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TOWARD A BETTER MATERNAL AND CHILDREN CARE IN INDONESIA
 

TOWARD A BETTER MATERNAL AND CHILDREN CARE IN INDONESIA

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Project Report from My exchange in India presented to professor and dean in Universitas Indonesia

Project Report from My exchange in India presented to professor and dean in Universitas Indonesia

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  • So the idea of social determinants of health is to closer the gapMaternal and child health shows health inequitis and disparity

TOWARD A BETTER MATERNAL AND CHILDREN CARE IN INDONESIA TOWARD A BETTER MATERNAL AND CHILDREN CARE IN INDONESIA Presentation Transcript

  • TOWARD A BETTERMATERNAL ANDCHILDREN CARE ININDONESIALESSON FROM INDIA NATIONALRURAL HEALTH MISSION FMUI, Jakarta October 3rd, 2012 Shela Putri Sundawa, Universitas Indonesia
  • PROPOSAL REVIEW
  • CLOSER THE GAP Social Health Inequities andDeterminants disparities of Health Maternal and child health problem
  • BACKGROUND
  • INDONESIA
  • MATERNAL MORTALITY RATESource: Report on the Achievement of the Millenium Development Goals Indonesia 2010. Bappenas. 2010
  • CHILD MORTALITY RATESource: Report on the Achievement of the Millenium Development Goals Indonesia 2010. Bappenas. 2010
  • Maternal and infant Major cause of maternal mortality death in Indonesia: haemorrhage in post partum Indicate inadequateIndicate effectiveness in health management of 3rd satge system functioning labor and failure in emergency care in health system Poor health system delivery in Indonesia
  • MATERNAL MORTALITY Need special attention and improvement in health care delivery system Skilled birth attendand delivery in urban > ruralSource: Report on the Achievement of the Millenium Development Goals Indonesia 2010. Bappenas. 2010
  • HEALTH SYSTEM DELIVERY rural urban
  • INDIA
  • Source: Millenium Development Goals India Country Report 2009. Central statistical organization, Ministry of Statisticand Program Implementation. 2009
  • Source: Millenium Development Goals India Country Report 2009. Central statistical organization, Ministry of Statisticand Program Implementation. 2009
  • MATERNAL MORTALITY
  • HEALTH SYSTEM DELIVERY Urban Rural National Urban Health Mission National Rural (not yet Health Mission launched) Different needs, different strategiesSource: Kishore J. National health programs of India: national policies and legislations related to health. 8th ed. NewDelhi: century publications. 2009
  • NRHM 212 in 2007-9Report of the working group of national rural health mission for the tweleft five year plan (2012-2017)
  • INDONESIA:COUNTRY HEALTH PROFILE
  • Basic Information Latest available value Year Total population (million) 222.05 2006 Area (sq.km.) 1,860,360 Area as percent of world’s total 1,37 Density of population (per sq.km.) 116COUNTRY PROFILE 2005 Administrative divisions 33 provinces, 349 regencies, and 91 municipalities Development Latest available value Year Gross national income (GNI) per 1280 2005 capita (US $) Population below poverty line – 5.9 2008 International $1 per day (%) Population below national poverty 17 2004 line (%) Adult literacy rate > 15 years (%) 91 2004 Net enrolment ratio – primary (%) 99.47 2009 Human Development Index 0.711 2004 Human Poverty Index (%) 18.5 2006 WHO. Mini Profile SEAR counties. 11 questions about the 11 SEAR countries. 2007
  • PROGRESS OF HEALTH RELAT Indicators 1990 2000 2005 2010 2015 (Target) Poverty and hunger Population below minimum level of 70 74 65 61,86 35 dietary energy consumption % (2000 kcal/capita/day) Under-weight (<-2SD) children (%) 38 25 28 17,9 18 Child mortality Infant mortality rate (per 1000 live births) 68 46 34 (2007) 23 Under five mortality rate (per 1000 live 97 58 46 44 32 births) (2007) One year olds immunized against measles 45 60 77 >90 (%) Maternal health Maternal mortality ratio (per 100,000 live 390 307 228 (2007) 102 births) Deliveries attended by health staff (%) 41 67 72 85 HIV/Malaria/Tuberculosis HIV prevalence in 15-49 years (per N/A 93 149 Decrease 100,000 population at risk) WHO. Mini Profile SEAR counties. 11 questions about the 11 SEAR countries. 2007.
