, and lack of
necessary equipment.
36
4. Strategic Issues
4.1 Financing and method mix
The majority of contraceptive users can afford to pay for their supplies, as evidenced by the
fact that the private sector now serves 73% of users, and that about 66% of users who
obtain services from the government (even the long-acting method) pay for the services. The
rest obtain the services for free – especially the long-acting method (IDHS 2012: 91).
However, the stress by private sector suppliers on short-term methods is undoubtedly
disadvantaging some clients – especially those who would prefer to terminate rather than
delay childbearing - in particular the poor who can ill afford the cost of contraceptive
resupplies. There are too many provider incentives for the use of injectables, and too little
support for vasectomy, implants and tubectomy (Hull and Mosley, 2009: 20-21; 26-30).
Thus, while “fully 50 per cent of all married women do not want another child yet the great
majority do not have effective access to the most secure methods of fertility control. This is a
huge “hidden unmet need” for the method of their choice to avoid another birth over the
remaining decade or more of their reproductive life.” (Hull and Mosley, 2009: 29-30).
The fee for services standard tariff varies due to lack of policy and guidelines from the
central government. This needs to be redressed.
4.2 Improvement of equity of access
There are many inequities in use, access and quality of FP/RH services - between
provinces, between districts within provinces, and between the general population and
marginalized groups. Reaching the hard-to-reach is costly, partly because groups are hard
to reach for different reasons: geography, religion, culture, leadership, political instability,
widely dispersed, tradition bound, illiterate, having poor access to health services, a legal
status that marginalizes, extreme poverty, or highly mobile (Lewis and Haripurnomo,
2009:51). The private sector is unlikely to address equity because it is difficult and costly to
reach society’s most marginalized groups. Government must take the lead on this issue.
Because the issues, approaches and required resources differ for each disadvantaged
group, required activities will differ. The key point is that government will need to set
priorities and develop interventions based on identification of priority areas and groups,
needs assessment and strategic factors (Lewis and Haripurnomo, 2009: 54-5).
4.3 Planning and budgeting: Lack of political commitment among Bupati or Walikota
The FP program is allocated a very small share of the APBD - between 0.04 and 0.2%. It is
hard to say what share it should receive, but non-involvement of SKPD-KB’s in planning and
budgeting at the district level means loss of opportunity in competing with other programs
such as education and health. There is also lack of integrated planning with the Dinas
Kesehatan and Ministry of Women’s Empowerment and Child Protection.
Of the total BKKBN budget, about 35% remains at the central level and 65% goes to the
Provincial BKKBN offices. At the provincial level, about 50-60% of the budget is distributed
to the kabupaten/kota level, depending on needs. The 40-50% which remains at the
Provincial level is used, among other things, for workshops, training etc. which draw
participants from the kabupaten/kota level. The budget at the kabupaten/kota level can be
used for all aspects of the population, family planning and family development program. It is
37
subject to control by the Provincial level. Since 2012, the distribution of the BKKBN budget
from the Province to the SKPD-KB has been by means of a MOU which is also signed by the
Bupati/Walikota.
The family planning program at the kabupaten/kota level has two sources of funding. The
first is the funds noted above, allocated by the BkkbN provincial level, and the second is the
APBD (kabupaten level budget), which depends on commitment by the legislative and
executive arms of local government.
BkkbN requires local government to provide 30% of contraceptives and supplies needed
(Minimum Standard of Services – Standar Pelayanan Minimal – SPM, SK Kepala BkkbN, 29
January 2010). Some kabupaten do meet the requirement, but the majority do not have
enough funding to do this. Therefore the Central office has to provide most of the free
contraceptives for the poor. There are seven provinces where contraceptives were provided
free for all of the acceptors: Papua, Papua Barat, Maluku Utara, Maluku, NTB and NTT
(discussion with the Director of Finance and Logistics Management at BkkbN, 20 January
2014). But there is also an issue that contraceptives provided by the central office and
delivered to kabupaten/kota level become commodities at this level, which means that
acceptors have to pay to obtain contraceptives.
Another issue is that funds are not provided for the handling costs of delivery of the
contraceptives provided by the central office to the point of services.
DAK (Dana Alokasi KhususorSpecial funds) also poses problems. Regulations specify that it
is only for infrastructure (sarana and prasarana) - which are not prioritized in the operational
mechanism at the local level. This means that although this is a source for funding at the
local level, regulations hamper its use for operational cost of the FP program. A solution has
to be sought to overcome this problem.
Since the family planning program is only one of 28 urusan wajib at the kabupaten/kota
level, it is important for the SKPF-KB to be able to negotiate the importance of family
planning for funding. Government regulation No. 41 of 2007, article 22, point 5 provides for
the establishment of BPKBD, but so far, out of 534 kabupaten/kota, only 18 have a BPKBD.
Of course, the program works well in many kabupaten that do not have a BPKBD, as the
SKPD-KB can conduct activities based on the MOU with the Province officials. But in many
cases, it does not appear to work well, as it depends entirely on the political commitment of
the local officials.
4.4 Capacity of BkkbN’s human resources
Assessment reports on the need for revitalization of the Family Planning Program suggest
the need for capacity building of BkkbN Staff at all levels (Lewis and Haripurnomo , 2009;
Thomas and Adioetomo, 2010). They found lack of skills to identify priorities, build
partnerships, generate political support, plan activities, and implement plans. This
assessment is also supported by the situation analysis in 14 Kabupaten. In general, the
technical competence and management capacity of the local officials at the district and
municipal level is lacking, in the following ways:
1.
Lack of competence in basic planning, program implementation, monitoring and
supervision
38
2.
Lack of capacity to advocate the importance of the FP program to executives and
legislators at the Kabupaten/Kota level.
3.
Lack of communication with other sectors.
4.5 Family Planning Services
The increasing role of the private sector has to be supported. The 2012 IDHS shows that 72
percent of acceptors obtained services from the private sector, which were mainly provided
by Bidan or Bidan di Desa. The estimated number of Bidan registered in July 2013, was
around 135,000 persons. Among these, 40,000 bidan provided FP services, of which 31,400
were from government and private practice, another 8,600 were Bidan Mandiri (nongovernment) who are only in private practice. About 10, 000 of the bidan who provide FP
services are called bidan delima; these provide a package of FP and maternal health
services that serves as the gold standard of the profession, in a private clinic of their
own.7(See also Parson, et.al.;2013).
But this number of qualified bidan is too small compared to the scale of demand for family
planning services, especially if the Government aims at increasing the use of long-acting
methods for more effective contraception and to reduce unmet need. The problem is not only
that the number and quality of bidan who are certified with CTU (Contraceptive Technology
Update) competence, especially in inserting IUD and Implant, is very minimal, but that there
is also a need for qualified bidan for counselling and with interpersonal relations skills.
BkkbN statistics in 2014 reveal that among 97,999 bidan registered by BkkbN, only about
44% have been trained in IUD, 37% in implant, and about 28% in counselling and
interpersonal communication8. Another issue is the highly uneven distribution of bidan. A
report by IBI in 2011 reveals that 105 Puskesmas, mostly in the Eastern Islands of
Indonesia, have no bidan.9
Thus, there is an urgent need to expand the number and distribution of Bidan, especially
those with CTU competence. This can be done through expansion of training programs for
bidan to acquire skills for long acting method services. During the 2010-2013 period, 35,000
bidan were trained, but the process of training faced many obstacles. Review of existing
documents and discussions with users as well as IBI officials leaves the impression that the
training system and quality of services of bidan who provide FP services leave much to be
improved.
