HEALTH SECTOR REVIEW

FERTILITY, FAMILY PLANNING AND REPRODUCTIVE HEALTH

JULY 2014 1

AUTHORS: GAVIN JONES SRI MOERTININGSIH ADIOETOMO

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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.

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A list of names of resource persons and their affiliation is attached in the annex

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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

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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

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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

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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

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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

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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-

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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.

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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.

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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.

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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

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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.

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References Bongaarts, John, 1978, “A framework for analyzing the proximate determinants of fertility”, Population and Development Review, 4(1): 105-131. BPS, 2011Pertumbuhan Penduduk dan Persebaran Penduduk Indonesia, Hasil Sensus Penduduk 2010, Jakarta: BPS. Brandt, P.M. Jesse and Clara L. Benarto, 2013, Final Report of the Contraceptive Supply Chain Management Assessment Team, Jakarta: UNFPA and BKKBN. Bryant, John, 2007, “Theories of fertility decline and the evidence from development indicators”, Population and Development Review, 33(1): 101-127. Darwin, Muhadjir and Sukamdi, 2009, Revitalization of Family Planning Program in Indonesia, Yogyakarta: Center for Population and Policy Studies, Gadjah Mada University. Febriani, Esty, 2012, “Laporan hasil analisa situasi program KB di kabupaten” Hayes, Adrian C., 2010, “The status of family planning and reproductive health in Indonesia”, UNFPA-ICOMP Regional consultation, Family Planning in Asia and the Pacific, Addressing the Challenges, Bangkok, 8-10 December. Hull, Terence, forthcoming, “Indonesia’s fertility levels, trends and determinants: dilemmas of analysis”, in Gavin W. Jones and Christophe Guilmoto (eds), 40% of the world: Population and Development Issues in China, India and Indonesia, Singapore: NUS Press. Hull, Terence and Henry Mosley, 2009, Revitalization of Family Planning in Indonesia, Jakarta: GOI and UNFPA. Jones, Gavin W., 2012, “Feedback report on status of implementation of “The call for the elimination of unmet need for family planning” in selected countries of Southeast Asia”, paper prepared for UNFPA-ICOMP Workshop on Operationalizing the Call for the Elimination of Unmet Need for Family Planning in Asia and the Pacific Region, The Imperial Queens Park Hotel, Bangkok. Lewis, Gary L. and Haripurnomo, 2009, Revitalization of Family Planning in Indonesia: A Strategy for Empirically Based Implementation, Jakarta: BKKBN. Lubis, Firman, 2003, “History and structure of the national family planning program”, in Anke Niehof and Firman Lubis (eds), Two is Enough: Family Planning in Indonesia under the New Order 1968-1998, Leiden: KITLV Press. Government of Indonesia, Coordinating Ministry of People’s Welfare (MENKOKESRA). Peta Jalan Menuju Jaminan Kesehatan Nasional 2012-2019. Nurjasmi, Emi, 2011, “Peranan Bidan dalam program kependudukan dan keluarga berencana”

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Parsons, J.S., Izhar Fihir and Inne Silviane, 2013, Rapid Situation Analysis of the Indonesian Family Planning Program: Assisting Indonesia Achieve its MDGs and FP2020 Commitments – The Role of Midwives, Robinson, Warren and John Ross (eds), 2007, The Global Family Planning Revolution: Three Decades of Population Policies and Programmes, Washington: The World Bank. Sedgh, G. And H. Ball, 2008, “Abortion in Indonesia, In Brief, New York: Guttmacher Institute. Statistics Indonesia (Badan Pusat Statistik—BPS), National Population and Family Planning Board (BKKBN), and Kementerian Kesehatan (Kemenkes—MOH), and ICF International, 2013, Indonesia Demographic and Health Survey 2012. Jakarta, Indonesia: BPS, BKKBN, Kemenkes, and ICF International. Thomas, William J. and Sri Moertiningsih Adioetomo, 2010, BKKBN Organization Development Consultation March 18-April 15, 2010, Jakarta: BKKBN. Utomo, Budi et al., 2001, “Incidence and social-psychological aspects of abortion in Indonesia: a community-based survey in 10 major cities and 6 districts, year 2000”. Utomo, Iwu Dwisetyani and Peter McDonald, 2009, “Adolescent reproductive health in Indonesia: contested values and policy inaction”, Studies in Family Planning, 40(2): 133-146.

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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