  • Continued..Malaria incidence (per N/A 850 N/A Decrease100,000 population at risk)Tuberculosis prevalence (per 443 786 262 244 Decrease100,000 population) (2009 )Tuberculosis detection rate N/A 19 29 73.1 70under DOTS (%)Water and sanitationPopulation with access to 69 76 88 86improved water source (%)Population with improved to 54 66 78 77access sanitation (%)WHO. Mini Profile SEAR counties. 11 questions about the 11 SEAR countries. 2007
  •  Indonesia is on track to achieve MDGs point 4 by 2015 However, there is disparity in neonatal, infant and uder-five mortality rates by demography. Maternal mortality also shows higher rate in rural areas than urban ares  related to disparity in births assisted by skilled personnel  higher in urban area
  • AVAILABLE RESOURCES FOR HEALTH SECTOR Indicators Latest Available Value Year Expenditure on health Percentage of GDP 2.8 2003 Per capita (US$) 33 2003 Per capita (Intl.$) 118 2003 Food Average dietary energy consumption 2880 2001-2003 (kcal.day/person) Services Health center (per 100,000 3.6 1998 population) Antenatal care coverage (at least 81 2004 four visits) (%) Deliveries by qualified attendant (%) 77,34 2009WHO. Mini Profile SEAR counties. 11 questions about the 11 SEAR countries. 2007
  • continued Children immunized (%) 2005 BCG 82 DPT-3 70 Polio-3 70 Measles 72 Primary Health Centre 31,581 Sub health centers 21,115 Community health centre 7,243 Integrated health post 243,783 Human resources Doctors of modern system (per 2.0 2001 10,000 population) Nurses (per 10,000 population) 13.0 2001 Midwives (per 10,000 population) 2.0 2004 Dentists (per 10,000 population) 0.3 2004 Community health worker (per 10,000 3.6 2004 population)WHO SEARO. Improving maternal, newborn, and child health in south east asia region: Indonesia.WHO. Mini Profile SEAR counties. 11 questions about the 11 SEAR countries. 2007
  •  Health expenditure on health is very low Public expenditure on health is 34%, private expenditure 66%  ¾ private expenditure is out of pocket One subdistrict at least 1 PHC  1 doctor, 1 public health nurse, midwive and other paramedic Each center supported by 2 or 3 sub- center At the village level: integrated healt post  cover 50-100 household WHO. Mini Profile SEAR counties. 11 questions about the 11 SEAR countries. 2007 WHO SEARO. Indonesia.:National Health system profile. 2007
  • WHO SEARO. Indonesia.:National Health system profile. 2007
  • HEALTH FACILITY IN DIFFERENT LEVELWHO SEARO. Improving maternal, newborn, and child health in south east asia region: Indonesia.
  • CHALLENGES A lot of vacant place for health care provider in PHC especially those in rural area Wide disparity in rural-urban area Health needs are rapidly increasing WHO. Mini Profile SEAR counties. 11 questions about the 11 SEAR countries. 2007
  • INDIA: COUNTRY HEALTH PROFILE
  • Basic Information Latest available value Year Total population (million) 1028.61 2001 Area (sq.km.) 3,287,590 Area as percent of world’s total 2.43 Density of population (per sq.km.) 325 2008COUNTRY PROFILE Administrative divisions 35 states, 593 districts, 5161 towns, 638588 villages Development Latest available value Year Gross national product (in crores) 2812758 2005 Population below poverty line (%) 25.9 2005- 2006 Food poverty line (Rs. Per person 2004 per month) 160.20 Rural 185.17 urban Literacy rate > 7 years (%) 65.49 2008 Source: Kishore J. National health programs of India: national policies and legislations related to health. 8th ed. New Delhi: century publications. 2009
  • Indicators Latest Available Value Year Expenditure on health Percentage of GDP 0.91 2008 Household health expenditure (%) of 2008 total health 6 Rural 5 urban No. Of Medical College 242 (2001-2006) No. Dental Colleges 205 2008 No. Of Colleges ISM & H 219 2005 No. Hospital 15393 2003 Subcenters 144988 2005 Primary Health Centers 222699 2005 Community health centre 3910 2005 Services Health center (per 100,000 population) 3.6 1998Source: Kishore J. National health programs of India: national policies and legislations related to health. 8th ed. NewDelhi: century publications. 2009
  • Deliveries by qualified attendant (%) 58 2008 Children immunized (%) 2005 Measles 69.6 Human resources Doctors per 100,000 population 70 2005 Dentists per million population 45 2005 Nurses ANM 527482 2007 Nurses GNM 930526 2007 Nurses LHV 51186 2007Source: Millenium Development Goals India Country Report 2009. Central statistical organization, Ministry of Statisticand Program Implementation. 2009Source: Kishore J. National health programs of India: national policies and legislations related to health. 8th ed. NewDelhi: century publications. 2009