1. The first issue is about the institutional arrangement of the training. Currently the JNPK
holds the MOH mandate as the sole training institution for health providers. In order to
achieve more effective training and increase the output of trained bidan, the government
needs to give permission to other institutions to engage in training. IBI can be invited to
organize this training program, working in collaboration with professional instructors such
as from POGI (Association of Indonesian OBGYN). The government regulations on the
mandate to conduct bidan training should be reviewed.
7
IBI claimed that by March 2014, the number of Bidan Delima has increased to 12,000 persons.
http://www. Bkbn.go.id/data/Default.aspx accessed March 2014.
9
Emi Nurjasmi, 2011. ‘Peranan Bidan Dalam Program Kependudukan dan Keluarga Berencana’.
8
39
2. Secondly, there are many problems in recruitment of trainees. For example, many of the
trainees did not have a permit to practice. The recruitment mechanism for trainees needs
to be widened to collaborate more with other related stakeholders and users - the
Dinkes, the IBI, the POGI, BKKBD/SKPD at Province level (in addition to JNPK at local
level), P2KS (province level), P2KP (Kabupaten/Municipal level).
3. Thirdly, a solution must be found for various barriers in training implementation, such as
the requirement that trainees must practice the insertion of IUD to five clients and the
implant to two clients as a requirement for obtaining CTU certification. It is difficult to find
‘models’ for IUD and Implant insertion. This problem hampers the trainee from obtaining
CTU certification, without which they are unable to practice as qualified bidan.BkkbN has
suggested that such practice can be done during the implementation of mobilfe FP
services10
4. Fourthly, the quality of the training must be improved to comply with standard training
requirements.
5. The Government budget for such training is lacking in alat bantu praktek, such as IUD
kits etc.
6. An overall lesson is the need to improve and strengthen collaboration with professional
organizations (IBI and POGY (OBGYN Association), as well as related institutions in the
local area.
The most urgent need is to increase the number of bidan delima. To acquire a certificate as
bidan delima, in addition to undergoing the same basic training as other midwives, a
candidate has been subject to a rigorous 6-month accreditation process focusing primarily
on quality of services and facilities (Parsons et.al, 2013). Thus it is a long process for a bidan
to obtain Bidan Delima certification. This is implemented by IBI as a professional
organization. IBI strongly suggests that this ‘branded Bidan Delima’ program should be
expanded. But, as well as cost, there are other obstacles: limited number of management
teams (tim pengelola), limited number of assessors, and limited number of facilitators.
Funding to expand the number of these officials is also limited and IBI requests the
government to assist them in conducting training for management team, facilitators and
assessors.
4.6 Issues of demand creation
The past success of the FP program lay mostly in the work of PLKB. The task of PLKB is
encouragement of couples to adopt small family size values and to use contraception. After
decentralization, the PLKB belongs to the Kabupaten and the numbers declined significantly.
Thus, the promotion of FP is rather neglected at the local level, with great variation between
districts.
Nowadays, the recruitment of new acceptors is mainly through strategic events, campaigns
to mobilize potential acceptors such as National Family Day (Harganas), and other events
which can be used for mobilization of couples to become new acceptors. This system is
10
Discussion with one of the BkkbN Directors
40
called ‘klinik bergerak’, which raises question on the sustainability of contraceptive use, the
referral system and contraceptive re-supply.
4.7 Contraceptive supply chain management issues
A recent report (Brandt and Benarto 2013) finds that managing contraceptive logistics and
the delivery system pose serious problems. The first issue is estimating the number of
contraceptives that should be available when needed. This is due to the use of target-based
rather than evidence-based methodology to determine contraceptive requirements, and poor
data in the recording and reporting system. The central government identified PPM
(Pelayanan Permintaan Masyarakat), as an estimate of demand for contraceptive but in
actual implementation, it is a target to increase new users.Stock outs are frequent in the
clinics supplied by BKKBN.Brandt and Benarto’s study stated that there is contraceptive
stock out of about 40%, but discussion with IBI indicated that the 40% is mainly about
unavailability of pills and injectables. Detailed discussion with a bidan, a member of
IBI,indicated that IUDs are mostly available when needed. Therefore, it is not clear from
Brand and Benarto’s study what specific methods of contraception are lacking.
The contraceptives and supplies are provided by the central government, delivered to
kabupaten/ kota through the province level. Whereas the MOH uses an E-catalogue system
for procurement, and drugs and medicines are delivered directly to the provincial or district
level, BkkbN receives all contraceptives at its central warehouse prior to their distribution to
the provincial level. This lengthens the supply chain. Moreover, it appears that in the storage
facilities used by BkkbN, both at the top of the supply chain and at its lowest levels,
temperatures are far higher than the 25 degrees celsius maximum recommended for
facilities used to store contraceptives. This puts at risk the potency of most of the
contraceptive stocks as they travel through the supply chain, before they reach the
consumer. There are low levels of competency in staffing both at the central warehouses in
Jakarta and at the lower level storage facilities (Brandt and Benarto, 2013). Another
problem is that there is no provision for handling cost for delivery from kabupaten to village
level and to the end users.
41
5. New and Emerging Challenges
5.1 Situation of family planning under the new JKN
The newly enacted Jaminan Kesehatan National (JKN) is deeply rooted in the National
Social Security System of 2004. Under the law establishing the National Social Security
System, family planning services and information provided by government health facilities or
by private sector facilities recognized and authorized by the government are included among
the health services covered by the system (see Article 22)11. Similarly, in article 21, ayat (1)
of the Presidential Decree No. 12 of 2013, on the JKN, family planning is included among
the promotive and preventive health services (ayat 4), with specific mention of basic
contraception, vasectomy and tubectomy, in coordination with the institution responsible for
the Family Planning Program. However, in article 25 it is stated that contraceptive devices
(alat and obat kontrasepsi) are not covered by JKN.12
There are a number of unresolved issues for users of contraception under the new JKN.
1.
The first is the difference of concept or philosophy between JKN as a social insurance
system and the family planning program. The concept of insurance is pooling risk
through a revenue collection from membership.13 The concept is to avoid risk through,
among others, health promotion and prevention of health risk. Providers of services are
given a sum of resources (capitation). Thus, a large number of JKN members who are
healthy and do not need to utilize health services will be profitable to the providers. This
is very different from Family Planning, the focus of which is on recruitment of increasing
numbers of acceptors from the ranks of those facing unmet need for contraception.
These acceptors have to utilize FP services from FP providers. If the same system of
capitation is used as the JKN for health, the higher the utilization of FP services, the less
profit the providers will receive. This is a crucial threat to Indonesia’s efforts to increase
CPR, reduce unmet need and therefore reduce TFR. (There is already evidence that
some Puskesmas are reluctant to provide FP services which absorb their capitation). A
system needs to be developed which still complies with the SJSN but does not conflict
with the efforts to revitalize the program.
2.
