Despite being thousands of miles apart, Indonesia and Kenya belong to two regions that have the worst global maternal indicators. The regions that there respectively in, South East Asia and Sub-Saharan Africa, share a lot of things in common, including health disparities. How is this the case? - A closer comparison between Indonesia and Kenya provides us with insights regarding the re-positioning of maternal health in a devolved system of governance for the two countries.
Devolution is a dynamic decentralization process that involves transfer of authority or power for decision making, planning and management of public services from national to subnational levels.
In both Indonesia and Kenya, administrative, political and fiscal responsibilities were transferred from the central government to subnational authorities following the introduction of nationwide ‘big-bang’ devolution reforms.
Twenty years ago (2001), Indonesia embarked on a journey to roll out a three-tier government (national, provincial (32) and district (440)) while the same rapid roll out process began in 2013 in Kenya with a two- tier government consisting of the national and county governments (47).
In Indonesia, the provincial level is tasked with coordinating the districts and drafting/formulating policies which should be implemented within the specific provinces. The districts are mandated to prioritize the delivery for public goods and services and for this case health as an essential service. Comparatively in Kenya, the county governments are tasked with managing all the operations in the county and budgeting for the same through their country integrated development plans.
Maternal health is one of the indicators that advances a country’s progressive health care system
Maternal health is one of the indicators that advances a country’s progressive health care system. Limited maternal healthcare results in increased maternal mortality and according to the World Health Organization (WHO), Sub-Saharan Africa and South East Asia accounted for approximately 86% (25, 000) of the estimated global maternal deaths in 2017. WHO estimated that 810 women died daily globally in 2017 as a result of preventable causes related to pregnancy and childbirth. This translates to about 697 women dying in Sub-Saharan Africa and South East Asia. Women die as a result of complications during and following pregnancy and childbirth. Most of these complications are unacceptably high but preventable if well managed. The major complications that account for nearly 75% of all maternal deaths include:
- Hemorrhage (severe bleeding during/after birth)
- Infections (usually after childbirth)
- High blood pressure during pregnancy (pre-eclampsia and eclampsia)
- Obstructed labor (complications from delivery)
- Unsafe abortion.
There has been little improvement in reducing the maternal mortality in Indonesia from 228 to 177 maternal deaths per 100,000 births between year 2010 and 2017 . In addition, Kenya also had a decline from 488 to 342 maternal deaths per 100,000 births between the same period. However, a lot still needs to happen and it’s high time we take stock of whether a devolved governance system response caters to the needs of the healthcare system.
Healthcare system in devolved governments
Thaddeus and Maine (1990) introduced the “three delays model ” concept which has been very useful globally in maternal health. The model gives a description of what, why and how maternal deaths occurred. Maternal deaths occur due failures of the health system in responding to the needs of its people and these include:
- Delay in decision to seek care
- Delay in reaching care
- Delay in receiving adequate health care
In the decentralized system, governments are addressing these delays in various way. For instance, in Kenya the Community Health Volunteers (CHVs) have been empowered by the county health departments to provide primary health care information on pregnancy, childbirth and newborn healthcare, so that the expectant mothers are able know when to seek medical care. The CHVs also keep track of the antenatal visit dates for their cohorts in the community. Some of the maternal mothers have formed income generation schemes that enable them to become financially independent and hence are able to make timely decisions about their own reproductive health . In Indonesia, the CHVs work with midwives at the community level also known as the Integrated Service Post (Posyandu), as community mobilizers ensure that women at least attend the 4 antenatal care visits as required by the Indonesian Ministry of Health.
In Kenya through the devolved system, Kilifi County with support from United Nations Population Fund (UNFPA) and International Center for Reproductive Health (ICRH) has improved access to healthcare with the adoption of the maternity shelters strategy where waiting bays (hosting shelters) are set up for expectant mothers to stay in before their due date. The approach has helped women who have to seek healthcare in far places from their remote rural homes with poor roads and terrains. The County is also empowering the CHVs to provide door-to-door home visits (home-based care) where they are able to identify expectant women and refer them to the nearest health centers for antenatal care. The pre-defined model of conducting medical outreaches is taking equitable and free services closer to the people who need them.
Additionally, in Kenya, the national government handles the operations of the 3 national referral hospitals however some critics have had their say regarding the transfer of functions and power of the other health facilities. This was seen to some as a panic move of burdening the counties with the health sector and yet the resources were limited. This has over the years presented unique learning opportunities for the counties with some struggling and others excelling in the same context.
In Indonesia, the Ministry of Health partnered with Phillips to provide the Mobile Obstetrics Monitoring Software (MOM) in order to improve access to maternal healthcare across the different islands. Philips; a health technology company improving people's health and well-being through meaningful innovation, supports pregnant women across the world through the MOM solution. MOM is a mobile software that facilitates delivery of antenatal care in low cost community settings. This innovation has been essential in overcoming challenges of managing the maternal health complications due to different provider encounter aspects.
As a strategy to address the delays in receiving healthcare while in facilities, the village midwives or the community enrolled nurses both Kenya and Indonesia have been trained to offer health promotion services. Ensuring health centers are suitably equipped to provide safe deliveries and improving referral systems between health centers and hospitals is one of the capacity enhancement approaches.
Despite the general improvements, the maternal health systems in both countries can be improved by the following:
- The allocated sub-national level funds for health should be disbursed fast enough to mitigate the resource, stock out and capacity issues that accelerate maternal mortality.
- Community Health Volunteers act as the interface between the community and the health system and hence they affect decision making at both the individual and community level. The government should build the capacity of CHVs periodically and also avail adequate resources for them to promote health at the primary level.
- Having a well-established and empowered community health network is critical in promoting community engagement and facilitating health policy reforms for advancing maternal health. This should be prioritized in the community health strategy and the CHVs should be recognized as one of the healthcare cadres of importance.
The devolved governance system in Kenya and Indonesia has massively transformed transfer of functions, power relationships, increased political, financial and administrative responsibilities at subnational levels. This has in turn availed opportunities to participate in the health system governance process by enabling their engagement in the civic process. Public participation is one of the civic processes enshrined in the 2010 Kenya Constitution and various public policy documents. In Indonesia, citizen participation is prioritized in the development planning process and this is geared towards promoting transparency and accountability for better policy outcomes.
As we are witnessing the benefits of devolution that encourage community growth and resilience, the health system would be more resilient and can improve the life and health of women and girls at risk from a maternal health perspective.