  • PUBLIC HEALTH CARE SYSTEM IN INDIA Urban  Central government health scheme  Goverment hospital  Urban health services  Urban family walfare centers  Urban health posts Rural  Community health center  Primary health center  Sub-centerSource: Kishore J. National health programs of India: national policies and legislations related to health. 8th ed. NewDelhi: century publications. 2009
  • URBAN-RURAL DISPARITY urban ruralSource: Kishore J. National health programs of India: national policies and legislations related to health. 8th ed. NewDelhi: century publications. 2009
  • NATIONAL RURAL HEALTH MISSION
  •  Start: April 5th, 2005 Aim:  provide accesible, accountable, effective and reliable primary health care, and bridging the gap in rural health care Goals:  reduction IMR and MMR by 50% from existing level in 7 years  universalize access to public health services Park K. Park’s Textbook of Preventive and Social Medicine. 20th ed. Jabalpur (India): Banarsidas Bhanot; 2009. P. 405-8.Source: Kishore J. National health programs of India: national policies and legislations related to health. 8th ed. NewDelhi: century publications. 2009
  •  Plan of action: 1. ASHA 2. Strengthening Sub-Centers 3. Strenghtening Primary Health Centers 4. Strenghtening CHC for first referral care 5. District health plan 6. Converging sanitation and hygiene under NRHM 7. Strengthening disease control program 8. Public private partnership 9. New Health Financing Mechanism 10. Reorienting health/medical education to support rural health issuesSource: Kishore J. National health programs of India: national policies and legislations related to health. 8th ed. NewDelhi: century publications. 2009
  • NRHM INFRASTUCTURE Park K. Park’s Textbook of Preventive and Social Medicine. 20th ed. Jabalpur (India): Banarsidas Bhanot; 2009. P. 405-8.
  • ASHA(ACCREDITED SOCIAL HEALTH ACTIVISTS)  Act as bridge between ANM and village and be accountable to panchayat  Receive performance based incentive  Together with Anganwadi worker, community wokers, and ANM develop Village Health Plan  Responsibility:  Create awareness and provide information to community on determinants of health  To counsel women about ANC, INC, PNC, nutrition, immunization, contraception  To mobilize community in accesing health serivice  To provide primary medical careSource: Kishore J. National health programs of India: national policies and legislations related to health. 8th ed. NewDelhi: century publications. 2009
  • TESTIMONY FROM THE FIELD Mrs. S, 41, ASHA Working as ASHA is enjoyful. First time I do this job , it is really hard because no one knows what ASHA works is. I have to make them aware of myself as ASHA and its work. But now, it becomes easier. I like being ASHA. I like to do the work for my community . By being ASHA, I can also increases my knowledge in health issue. Until now, there is no major obstacle. To communicate with medical officer or ANM in PHCis easy because I have their mobile phone number. If there’s inlabor patient I only need to call ambulance from PHC. However, they only paid salary based on my works, there is no fix salary. Therefore, I have to work in the farm to secure my family income.
  • PHC PHC in NRHM plan of action  Strengthening PHC for quality preventive, promotive, curative, supervisory and outreach service  Adequate and regular supply of essential quality drugs and equipment of PHC  Provision of 24 hour services in 50% PHCs  Standard treatment guideline and protocolsSource: Kishore J. National health programs of India: national policies and legislations related to health. 8th ed. NewDelhi: century publications. 2009
  • TESTIMONY FROM THE FIELD Mr. A, 28, Medical OfficerI just started to work here for 2 months. It feels really different to work here compared to work in district hospital. There are many problems including infrastructure and technical problem. Examination of Hb level also is not really accurate. There are only 4-5 deliveries/month in this PHC. It is very less, I think home deliveries are still common here. Mrs. R, 42, ANM I have worked here for 7 years. Before working in PHC, I worked in subcenter for 13 years. Working in those 2 places have its own difficulty. Working in PHC is more convenient because there are more facility to help delivery than subcenter. But the workload is heavier in PHC than subcenter. In PHC I work for larger population therefore it is more tiring. Until now, I have never helped home delivery because government does not promote it. I think patient’s satisfaction in PHC service is quite good. The programs are very good here.