The second issue is the need to make a clear distinction between contraceptive
acceptors who are able to pay the premium and those who are entitled to receive
free services. This may require a review of the Ministerial regulation/BPJS, and at the
very least a clear explanation of who has to pay for the contraceptive services and
supplies and who gets them free. At present, most contraceptive users pay for the
contraceptives (72% of users pay out of pocket to private sector providers), while BkkbN
11
Pasal 22, Ayat (1)
Yang dimaksud pelayanan kesehatan dalam pasal ini meliputi pelayanan dan penyuluhankesehatan, imunisasi,
pelayanan Keluarga Berencana, rawat jalan, rawat inap, pelayanangawat darurat dan tindakan medis lainnya,
termasuk cuci darah dan operasi jantung.
Pelayanan ersebut diberikan sesuai dengan pelayanan standar, baik mutu maupun jenispelayanannya dalam
rangka menjamin kesinambungan program dan kepuasan peserta.
Luasnya pelayanan kesehatan disesuaikan dengan kebutuhan peserta yang dapat berubahdan kemampuan
keuangan Badan Penyelenggara Jaminan Sosial. Hal ini diperlukanuntuk kehati-hatian.
12
The usual practice of FP program is that BKKBN provided the contraceptive devices. So the JKN covered only
cost of FP services.
13
Menkokesra, 2012. Peta Jalan Menuju Jaminan Kesehatan Nasional (Road Map of JKN) 2012-2019.
42
provides the contraceptives free for those obtaining contraception from the public clinics.
Under the new regulations,contraceptive devices and medicines (ALOKON) have to be
covered by BkkbN for all contraceptive users. This would be in sharp contrast with the
present situation. If the BkkbN has to provide free contraceptives for all users, this will
mean that the family planning program will depend on government funding for a very
long time.
Even if government sources provide ALOKON only for those who are penerima bayaran
iuran (PBI), with a separate identity card from those who pay a JKN contribution, there is
still a problem of delivery of ALOKON for non-PBI participants. From where would these
acceptors obtain their supplies? If they have to obtain the supplies from the market and
bring them to the provider, this would be cumbersome. One possible solution may be for
the clinic facilities to be given a supply of ALOKON, but users who are contributing
members of JKN would have to pay for the ALOKON.
3.
The third issue is the role of Bidan and the process of remuneration of services they
provide. This is related to the regulation that Bidan who provide FP services as Klinik
Pratama (Klinik Bidan, dokter gigi or dokter praktek swasta) have to develop networking
under the coordination of a doctor (in order to maintain high quality of services). Thus
klinik bidan athough registered and accredited, cannot be contracted directly by BPJS,
except in cases where the bidan is covering less than 3000 population. This is related to
the benefit package. Again this is an insurance concept which is against the FP goal.
Therefore there are two alternatives: decide whether FP is outside BPJS – JKN or
Review BPJS and Ministerial Regulation on JKN implementation. A similar case can
also be found with regard to nutrition policy.
43
6. Policy Directions and Strategies
6.1 Key policy objectives
The key policy objectives, expressed very broadly, are as follows:
1.
Lower the fertility rate to replacement level as soon as possible, in the face of still
relatively high desired family size, while respecting the rights of individuals and couples
to have the number of children they desire.
2.
Promotion of a rising age at marriage in the interest of the wellbeing of young people
(especially young girls) whose freedom to choose their partner must be promoted, and
who face health consequences from early childbearing. A rise in age at marriage will
also lead to lower fertility.
3.
Revitalization of the family planning program, in order to meet the reproductive health
needs of the population and lower the level of unmet need for contraception.
With regard to the first objective, it is expected that continuing success in economic and
social development (rapid economic growth, further lowering of mortality rates, urbanization,
further increase in educational enrolment ratios, growth of formal sector employment) will
play a major role in delaying marriage and lowering desired family size. Such has been the
experience of the more developed countries. However, crucial as they may be, planning for
these developments lies outside the scope of the present report.
The second and third objectives are linked directly to the first objective. The second
objective is to raise age at marriage, with special emphasis on reducing teenage marriage,
and enforcing the legal minimum age at marriage. Early marriage is likely to result in early
childbearing, and this will cut short the studies of many teenagers. In cases where marriage
results from premarital pregnancy, it reflects a need for reproductive health information and
family planning services to be available to the unmarried. In cases where the marriage
occurs when the girl is aged below 16, it reflects the need to enforce the minimum legal age
at marriage. In cases where the marriage is arranged without the consensus of the bride, it
reflects the need to enforce human rights legislation.
The third objective, revitalization of the family planning program, is aimed at sharply lowering
the level of unmet need for family planning through more focused and efficient provision of
family planning information and services. The strategy should be to clearly delineate the
respective roles of the BkkbN, Kemenkes and local government in (1) providing public sector
family planning/reproductive health information and services, and in advocacy activities
related to such activities; (2) supporting the private sector and community groups involved in
provision of contraceptive supplies and services; (3) promoting contraceptive use by couples
in planning their families (demand creation).
The revitalization of the family planning program will lead to a reduction in the level of unmet
need for family planning, enabling those wishing to avoid births that are unwanted in the
sense of not being wanted at present, or not being wanted at all, to achieve their objectives.
Aside from enabling individuals and couples to achieve their preferences in this way, there
will be wider benefits. For example, it would enable more women to enter the workforce,
rather than bringing up babies they had not wanted.
44
The close synergy between the revitalization of the family planning program and the aim of
reducing maternal mortality needs to be stressed. Indonesia has fallen far short of achieving
the MMR target, one of the key MDG goals, and it is agreed that the utmost effort is needed
to lower maternal mortality. A revitalized family planning program would contribute to
lowering the maternal mortality rate in two ways: avoiding some pregnancies that would
have resulted in unsafe induced abortions, and avoiding some births that would have
occurred in circumstances with an above-average chance of delivery complications that
could not be well met by available health facilities.
Success in implementing these policies can be expected to have an influence on population
growth rates and their determinants (fertility and mortality), and the implications of these
demographic trends for the growth of different segments of the population. However, the
demographic targets of the RPJMN 2015-2019 should first be modified in light of the latest
understandings of fertility trends and their likely trajectory, as reflected in the recently issued
official population projections and given the policies to be discussed below. The suggested
revision in these targets is shown in Table 3. The longer-term target consistent with the
population projections would be that in 2025, TFR would be 2.1, CBR 15.6, CRD 7.4 and the
rate of population growth would be 0.82 per cent annually.
As noted earlier, these targets can be considered very conservative, the resumption of
fertility decline could well be faster, and TFR=2.1 could be reached much sooner if the
following are achieved:
•
Most of the unmet need for contraception is met
•
Long-term family planning methods are emphasized more
•
Communication efforts to reduce early marriage succeed
•
General economic and social development, especially further increase in educational
enrolment rates, is achieved
Table 3. Demographic Trends According to the Official Indonesian Population Projection
2014
2015
2016
2017
2018
2019
TFR target RPJMN
2.1
2009-2014
Official population projection
TFR
2.4
2.4
2.3
2.3
2.3
CBR
19.2
18.8
18.5
18.2
17.8
CDR
6.4
6.4
6.4
6.5
6.5
Rate of growth
1.3
1.2
1.2
1.2
1.1
# births (x1000)
4,985
4,869
4,840
4,810
4,780
# deaths (x1000)
1,622
1,653
1,684
1,717
1,753
Population increase (x
1000)
3,362
3,216
3,156
3,093
3,027
Nevertheless, it is appropriate for planning purposes to use the official population
projections, recognizing that such projections will always need to be modified as time goes
on in the light of emerging trends.
