Thinkwell indonesia covid

Presenting Research at the Annual Scientific Forum of the Indonesian Public Health Association

08 December 2020

Written by Prastuti Soewondo, Halimah Mardani, and Nadhila Adani

ThinkWell’s Indonesia team presented research findings from three studies at the Annual Scientific Forum of the Indonesian Public Health Association on November 24-26, 2020. The conference was conducted by the Indonesian Public Health Association, Ministry for National Development and Planning, UNFPA, and Faculty of Public Health University of Indonesia. The studies stem from primary research conducted by ThinkWell’s Indonesia team, in partnership with the Indonesian Vice President’s Office, as part of the Strategic Purchasing for Primary Health Care (SP4PHC) project, supported by the Bill and Melinda Gates Foundation. Comprehensively, the research explored how the government’s response to Covid-19 affected essential services like family planning (FP), maternal and newborn health (MNH), and nutrition.

We’ve summarized our presented studies below. The conference’s steering committee selected two of three our submitted papers as the ten best papers at the conference.

How did Family Planning Service Providers Respond to the Covid-19 Pandemic in Indonesia: A Case Study in Eight Districts/Cities?”

Presenter: Nurul Maretia Rahmayanti

The conference’s steering committee selected this paper as one of the ten best papers at the conference

The team aimed to answer this research question by analyzing how PHC providers (e.g., public and private PHC facilities, midwives, and volunteer cadre workers) adjusted how they provided FP services during the pandemic. Using qualitative methods, we found several challenges that FP providers faced during their response to Covid. First, the central government did not provide clear guidance about how FP services should be adjusted after the Indonesia’s initial Covid cases. Instead, FP providers had to wait three months before they received guidance. Because of that, much of the providers’ initial Covid response was scattered.

The guidance they eventually received included recommendations that FP providers shift towards distributing short-term contraceptive methods (i.e., contraceptive pills and condoms), rather than long-acting reproductive contraceptives (LARCs), that could be more quickly given at the facility and easily distributed in the community. Usually, this type of policy change would require the government to provide socialization and training of PHC providers to implement this policy change. However, this socialization was poorly implemented largely due to the halting of in-person trainings and supervision. In addition, there were many technical issues, such as limited access to internet services among these PHC providers.

indonesia family planning

Other key policy changes that PHC providers made during Covid was to reduce their opening hours, mandate appointments before visits, and shift as much as they could to telemedicine (mostly via WhatsApp).  Again, the central government’s lack of detailed guidance, socialization, and poor access to internet led to a very scattered response among PHC providers.

Another challenge was that the FP budget was reduced during Covid, which impacted provider’ ability to maintain FP service provision. Many noted that out-of-pocket (OOP) payments among FP patients likely increased, which probably further perpetuated a dip in FP access, use, and a potential increase in unwanted pregnancies.

During the Q&A following the presentation, there was a question on the impact of the FP budget reallocation process on FP service delivery. According to our findings, the government tried to keep an adequate budget for maintaining contraceptive logistics, but reallocated the FP activity implementation budget for the Covid-19 response. This could affect FP services provision, which could lead to a potential increase in FP unmet need and unwanted pregnancy. The research team recommended that the budget reallocation leaders should consider the urgency of adequate program implementation funding, not only funding for the logistics of contraceptive distribution.

Prof. Siswanto from the University of Gadja Mada (UGM), one of the premier FP experts in Indonesia, noted that these presentations are important to understand issuers affecting access and quality of care during the pandemic. Still, he noted that there are many aspects outside of Covid’s scope that affect access and quality of MNH and FP services. Most of this analysis was carried out from the providers’ point of view, but there are other aspects that must be considered, such as the psychological and socioeconomic dynamics of the patient themselves. He noted that there is little response from the government to reduce this socio-economic burden.

You can view the presentation as a PDF here.

“How was the Practice of Private Midwifery Continued during the Covid-19 Pandemic in Eight Districts/Cities across Indonesia?”

Presenter: Retno Pujisubekti

The conference’s steering committee selected this paper as one of the ten best papers at the conference

To answer this question, we interviewed private midwives and other health system stakeholders involved in private midwife practice. We analyzed how private midwives, and those that govern them, adjusted their practices during Covid-19, especially around essential services provision. Private midwives are one of the most used and trusted providers of MNH services across Indonesia. Our research found that guidance was delayed, socialization was weak if often nonexistent, and technology challenges hampered effective telemedicine and data reporting. For instance, many private midwives noted that it was very difficult to continue to provide services when they had very little access to PPE or rapid testing. Therefore, especially in the pandemic’s initial stages, many private midwives had to shut down their practices. Naturally, many women did not seek services during the pandemic due to fear of contracting Covid-19. This led to a significant decrease in revenue among midwives, which was not aided with government support. Many midwives feared that the lack of support, whether it be financial or PPE, could have led to a significant decrease in FP, MNH, vaccine, and nutrition services during the pandemic. They see this as a missed opportunity because since many women feared going to health facilities during the crisis, midwives could have been better deployed to fill in the gaps.

After our presentation, the audience discussed the financial sustainability of private midwifery practices, both during and after the pandemic. The audience agreed that the government should evaluate the non-capitation payment under JKN to offer better incentives for midwives, equivalent with the services they provided. Due to the pandemic, there is a decrease in visits to midwives for the range of services (including FP and MNCH), so midwives have been receiving less income. However, midwives are forced to buy their own PPE, which has proven to be quite expensive for them. Private midwives are willing to provide comprehensive midwifery services, from pregnancy stage to childbirth, but several members of the audience stated that they are not given the support they need from the government.

You can view the presentation as a PDF here.

“How Were Nutrition Services Adjusted during Covid-19 Pandemic: Study Cases at Eight Cities/Districts in Indonesia”

Presenter: Dwi Oktiana Irawati

To answer this question, we analyzed how health authorities at the central and district levels adjusted their policies during the pandemic. We then analyzed the impact this had on how PHC providers maintained access to essential nutrition services. Similar to FP and MNH providers, PHC providers faced limited and delayed guidance from the higher levels of government on how to adjust their service provision and meet previously laid out nutrition goals. Not only was guidance delayed, but the national budget for nutrition was reduced by over 23%. This had a rippling effect for districts and PHC providers, often in the form of PHC providers’ reduced ability to track and report on essential nutrition indicators (e.g., malnutrion, child height/weight). It also hampered PHC providers’ ability to provide key services,  like food supplementation to mothers and children.  There was a missed opportunity to empower frontline community health workers like Kaders (volunteer community health workers) and midwives to fill the gaps, as they were not properly equipped with PPE or given incentives for service continuation.

Our findings are very useful for policy makers, especially for decision-making around the national program for stunting reduction. Since this program is one of Indonesia’s national priorities, the government must monitor the budget and ensure implementation at the community level. Active participation from Kaders is important to reach the community and increase knowledge, attitude, and practice among these community members.

At the end of our presentation, conference participants discussed the strategies needed for preserving nutrition services and preventing negative impact on several MCH indicators such as stunting, as well as anemia among adolescent and pregnant women.

You can view the presentation as a PDF here.