  • RURAL HOSPITAL Rural Hospital in NRHM vision:  Strengthening rural hospital for effective curative care and made measurable and accountable to the community through Indian Public Health Standards (IPHS)
  • TESTIMONY FROM THE FIELD Mr. V, 49, Lab Technician I have worked in RH for 22 years. Before working in RH, I worked in otherhospital. I like to work as lab technician. It is very interesting. Working in RH isbetter than working in any other I have worked before. The kits are al sufficient and within expiration date. Some test which be done in this RH are free and some are not. Free test are only for blood sugar level, PS 4 MP, and sickle cell. For every patient I always use new needle. However I often do not usehand gloves since it take sometime and most of the time, it is really rush here. Mr. G, 53, Pharmacist I have worked here for 5 years. Before working in RH, I have practiced pharmacy for 22 years. Drugs in these RH are supplied by district hospital inWardha. Every once in a month, they will drop the drug supplies. Drugs in thiscounter are all free. However not all essential drugs are availble here. If there are some drugs in prescription which are not availble, I will give them the substitute with same effect. Patients can also buy the drugs outside the RH.Though there is NCD clinic, most of the drugs are not availble here. Drugs for helping delivery and newborn baby are available here.
  • Mr. R, 50, patientI like this hospital. It’s cheap. The services are also good too. However, there are some drugs that I have to buy outside the hospital because they don’t have it. I hope the hospital can provide all the drugs needed. Mrs. A, 42, patient This hospital is too cheap. This is my second timeadmitted here. My first time I only have to pay Rs 20 for my 4 days admission. All of the doctors are really nicehere. However I hope they can provide X-ray and USGexamination so that patients do not have to go to other hospital which is far away from here
  • NRHM ACHIEVEMENT Update in NRHM: health outcomes final year of the first phase: 2005-2012.
  •  Janani Surakhsa Yojana is a safe motherhood intervention under NRHM The aims is to have 100% institutional delivery ASHA is key component in this programSource: Kishore J. National health programs of India: national policies and legislations related to health. 8th ed. NewDelhi: century publications. 2009
  • JSY ACHIEVEMENTNational health system resource center. Program evaluation of Janani Surakhsa Yojana. New Delhi: 2011.
  • NATIONAL HEALTH SYSTEM COMPARISON
  • INDIA INDONESIA Different health sytem  Same health system delivery in urban and delivery in urban and rural area rural area Certain strategy for  Same strategy for certain area (NRHM, different area NUHM)  Health expenditure > 2% Health expenditure < 2% GDP GDP  Lower ratio of health Higher ratio of health resources per 100,000 resources per 100,000 population population
  • WHAT CAN BE LEARNED?
  •  Indonesia need to end disparity between urban and rural area by improvement in rural health system India and Indonesia are facing the same problem including disparity in many health indicators Both countries are practicing the same scheme for health care system However India has developed their rural health system since 2005 by implementing National Rural Health Mission (NRHM)
  •  NRHM has succeded to improve health indicators in rural area NRHM is a good example that can be used as a model to design a rural mission to improve rural health system in Indonesia Improvement in health system will result in better health indicator. Therefore maternal and child care will also be improved
  • THANK YOU 
  • WHAT CAN WE DO?• Government• Faculty• Student
  • GOVERNMENT
  • UNIVERSAL HEALTH COVERAGE “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost” World Health Assembly, 2005
  • FACULTY
  • REFORM ON MEDICAL EDUCATIONInstructional reformso Patient and population centered curriculao Promote interprofessional and Objectiv Outcome es transprofessional education Informativ Informati Expertso Harness global resources and e on, skills adopt locally Formative Socialisa Professiona tion, lsInstitutional reform valueso Nurture a culture of critical Transform ative Leaders hip Change agents inquiryo Link through networks, atrribute s alliances, and consortia
  • STUDENT
  • COMMUNITY DEVELOPMENT CIMSALocation: Menteng JayaVision: to build stronger communities, to enhance quality of life with a better health aspectPOA:Community diagnosisPlanning and OrganizingExternal collaboration and partnershipCampaign and Education Project
  • INTEGRATED COMMUNITY DEVELOPMENT Faculty and Student Collaboration One step closer for transformative medical education Students can be trained as change agents in a real setting Greater impact for community