45
In brief, the following strategies for revitalizing the family planning program are
recommended:
1.
Assist the private sector to better meet the needs of the 73% of users it serves
2.
Assist the BKKBN to better serve the needs of the poorer sections of the community for
whom the cost of contraceptives is likely to be an obstacle to use
3.
Reinvigorate BKKBN’s postpartum, post-abortion and workplace-based family planning
programs
4.
Facilitate cooperation between BkkbN, Dinkes and Pemda at the district level; this is a
crucial requirement of an effective family planning program
5.
Follow a bidan-focused strategy for ensuring the effective provision of family planning
services with high quality of services.
6.
Mount a communications program through BkkbN and supportive local government
agencies, workplaces and schools to foster later marriage
7.
Through a communication program and provision of services, meet the reproductive
health needs of the unmarried
Some more detail on each of these strategies follows:
6.2 Assist the private sector - A bidan-focused strategy
Most private sector services are provided by Bidan. Therefore strengthening the role of the
private sector should be focused on strengthening the role of bidan.
Of the 135,000 midwives in Indonesia, approximately 40,000 provide family planning
services, of whom about 10,000 to 12,000 belong to an elite accredited group called Bidan
Delima, who provide a package of high quality MCH and family planning services in the
private sector. The strategy proposed by Parsons et al., 2013 (p. 4-5), is to
“Focus programmable inputs first on strengthening and enlarging the
group of Bidan Delima and then other licensed midwives to provide a
cafeteria range of contraceptives, including longer acting methods
depending on the needs of individuals in different reproductive stages of
life. To accomplish this, the family planning program will need to expand
the range of training opportunities for clinical skills and supervised hands
on experience. Midwives and supervisors also need in-service training in
interpersonal counselling techniques. One of the objectives of this training
is to eliminate the current evident provider bias favouring injectables.
Couples need to have effective access to the full range of contraceptive
methods.”
6.3 Demand creation: Reinvigorate specific BkkbN programs
Revitalize understanding of the benefits of having small family size through IEC and BCC,
through the following key messages:
1.
Will improve mother’s and child’s health
46
2.
With a small number of children, parents will be able to meet the basic needs of their
children, and invest more in their educational development.
3.
In the long run, the quality of the next generation will be better than that of the previous
generations.
4.
Smaller family size will help poverty reduction.
The main challenge facing demand creation is the shortage of PLKB who were formerly the
spearhead of communication efforts. This problem can be overcome by (1) arranging for
bidan who have completed PTT duties to double up as motivators; (2) Working with the
Dinas Kesehatan to develop health promotion working groups which include family planning
promotion. But appropriate media campaigns should also be stressed.
6.4 Meeting the unmet need of economically disadvantaged couples
1.
Communication about use of contraceptives according to life cycle approach (spacing or
limiting)
2.
Especially for limiting, ensuring that information and services relating to long-acting
methods are available
3.
Provide access to contraceptive services which are affordable to the poor
4.
Reduce side effects or health related problems resulting from contraceptive use, through
more effective counselling and increased availability of trained personnel
6.5 Balancing method mix through increasing long-acting method use
1.
Counselling on the benefit of using long-acting method
2.
Counselling to switch from short term to long term method for users who plan to limit
family size
3.
Increasing the number of bidan who are qualified to insert IUD and Implant
4.
Ensuring that information and services relating to long-acting methods are available
6.6 Strengthening contraceptive supply chain management
1.
Move from target-based to evidence-based methodology to determine contraceptive
requirements; improve field data on kinds of contraception needed, supported by
recording and reporting activity, checked against PPM data from BkkbN.
2.
Transparent provision and purchase of contraceptive supplies using e-catalogue. Cease
receiving all products at the central warehouse prior to their distribution to the provincial
level.
3.
Keep accurate records of contraceptive supply availability so that stock outs do not
occur
4.
Improve storage warehouses consistent with standards needed to maintain the quality
of contraceptives. Consider the recommendation of Brandt and Benarto (2013) to
47
bypass the district level and deliver contraceptives directly to SDPs from provincial
warehouses.
5.
Allocate funds for management of the warehouses.
6.
BKKBN should allocate funds for ‘handling costs’ and transportation and ensure through
discussions between BKKBN district administrators and local government that
contraceptives reach the clients who need them.
7.
Strengthening the capacity of storage managers and staff to maintain high quality of
contraceptives and supplies.
6.7 Fostering more effective collaboration at the district level
1.
Comply with the Health Minister’s instruction that Dinkes at the Kabupaten/Kota Level
have to assist SKPD-KB in implementation of the FP program.
2.
Strengthen advocacy to Bupati, Walikota and key members of the executive and
legislative arms of government about the importance of the family planning program for
the future generation, by building a solid team consisting of SKPD-KB, Dinkes, Bidan,
Camat, and community leaders (including religious and adat) to obtain commitment for
the FP program.
3.
Strengthen the involvement of SKPD-KB in social development planning (education,
health) at the Kabupaten level to include the FP program, and so ensure budget
allocation for FP/RH activities.
4.
Capacity of the SKPD-KB at the Kabupaten/Kota level to identify issues, set priorities,
and conduct planning and budgeting for the district family planning program needs to be
strengthened. Strong and accurate program planning and budgeting with supporting
argumentation is needed to provide the necessary ammunition for convincing the
Pemda of the importance of allocating a budget for family planning.
5.
Point 4 needs to be supported by the national and provincial government through
guidance and technical support for increasing the capability of SKPD-KB to carry out
their duties.
6.8 Support for later marriage
1.
Advocacy to executive and legislative officials, religious and community leaders on the
reasons why delayed marriage is beneficial. Ensure that the team proposed under 6.7.2
above includes commitment to the goal of countering under-age marriage as one of its
key concerns.
2.
Activate the enforcement of the minimum marriage age in the marriage law, especially
the minimum age of 16 for girls.
3.
Enforcement of regulations to keep children in school longer (the Wajib Belajar 9 years
and then 12 years) and facilitate this through fellowships for poor students (available
through MOED).
48
4.
IEC to parents and children to delay marriage to benefit fully from educational
opportunities and avoid unintended pregnancies and unsafe abortion that is hazardous
to maternal mortality.
6.9 Meeting the reproductive health needs of the unmarried
1.
Support the GENRE program which assists young people to pursue quality living and
avoid risky behavior including pre-marital sex or unsafe sex.
2.
Work with NGOs to meet the reproductive health needs of youth.
3.
Strengthen the coordination between government and partner (NGO).
6.10 Financing of the family planning program
1.
In order to provide an appropriate legal framework for the financing of the family
planning program, there is need for a MOU between BKKBN and the Ministry of the
Interior about the financing of the family planning program at the regional level.
2.
In order for funds to flow more rapidly, consideration should be given to disbursing
APBN funds directly to the kabupaten/kota level, bypassing the Province level. This
would require an appropriate monitoring and evaluation mechanism, and technical
support for the SKPD-KB to develop relevant program planning and budgeting.
3.
Since the family planning program is only one of 28 urusan wajib(obligatory programs)
at the kabupaten/kota level, it is important for the SKPD-KB to be able to negotiate the
importance of family planning for funding. Government regulation No. 41 of 2007, article
22, point 5 provides for the establishment of BPKBD; efforts should be made to increase
the number of kabupaten that have done so.
