FAMILY PLANNING/REPRODUCTIVE HEALTH (FP/RH)

UNCLAS JAKARTA 000260 SIPDIS SENSITIVE AIDAC USAID FOR MELLIS/ASIA/AA, SSOLAT/ASIA/EAA, GCOOK/ME/TS, SRADLOFF/GH/PHR, JBORRAZZO/GHIDN/MCH SENSITIVE BUT UNCLASSIFIED E.O. 12958: N/A TAGS: SENV CASC EAID ID SUBJECT: FAMILY PLANNING/REPRODUCTIVE HEALTH (FP/RH) SERVICES LAGGING IN INDONESIA: TIME TO ACT 1.(SBU) Summary. Several national surveys and a recent report by senior experts provide compelling evidence that IndonesiaQs reproductive health program is lagging and has lost its status as an exemplar of global excellence. This cable outlines these problems and proposes several actions by USAID to address them. Most importantly, now is the time for a targeted re-engagement on this problem. End Summary. Background: Disappointing Results -------------- ¶2. Preliminary Demographic Health Survey (DHS) results provide evidence of the poor performance of the recently decentralized health system in Indonesia and slowed progress toward achieving Millennium Development Goals (MDG),particularly with regard to maternal and child health indicators. This was reported in reftel: #00089 Jakarta May 08. ¶3. A World Bank coordinated meta-analysis, the 2008 Health Public Expenditure Review (HPER),revealed that public expenditure in the health sector by the Government of Indonesia (GoI) has been very low. Since 2001, public expenditure on health constitutes only 1% of GDP, among the lowest in the Asia region. The financial commitment has not improved and is exacerbated by poor leadership in the Ministry of Health. New leadership might emerge after the 2009 elections. Results from the HPER were delineated in reftel: AID 08/07/08. ¶4. In November 2008, an independent study conducted by Professors Mosley (Johns Hopkins University) and Hull (Australia National University) of the Indonesia National Family Planning Program (BKKBN) called for revitalizing FP/RH services. The authors expressed concern with the situation, noted the global demographic consequences of the backsliding and recommended an urgent re-engagement in this sector by international partners. The report calls for: a) a measured approach to capacity re-building for the BKKN; b) an effort to expand the narrowing method mix of voluntary family planning options in order to reduce maternal mortality and unwanted abortions; and c) increased access to quality post abortion care. USAIDQs Past Role -------------- ¶5. USAID supported FP/RH programs for over two decades. This resulted in increased contraceptive prevalence and reduced fertility rates. Unfortunately, early successes have since been eroded, first in the wake of the Asian economic crisis in the late 1990s, and secondly over the past 5 years as the GoI attempted to deploy a new decentralization plan under IndonesiaQs first democratically elected government in the worldQs fourth most populous nation. In 1997, the Indonesia program had been a model for the world. Missing Women -------------- ¶6. The Mosley/Hull report found one omission in the DHS (unmarried women were not included in the respondent pool), representing a group with unmet needs that if unaddressed could lead to an increase in unwanted abortions. A report by the Indonesia Planned Parenthood Association (PKBI) estimates that there are 2 million illegal abortions annually, which include many unmarried women. Secondary analyses will provide further insights regarding geographic and demographic disparities which are assumed to be significant. According to the authors, total fertility rates were unaffected by this finding and not unusual for a DHS. What To Do -------------- ¶7. The Mosley/Hull report calls for a revitalization of the FP/RH sector in light of the stagnating DHS indicators. The report recommends: a) increasing capacity building for the BKKBN, with a particular focus on capacity building at the local (provincial/district) levels; b) technical assistance to address post-abortion care; and c) widening contraception method-mix options, which have also substantially narrowed over the past decade with the predominant method of choice now being the use of short- term injectable contraceptives. Planned USAID Response -------------- - Analysis ¶8. While FP/RH support from the DA account was concluded in 2007, USAID plans to utilize discrete carry-over funds to support secondary analysis of the 2007 DHS (final results to be published in February 2009) in order to further inform current and future policy makers, particularly at the decentralized levels, in order that future policies (and legislation) in support of FP/RH are evidence-based and fully deployed throughout the archipelago. - Advocacy ¶9. USAID will continue its innovative efforts to advance local legislation in support of health priorities such as MCH and FP/RH. It also plans to work more closely with the National Midwives Association to ensure that more equitable and wider method-mix options are recognized and accessible. However, this effort has been severely limited in light of a 30% decrease in MCH funding during 2008 (in lieu of support for water & sanitation). - Care ¶10. Since one of the objectives in the new USAID strategy is to reduce maternal mortality (in line with MDG 5: Improving Maternal Health),USAID is urgently seeking targeted support for FP/RH from the DA account that could be made available from the 2009 plus up for the FP/RP earmark. This vital support for an under-served sector would be utilized toward achieving the intermediate result of reducing deaths during pregnancy, and the overarching global goal of reducing unwanted abortions. The BKKBN and MOH would clearly welcome any related technical support that could be forthcoming. Currently, the only major donor support for family planning in Indonesia is via UNFPA, largely through the sporadic provision of contraceptives. - Private Sector ¶11. Given that the majority of health and FP/RH services are provided through the private sector (a little understood and largely unregulated industry in Indonesia), USAID is supporting (in coordination with the World Bank and other donors) the first assessment of the private health sector as part of a larger National Health Sector Review that could be a valued resource for senior policy makers in the next GoI administration as it seeks to strengthen strategic synergies between public and private sectors. HUME