The flight over to Indonesia was, well, long! Within just a few minutes in the airport, I knew I was very far from home. One thing stuck out almost immediately—not only how beautiful everyone’s smiles were, but just how abundant they were. Customs agents, security guards, and even equally as tired, fellow passengers—all beaming! Though I didn’t know anyone at the time, it was still hard not to feel welcomed to the country. I’ve quickly learned, no one greets anyone without a smile and everyone is always nodding in agreement—a welcomed and slightly confusing contrast to life back in New York. In this gracious culture saying no to someone is impolite and can you believe that in the native language of Bahasa, there are 12 words for yes?.
From the airport to the apartment in central Jakarta, it was hard not to notice the skyscrapers that rivalled those of home, malls that seemed to showcase the same stores as 5th Avenue, and every range of luxury car—creating, what I quickly learned was, the common traffic jam on the street. It was surprising to think I was in Indonesia to work on maternal and neonatal healthcare issues when a booming economy and advanced technology was extremely apparent. Despite this exterior of modernism and the smiles found on everyone’s faces, the truth is that pregnant women still die in much higher numbers than women in other neighboring countries. The lifetime risk of maternal death in Indonesia is 1 in 210, compared with 1 in 870 in Vietnam and 1 in 1300 in Malaysia1. Further, it is estimated 66,000 newborns die every year2. The national newborn death rate masks inequities across Indonesia and highlights the disparity in access to care. For example, East Java rates range from 13 and 14 deaths per 1,000 live births whereas the more remote areas of West Papua have a stark rate of 37 deaths per 1,000 live births3.
The USAID-funded Expanding Maternal and Neonatal Survival (EMAS) program goal is to contribute to a 25 percent reduction in maternal and neonatal mortality by 2016 using a multifaceted approach: improving the quality of emergency services through high impact life-saving interventions and improving the referral system. At the heart of both of these initiatives is generating more accountability within government and facilities and mobilizing citizens to demand quality services, efficient referrals and effective resource allocations. Indonesia has an extremely decentralized healthcare system which highlights the need to build an effective network amongst small health centers (puskesmas) at the village level to the hospitals with comprehensive emergency care. Families at the village level are often not aware of their rights and options when faced with a critical emergency. In fact, only 10 percent of the poorest quintile of Indonesian citizens in two districts in western Java gave birth with a health professional, as opposed to nearly 70 percent of Indonesia’s wealthiest.
This raises two important questions. How does one encourage civic engagement and participation in a culture where raising complaints and your voice, so to speak, often go against the social norm? Also, how does one create a space in which citizens of all socioeconomic statuses can participate in the public arena and call attention to the outstanding healthcare issues? The governance mechanisms that EMAS is focusing on to help strengthen the citizen’s voice include civic forums, citizen report cards, focal group discussions, and working groups. These mechanisms are designed to enable citizens to hold facilities and local government accountable for service delivery. My goal here is to help strengthen the civic forums' voice with local government, improve its utility in fostering advocacy initiatives, and strengthen its sustainability as an effective tool in governance in the maternal and child health arena. Although people’s smiles here are as warm as the country’s tropical climate, the fact remains that there is still work to be done to encourage citizens to raise their voice and be heard4.
Badan Pusat Statistik. Indonesia Demographic and Health Survey 2007 Final Report. Retrieved June 3 2013, from http://www.measuredhs.com/publications/publication-FR218-DHS-Final-Reports.cfm
2United Nations Children’s Fund. Levels and Trends in Child Mortality: Report 2012. New York: UNICEF; 2012
Badan Pusat Statistik. 2012 Indonesia Demographic and Health Survey Preliminary Report. Retrieved May 27 2013, from http://www.measuredhs.com/pubs/pdf/PR25/PR25.pdf
Mize, Lucy at al. World Bank. February 2012. “…and then she died”: ,Indonesia Maternal Health Assessment. Retrieved March 28, 2014, from https://openknowledge.worldbank.org/handle/10986/2837