4.
As well as the regular budget, there is the DAK (special allocation budget). This is a
central government contribution to fund specific activities at the kabupaten/kota level
which are in line with national priorities.Priority is given to lagging regions with relatively
poor fiscal capacity, but with good potential to carry out the programs being funded. The
budget goes direct from the Finance Ministry to the kabupaten/kota receiving it, not via
the Provincial BKKBN office (in the case of family planning activities). Utilization of this
budget in the case of family planning activities is usually for infrastructure such as
buildings,vehicles, (e.g. mobile units, motor bikes for fieldworkers), and IUD kits..There
are a number of issues. First, the utilization of the buildings or vehicles concerned is
often not optimal because of lack of operational funds or diversion to other uses.
Second, family planning program needs are often not for infrastructure, but rather for
operational expenses of various kinds. Third, the Pemda has to put aside counterpart
funds amounting to 10 percent of the total DAK. This reduces the funds which should be
able to be used for operational expenses of the family planning program.
5.
It is recommended that for the kabupaten/kota where infrastructure needs have been
met, the DAK budget could be used for operational aspects of the family planning
program including for training of bidan, contraceptive supplies, etc.
49
7. 2019 Targets
7.1 Fertility – Population Dynamics
Indicator
TFR
2015
2.4
2016
2.4
2017
2.3
2018
2.3
2019
2.3
CBR
19.2
18.8
18.5
18.2
17.8
CDR
6.4
6.4
6.4
6.5
6.5
1.2
1.1
4,810
4,780
1,717
1,753
3,093
3,027
Rate of
1.3
1.2
1.2
growth
# births
4,985
4,869
4,4840
(x1000)
# deaths
1,622
1,653
1,684
(x1000)
Population
3,362
3,216
3,156
increase
(x1000)
Source: Official Population Projection, 2010-2035.
Notes
#Children
per woman
Births per
1000
population
Deaths per
1000
population
Annual %
7.2 Contraceptive Use- Balancing Method Mix
Indicator
2015
2016
2017
2018
2019
Notes
CPR all
60.5
60.8
61.1
61.5
61.8
% of
method
MWRA
Method
% of all users
Injectables
44.8
44.3
41.8
40.0
38.8
Pill
25.0
24.0
23.5
22.5
22.2
Condom
2.8
3.0
3.4
3.4
3.8
IUD
11.3
11.8
12.8
13.8
14.1
Implant
11.3
11.8
12.8
13.8
14.1
Female
3.8
4.0
4.6
5.3
5.8
Sterilisation
Male
1.0
1.1
1.1
1.2
1.2
Sterilisation
Source: Estimated by SMA and GWJ based on the policy to balance method mix while at the
same time strengthening the role of private sector and increasing male participation.
7.3 Reducing unmet need and increase in private sector use
Indicator
Unmet
need
Short term
method
Long
acting
Use of
private
sector
2015
10.2
2016
9.8
2017
9.4
2018
8.9
2019
8.5
71.3
68.7
65.9
64.8
62.8
Notes
% of (new
formula)
% of users
28.7
31.3
34.1
35.2
37.2
% of users
72.7
72.8
72.9
73.0
75
% source
of supply
50
7.4 Increase in quality assurance; Bidan competence and contraceptive supply chain
management
Indicator
Increase in
# bidan
delima
2015
12,500
2016
14,000
2017
16,000
2018
18,000
2019
20,000
Increase in
CSCM
20%
40%
60%
80%
100%
Notes
To anticipate
increase in
Long term
method
% of storage
management
meeting gold
standard
7.5 Adolescent RH - reducing teenage fertility
Indicator
Teenage
fertility, 1519
Age at first
marriage
2015
43
2016
41
2017
39
2018
37
2019
35/1000
Notes
ASFR
22.2
22.3
22.4
22.7
23 years
% teenage
unmet
need for
spacing
% teenage
unmet
need for
limiting
14.4
13.4
12.0
10.0
8.0
SMAM
based
SP2010
Age 15-24
years
1.0
0.5
0.3
0.1
0.1
Age 15-24
years
7.6 Coordination among stakeholders and community participation
Indicator
% of coordination between dinkes
and SKPD
Demand Creation
% increase of outreach by Bidan
% increase in community
participation
2015
2016
2017
2018
2019
40%
60%
70%
80%
90%
30%
30%
50%
50%
70%
70%
90%
90%
100%
100%
7.7 Equity
Indicator
Universal
access to
contraceptives
Increase in
contraceptive
use by the
poor*
Increase in
contraceptive
use
2015
60.5
2016
60.8
2017
61.1
2018
61.5
2019
61.8
Notes
Same as
CPR
53.0
55.0
57.0
59.0
61.8
20%
lowest
quintile
61.0
63.0
65.0
67.0
70.0
20%
second
lowest
quintile
51
Source: Estimated based on IDHS 2012.
52
8. Program and Main Activities
Policy, Programs, Activities and Indicators:
Fertility Family Planning and Reproductive Health (FFR)
FFR: (1) Lowering Fertility Rate to Replacement Level; (2) Promotion of Rising Age at
First Marriage; (3) Revitalization of Family Planning Program
(1) Lowering Fertility Rate
Program
•
•
Activities
Reinvigorate the
promotion of
benefit of having
small family size
values
•
Advocacy to
legislatures,
executives, at
national,
provincial and
district/municipal
level of social
and economic
benefit of
lowering fertility
•
•
•
Mass campaign to the wider community
and their leaders at the local level. Key
message is that having small family size
will improve the health of mothers and
children.
It is important to focus also to young
couples.
Meetings, Workshops, Auditions, or
Round table discussions with
executives, legislatives to advocate that:
Investment in population
control and family planning
program reduces the cost
of meeting basic needs for
the future generations and
therefore more money to
increase access of
children’s education and
health services.
In the long run reduction in
number of births will
reduce unemployment rate
Build an advocacy team at the national
and provincial level involving Ministry of
Health, Ministry of Education, Ministry of
Religion, Ministry of Interior, Ministry of
Finance etc. to implement this action.
Indicators
Data
Reduction of Ideal
Family Size among
young couples
IDHS
(three-five
years)
Increase in political
commitment to
implement family
planning as is
indicated by
increase in budget
for FP, especially at
the district/municipal
level
Reporting
base
(2) Support For Later Marriage (Remaja)
Program
Activities
•
IEC BCC to
community and
religious leaders to
comply with the legal
minimum age at first
marriage (16 years)
for girls
•
•
Advocate government
to enforce the
implementation of 9
years compulsory
education
•
The Provincial BKKBN representative
invites collaborations with Governors,
Bupati, Mayors and Indonesian
Commission of Child Protection (KPAI),
and SKPD-KB to strongly advise Village
and Sub-district Heads and the
Religious leaders and KUA to enforce
the Law on minimum age at marriage
for girls (16 years).
The Provincial BKKBN representative
invites collaborations with Governors,
DinDikBud, Bupati, Mayors, SKPD-KB
and KPAI to strongly advise Village and
Sub-district Heads and the Religious
and SKPD-KB to enforce the
implementation of 9 years compulsory
education
Indicators
Data
Increase in age at
first marriage
especially among
girls
IDHS
(three-five
years),
SUPAS
2015
Increase in
education level up to
9 years of schooling
Susenas
(yearly).
53
•
IEC to parents and
youth about the
danger in early
marriage and
childbearing
•
•
Teenagers who
already married, IEC
to delay childbearing
•
The Provincial BKKBN representative
invites collaborations with Governors,
DinKes, DinDikBud, Bupati, Mayors,
Village and Sub-district Heads, SKPD
KB and KPAI
to inform parents and the
youth about the danger of
early marriage, early
childbearing, unintended
pregnancies which lead to
unsafe abortion and
maternal mortality
IEC to parents to keep
children in school at least
until 9 years of schooling
The Provincial BKKBN representative
invites collaborations with Governors,
DinKes, Bupati, Mayors, Village and
Sub-district Head and SKPD-KB
To inform parents about
the danger of early
marriage, early
childbearing, unintended
pregnancies which lead to
unsafe abortion and
maternal mortality
To educate teenage
couples to delay their first
birth, to plan their families
and have small family size.
Increase in age at
first marriage
especially among
girls
IDHS
(three-five
years)
Reduction in
teenage fertility
indicated by age
specific fertility rate
15-19 years.
IDHS
(three-five
years)
(3) Revitalization of Family Planning Program
Program
•
•
Demonstrate political
commitment to the FP
program and
strengthen
coordination at the
central level
Strengthen political
commitment to
implement FP
program especially at
the district/municipal
level
Fostering more
effective collaboration
at the District Level.
Activities
Indicators
Data
Directive of collaboration among MOH,
Mendagri and BkkbN through a Ministerial
surat edaran (Especially PERDA from the
Ministry of Interior)
Issuance of surat
edaran and PERDA
BkkbN at the Central and provincial level
and SKPD-KB to advocate Dinkes, Bupati,
Mayors and SKPD-KB that:
•
family planning is essential to improve
mother and child health
•
Investment in family planning program
will be beneficial in the near future as it
reduces child development cost and
therefore resources can be focused on
meeting basic needs for children.
•
BkkbN at the provincial level provide
technical support to SKPD-KB:
To identify potential and
challenges and set
priorities in program
planning and budgeting
and implementing family
planning program
Support the SKPD-KB to
participate in developing
family planning and
budgeting in collaboration
with other local
stakeholders (DinKes,
DinDikBud, Bupati, Camat
Increase in budget
allocated for FP
program at the
district/municipal
level
Reporting
base
Increase in
complying with the
Minister of Health’s
instruction on the
collaboration
between SKPD-KB
and DinKes
Reporting
base
54
•
Demand creation to
promote
contraceptive use
•
Meeting the need for
FP of couples who
want to space or to
limit childbearing but
are not using
contraceptives
•
Balancing method
mix
•
Assist private sector
etc) and Bappeda at
Kabupaten and Minicipal
level in development
planning
•
BkkbN at the provincial level in
collaboration with DinKes lead SKPDKB, Bidan, PLKB, sub-district and
village head,
to inform couples about
the benefit of family
planning for the health of
mothers, the children and
the welfare of the whole
family
to promote contraceptive
use on the basis of life
cycle approach (couples
who want to space or to
limit childbearing)
to provide information to
couples about various
contraceptive devices
each with its benefit and
risk
to support Bidan dan
Doctors at Puskesmas to
help couples to choose the
appropriate contraceptive
method to the couples
(effective counseling).
•
BkkbN at the provincial level and SKPDKB in collaboration with Dinkes at
Kabupaten leve to:
Prepare accurate and
timely data on number and
location of couples with
unmet need for
contraceptive services.
To promote couples with
unmet need to use
appropriate contraceptive
method (short term and
long acting method)
To advise couples to
comply with regulation of
using contraceptives
(taking pills daily, etc).
BkkbN at the provincial level and SKPD-KB
in collaboration with Dinkes, Bidan and
Puskesmas Doctors at Kabupaten level to:
•
Advise couples about the benefit of
using long-acting contraceptive
method. That investment in longterm method use is more costly but
yearly cost is cheaper
•
Inform couples to use contraceptive
method according to their need,
spacing or limiting. Couples who
want to limit childbearing are
suggested to switch to long-term
method.
•
Promote couples who have unmet
need to use appropriate
contraceptive method (short term
and long acting method)
• BkkbN and Ministry of Health and IBI at
province and district level to support
Increase in the use
of contraceptives for
family
planning(CPR)
Susenas
(yearly),
IDHS
(three – five
years)
Reduction in
percentage of
couples with unmet
need for
contraceptives
Susenas
(yearly),
IDHS
(three – five
years)
Increase in the
percentage of
couples using longacting
contraceptives
Susenas
(yearly),
IDHS
(three – five
years)
•
Increase in
number and
Reporting
base
55
to better meet the
needs of the 73% of
users - A bidan
focused strategy•
•
•
•
Strengthening
contraceptive supply
chain management
•
•
•
•
•
•
Meeting the need of
economically
disadvantaged
couples
•
•
•
•
•
Meeting the
•
efforts to increase number and
distribution of bidan who are certified
with Contraceptive Technological
Update (CTU).
BkkbN and Ministry of Health and IBI to
support efforts to Improve and increase
the training opportunities for qualified
bidan with CTU certification and
counseling competencies
BkkbN and Ministry of Health Assist IBI
to increase number of Bidan Delima
BkkbN and Ministry of health at central,
provincial and district level to support
SKPD-KB in efforts to improve field data
as basis for providing contraceptive
supplies (based on the Pemenuhan
Permintaan Masyarakat data).
Keep accurate records on contraceptive
availability to avoid stock out
BkkbN promote the procurement system
using e-catalog for transparency.
Improve storage warehouses consistent
with gold standards needed to maintain
the quality of contraceptives
Allocate funds for the management of
the warehouses
Allocate funds for ‘handling cost’ and
ensure that contraceptives reach the
clients who need them
BkkbN allocates resources to support
economically disadvantaged couples
BkkbN and Dinkes provide access to
services which are affordable to the
poor
BkkbN at the central and provincial level
support the SKPD-KB and DinKes in
communicating to poor couples about
the benefit of using contraceptives for
planning their births.
Support Bidan and Puskesmas Doctors
to reduce side effect or health related
problem resulting from contraceptive
use
BkkbN to support GENRE program at all
better
distribution of
bidan with
CTU
certification
•
Increase in
number and
better
distribution of
bidan with
CTU
certification
and
counseling
•
Increase in
number and
distribution of
Bidan Delima
•
Availability of
data needed
to estimate
number of
contraceptives
by method
•
Improve
recording and
reporting
system of
contraceptive
availability
and need
•
Increase in
number of
storages
consistent
with standards
needed to
maintain the
quality of
contraceptives
•
Increase in
funding for
management
of storage to
maintain
quality of
contraceptives
•
Increase in
funding for
handling cost
(delivery to
end users)
Increase in
contraceptive use
among the poor
IDHS
(three-five
years)
Increase in the
IDHS
Reporting
base
Reporting
base
56
reproductive health
needs of the
unmarried
•
•
•
Financing of the
family planning
program
11. FP Program under
BPJS and JKN KB
•
•
levels of government administration
which assist young people to pursue
quality living and avoid risky behavior
including pre-marital unsafe sex
BkkbN supports NGOs to meet
reproductive health information and
service needs of the youth
Strengthen the coordination between
government ad partners (NGOs).
Regular budget from APBN
When infrastructure and equipment at
the kabupaten level have been met, it is
suggested that DAK to be used for:
contraceptive supply chain
management,
handling cost of
operational family planning
program
training of bidan to
increase the number and
distribution of CPU
certified bidan.
To be discussed further
coverage of
reproductive health
services of the
unmarried
Increased budget
and resources for
contraceptive supply
chain management,
handling cost of
operational family
planning program,
training of bidan to
increase the number
and distribution of
CPU certified bidan.
Reporting
base
57
9. Risks
There are many potential risks involved in the policy proposed for population, family planning and reproductive health. A matrix
setting out these risks, their potential impact, and proposed solutions to them is provided below.
Matrix of Risk, Potential Impact and Potential Solutions
Guidance
No. Area/Issue
Potential Problems
Policy or Topic Area Describe the problem is risk
POLICY
1
Institutional
arrangement
POLICY
2 FFR JKN-KB
Potential Impact
What is the impact of this risk why is it important to respond political risks,social or equity risks, technical risks, economic risks
List the proposed technical solution and who should take lead in
responding to the problem
(1) lack of political commitment to implement
Family Planning Progarm at the
Kabupaten/Kota level; (2) lack of clear division
of work and responsibilities among local
institutions, leading to lack of coordination in
FP imlementation; (3) these are due to laws
and regulations that result in FP having no
institutions with authority to conduct FP at
the local level; (5) capacity of local officials
who are able to develop program planning,
budgeting and monitoring.
(1) this leads to inadequate funding for FP program
implementation; (2) sustainability of FP services is challenged as
well as hampering the effort to reduce unmet need for FP
services (especially for the poor), which leads to unwated
pregnancy and maternal mortality due to unsafe abortion; (3)
meanwhile mothers with uncontrolled fertility will have high
morbidity due to too many births and short space between
births (4) the macro effect is increase in fertility, maternal
mortality; (5) low capacity of local officials to negotiate the
benefit of FP program will lead to the lacki of FP funding.
(1) Work with Ministry of Interior (Mendagri) and MOH to implement
Law number 52 of 2009 to establsih BPKBD which have authority to
implement FP program in all kabupaten/kota; (2) Work with Ministry of
Interior to devleop PERDA to establish BPKBD and Perda on FP
implementation (as one of the 'urusan wajib' mandated by PP 2007;
(3)Meanwhile, build an advocacy team with capacity to convince
executives and Legislatures at Kabupaten level that FP program is
beneficial for the future generations; (3)mass campaign about the
benefit of the FP program;(4) increase coordination of SKPD-KB with
Dinkes and Bupati; (5) Increase involvement of SKPD-KB in District
Development planning to include FP program at the Kabupaten level; (6)
at the central level - coordination with clear responsibilities between
BKKBN and MOH and Mendagri should be strengthened; (7)BkkbN
should provide technical support and guidance to increase capacity of
local staff.
(1) Difference in philosophy between
insurance and risk pooling and planning as in
FP (promote as many acceptors as possibe to
utilize JKN-KB) (2)73%of acceptors are
already paying out-of-pocket for FP services,
while BPJS mandated that contraceptives are
provided for free ; (3) BPJS mandated that for
individual providers to have direct contract
with BPJS, this individual should be within the
area coverage of 3000 population; this
hampers the reimbursment of service
providers who are mostly bidan; (4)
contraceptive use is skewed toward the use of
short-term methods with high discontinuation
of use. This challenges the effort to reduce
fertility rate.
(1) Providing contraceptives for all users challenges the
sustainability of financing JKN-KB which in turn challenges the
sustainability of FP services; (2) Problem of providers'
reimbursement for their services demotivates them from
providing FP services under the JKN system; (3) Regulation on
the basis of number of area coverage is difficult to implement in
regions with low density of population such as Kalimantan and
Papua; (4) All of these increased number of couples with unmet
need for contraception especially those who are poor
increasing risk of unintended pregnancy leading to unsafe
abortion, and maternal mortality, (5) mothers with unwanted
birth tend to be less motivated in child care and development,
which challenges the quality of the future generations, (6) the
macro effect of unmet need is higher fertility and poverty
(1) Review BPJS law and regulations that mandated that every acceptor
should be provided contraceptives for free. (2) Suggest special
regulation for JKN-KB where acceptors of IUD, Implants and Injectables
who were able to pay have to bring their own contraceptices for FP
services; (3) establish a system where IUD, Implants and Injectables are
easily accessible and affordable by acceptors who used to pay for the
services; (4) for the PBI members of JKN contraceptives are provided for
free; (5) review regulation that bidan can have direct contract with BPJS
if they have 3000 population (area coverage - too wide); (6) review
regulation that BPJS only covered sterilization of FP and suggest
inclusion of IUD and Implant insertion and expulsion to increase the use
of Long-acting method, to support the fertility reduction efforts
58
Guidance
No. Area/Issue
Policy or Topic Area
Potential Problems
Describe the problem is risk
Potential Impact
What is the impact of this risk why is it important to
respond - political risks,social or equity risks, technical
risks, economic risks
List the proposed technical solution and who should take lead in responding
to the problem
POLICY
3 FFR- RH- services
for the unmarried
(1) the tendency of declining age at first marriage
especially among the uneducated and poor
increases the incidence of early childbearing; (2)
government program to increase age at marriage
without appropriate RH services for the
unmarried youth increases the risk of unintended
pregnancy among the youth; (3) increase in
educational attainment and labor force
participation among the youth increases age at
first marriage and therefore increases demand for
RH services among the youth; (4) increasing
tendency of special group of people remaining
single
(1)Early childbearing increases the risk of maternal
morbidity and mortality. (2) Increasing age at marriage
and the proportion of women remaining single without
appropriate RH services will lead to unintended
pregnancy which in turn leads to unsafe abortion among
the youth. This increases the risk of maternal mortality;
(3) young girls/couples are not prepared to be responsible
parents which puts at risk the quality of the future
generations
(1) law of 2009 that FP services are only for married couples should be
reviewed; (2) meanwhile the ambiguity of government about providing RH
services for the special group of people (the youth and the unmarried) has
to be solved by strengthening collaboration with NGOs and private sector;
(3)Government should advocate executives and legislatures at all levels as
well as community leaders to NOT Criminalize unmarried people and youth
with regard to such behaviour; (4) IEC for the unmarried youth about the
risk of unsafe sex; (5) strengthen BkkbN's role to educate youth to avoid
risky behavior and to be prepared for responsible parenthood through the
GENRE program aiming for better quality of the future generations
SYSTEM
4 Supply side
readiness
(Midwives and
Contraceptive
availability)
(1) shortage of bidan with certifications and low
quality of contraceptive supply chain
management; (2)shortage of bidan with
Contraceptive Technology Update (CTU) and
geographically uneven distribution of bidan: (3)
stock out of contraceptive supplies; (4)poor
management of contraceptive supply chain
(1) lack in number and uneven distribution of bidan and
poor management of contraceptive supply chain
threaten the sustainability of FP services; (2) shortage of
bidan with CTU certification threatens the quality of FP
services which leads to high risk of side effect and
discontinuation, and therfore increases TFR; (4) increased
rumours of side effects demotivate women from using
contraceptives; (5) increased unmet need for
contraceptive use --> increased unintended pregnancy
and abortion that lead to maternal mortality
(1) Suggest BkkbN to recruit more bidan and improve the geographic
distrbution; (2) advocate executives at the Kabupaten level to also recruit
more bidan; (3) work with MOH to increase number of training programs
and improve the quality of bidan training; (4) MOH and BkkbN review rules
and regulations hampering the training organizations; (5) BkkbN
strengthen collaboration with private sector, especially the professional
organization such as IBI to organize and conduct training of Bidan and
Bidan Delima. (6) BkkbN provide financial support for IBI to conduct bidan
training, monitoring and evaluation; (7) DAK money should be able to be
used to improve storage of contraceptives, to cover handling cost and
improve delivery mechanism to end users, and to conduct training for
bidan and training for contraceptive storage managers
59
10. Challenges
Many aspects of the situation in Indonesia hamper the effort to apply the policies and solve
the strategic issues already identified. Some of them have to do with the political and
administrative situation; others have to do with cultural and other aspects. The devolution of
authority to the districts, implemented in 2004, is one major factor which has had benefits in
locating the planning decision-making closer to the people whose lives are affected by it, but
at the same time it has introduced numerous headaches for development programs which
previously relied on a centralized, vertical approach to planning and implementation. The
family planning program was one such program. The capacity for planning at the local level
varies considerably as does the efficiency in program implementation. Currently, we see the
SKPD-KB typically being marginalized in district-level decision-making about budget
allocation and allocation of resources. At the district level, there is not always effective
collaboration between Depkes, BkkbN and the Pemda. In any case, the private sector now
supplies 73% of contraceptive users; though the further complication is that the private
sector often means the public sector after office hours, in that the private sector may be the
same person (doctor, nurse, bidan) wearing a different hat. This can lead to conflict of
interest issues, distortion of public programs and at worst, neglect of the best interest of
clients for the sake of personal profit.
As already mentioned in Section 3, there are major personnel limitations and supply chain
issues in the revitalization of the family planning and reproductive health program in
Indonesia. There are also some very specific challenges in integrating family planning and
reproductive health in the new Jaminan Kesehatan National, which have been outlined in
Section 5. An ongoing issue is widely different perspectives within the community and within
government about the provision of reproductive health information and services to the
unmarried. This is an issue that is not going to go away, and it cannot be swept under the
carpet, because it concerns matters of life and death for many young women. In dealing with
all these issues, an open attitude by government officials will be needed, and an effort to
overcome institutional rivalries in the interest of the greater wellbeing of the Indonesian
people.
60
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62
Appendix Table 1. Changes in Singulate Mean Age at Marriage (SMAM) and in %
females ever married at ages 15-19 between 2005 and 2010, Indonesian provinces
Province
SMAM
% females ever married aged
15-19
2005
2010
difference
2005
2010
INDONESIA
23.4
22.2
Yogyakarta
25.7
West Sumatra
difference
-1.2
9.2
14.4
5.2
24.2
-1.5
2.2
6.1
3.9
24.4
22.9
-1.5
4.7
6.2
1.5
Riau islands
24.6
24.4
-0.2
5.2
7.5
2.3
East Nusatenggara
24.0
23.4
-0.6
5.9
7.7
1.8
Maluku
23.7
23.6
-0.1
5.6
8.3
2.7
Bali
23.2
22.3
-0.9
6.6
10.5
3.9
Riau
23.7
22.5
-1.2
8.0
10.6
2.6
Lampung
22.9
22.0
-0.9
8.8
12.0
3.2
North Maluku
23.2
22.7
-0.5
9.7
12.7
3.0
South Sulawesi
24.4
23.0
-1.4
9.7
13.3
3.6
Central Java
23.4
22.0
-1.4
7.9
13.4
5.5
West Java
22.9
22.2
-0.7
11.2
13.5
2.3
Bengkulu
23.0
22.2
-0.8
9.7
13.5
3.8
North Sulawesi
23.9
22.4
-1.5
5.9
13.6
7.7
South Sumatra
23.7
22.2
-1.5
7.7
14.5
6.8
Papua
21.9
22.3
+0.4
14.7
14.6
-0.1
Southeast Sulawesi
23.2
22.3
-0.9
11.7
15.1
3.4
West Nusatenggara
22.4
22.1
-1.3
13.6
15.4
1.8
East Kalimantan
23.4
22.1
-1.3
9.3
15.4
6.1
East Java
22.7
21.9
-0.8
12.6
15.6
3.0
West Kalimantan
23.7
22.1
-1.6
8.2
16.0
7.8
Gorontalo
21.9
21.7
-0.2
13.0
16.0
3.0
63
Central Sulawesi
22.4
21.8
-0.6
15.0
17.0
2.0
Jambi
22.3
21.1
-1.2
9.6
17.1
7.5
DKI Jakarta
26.4
23.4
-3.0
14.0
17.1
3.1
North Sumatra
24.9
21.7
-3.2
13.7
17.5
3.8
Bangka-Belitung
22.0
21.3
-0.7
14.3
19.0
4.7
South Kalimantan
22.2
21.1
-1.1
16.3
22.3
6.0
Central Kalimantan
22.0
21.0
-1.0
10.5
22.7
12.2
Banten
22.9
21.5
-1.4
8.2
22.8
14.6
64
Appendix Table 2. Projection of TFR 2010-2035 by Province.
65
Appendix 3 List of Individuals and Organizations Consulted
1
Dates
13 Jan
Organization
BkkbN
2
13 Jan
BkkbN
3
20 Jan
BkkbN
4
20 Jan
BkkbN
5
28 Jan
Johns Hopkins Center for
Communication Program for FP
6
4 Feb
Director of BkkbN Private Sector FP
7
4 Feb
BkkbN
8
7 Feb
AFP JHU CCP
9
10 Feb
Bappenas
10
24 Feb
11
3 March
12
19
March
13
29 April
14
30 May
2014
Meeting with Staff of Bappenas on
JKN KB
Meeting with Chairpersons of IBI
and some staff at IBI headquarter
Discussion on JKN-KB with Director
ofPrivate Sector FP and staff
Bappenas handling JKN.
Consultation on JKN-KB with staff
of Deputy FP at BkkbN
Director of Planning at the BkkbN
Name and Title of Individuals
Head of BkkbN: Prof Dr Fazli Jalal,
with Prof Gavin Jones and Prof
Endang Achadi.
Deputy FP and RH: Dr dr Julianto
Wicaksono
Director of Finance and Logistics
Management : Mr Sugilar
Deputy Family Welfare: Dr Sudibyo
Alimuso
Ms Fitri Putjuk, Dr Ishar Fihir, dr Cut
Idawani, ms Inne Sylviane, ms Utari,
Mr Eddy Hasmi, Dr Rahmat Santika.
Ibu Sri Rahayu
Deputy Family Welfare: Dr Sudibyo
Alimuso on GENRE
Ibu Tuminah member of IBI, Ibu
Inne, Ibu Utari, Ibu Fitri Putjuk
Deputy of HR. Ibu Nina Sardjunani.
DR Theresia Ronny and Secretary
General BKKBN Ibu Ambar
Ibu Emi, Ibu Tuminah and two other
Bidan
Ibu Yayuk from BkkbN and Ibu Tere
from Bappenas.
Dr Irma Adiana MSI.
Mr IPIN MSI
66