Archipelagic Gaps: Challenges in Access to Maternal and Child Health Care within Indonesia’s 17,000 Islands

After months of stumbling on my words and the embarrassment of excessive sweating, I've finally learned how to enter and exit conversations without being socially awkward and to keep my clothes dry. Oh yeah, and I've made some headway on my original research project. For those of you who still have no idea what I do here, I have a little story for you.














After receiving a Masters of Public Health in international health from the University of Michigan, I decided it was time to break from the ivory tower of academia. I was tired of reading about epidemiologic theory and disease prevention and craved the opportunity to investigate a real public health issue on my own. The Fulbright scholarship was an opportunity to do research, but also to “get a little dirty” and find my way in a new culture outside of classroom walls.

I applied to Indonesia as a Fulbright Scholar to study the impact of decentralization on maternal and child health care. I chose this topic because, from my experience in graduate school, I believe governments can reduce maternal mortality if and only if they prioritize health education and improve access to medical care. I chose Indonesia because maternal mortality has remained stagnant in recent years. Also, within the context of a huge political change such as decentralization in 2001, I could analyze the relationship between good governance and maternal health.

My Fulbright experience in Indonesia began with listening. Each person I talked to revealed a new kernel of truth that deepened my understanding and led me to new insights. I will always remember Dr. Joedo, a doctor at an NGO that started out as a maternal and child health organization, and his poignant comment about decentralization in Indonesia.

We sat in a meeting room at a shabby wooden table stained with water rings from coffee cups. A flimsy wall divided the meeting room from employee cubicles. The office I sat in was quite austere compared to the glamorous malls in Jakarta I passed on the way there. He told me, “Decentralization in Indonesia has been like going through withdrawal from medication. The provinces and regencies lost their decision-making support and suddenly became responsible for planning public services. It all happened so fast”.

The decentralization laws split Indonesia into 33 provinces, 349 regencies and 91 cities. The regencies gained autonomy, and thus the ability to decide how money is allocated and the types of programs to implement. Some regions prioritized short-term development projects over long-term ones like health, creating regional inequality in health care.

Imagine the potential for disparities in access to health centers between regencies that prioritize spending on health and those who don’t. Imagine how difficult it would be to attract trained health professionals to work in remote regions if the local government doesn’t have an incentive program to bring them there. Now think about a woman who lives in a region where the nearest hospital is hours away and the local government lacks education programs about what do when her labor is not going well. Some local governments in Indonesia are creative in finding solutions, but it takes dedication from each regency to close the access gap.

Decentralization, however, is not all bad. In fact, the intention of the process is to allow local governments to tailor their budgets to the particular needs and contexts of their district without constraints from a central, often uninformed power. The fact that each region has different demographics - average age, geography and education - means each region needs a unique public health program. Local political environments that are prepared for the responsibility to develop health programs might be more successful than if the planning happened in Jakarta.

In a decentralized Indonesia, I’ve realized that it is essential to get decision-makers to care about the important things. The money saved from forgoing a plan to build another upmarket mall in Jakarta could probably contribute to making health care more affordable for the urban poor. It is important to find leaders who realize that long-term development means investment in the health of Indonesians.

The handicap that bureaucratic ineffectiveness places on health care is not just an Indonesian problem, but also a worldwide concern. For the past seven months I have been fortunate to live in Indonesia and to study how maternal and child health challenges manifest in the Indonesian political, economic and cultural environment. The most important lesson I’ve learned is that it takes a deep understanding of these elements to be able to begin to find solutions.

Thoughts about Indonesia and the Israeli-Arab conflict

One day my Indonesian friend and I chatted about life abroad and I asked her to tell me about her most "shocking" experience in the US.

Me: What was your most unexpected discovery about American culture?"

Friend: That Jewish people still existed.

Me: What?! You mean you didn't realize that Jews existed in the US?

Friend: No, I mean, before coming to University of Wisconsin I didn't realize that Jewish people existed, at all. I guess in Indonesia the education about Judaism and Jewish culture is poor.

Me: So how did you come to realize they did?

Friend: I met Jewish students at school and in my first job I worked for a company owned by Jewish people. I became fascinated with their culture because, all of a sudden, I was surrounded by them and I realized that the Jewish culture and my own Chinese Indonesian culture had commonalities.

Me: Like what?

Friend: Well, for example, that we both have overbearing mothers, haha. Also, that the Chinese and the Jews have diaspora communities all over the world and have great work ethic, often starting from nothing, to create good lives for themselves.

I had no idea that my well-educated friend, who obtained a bachelors deree from University of Wisconsin and worked in New York for four years, thought an entire culture that in fact exists, didn't. Suddenly I wanted to find out what Indonesian high school curriculums teach their students about WWII, the Holocaust or about the creation of the state of Israel in 1948. While listening to Yuyun's example about her culture shock in the US, I was in fact having a moment of culture shock myself. As an American woman who grew up in a largely Jewish town, I now live in a country where education about the Jewish people is inadequate at best. Perhaps my surprise was naive. I already knew that Indonesia didn't recognize Judaism as an official religion.

The reason I mention this story is because I'm interested in the Indonesian response to the recent raid of the flotilla. As soon as the news broke, almost a dozen of my Indonesian friends posted opinions about the conflict. Most were expressions of concern for the people involved, but a few were strongly pro-palestinian remarks, with almost violent tones. One particularly stongly-worded one went something like this: "Israel, you missed your target. Next time look in the mirror!"

I started to think about the fact that most Indonesian people probably support the Palestinans not only in this particular situation, but always. But my point is not that Indonesians should or shouldn't be pro-palestinian. What I am concerned about is the origins of their beliefs. Do most Indonesians have reasons for this support other than a shared religious faith? Is this support based on a true understanding of the facts and a subsequent independent belief, or based on a blind following of their Muslim friends and family members, without much concern for the context.

My questions might sound provocative and over-simplified. I'm sure there are a diversity of stances in Indonesia about the Israeli-Palestinian conflict and nuanced explanations for these opinions. But given the fact that Judaism is not an official religion in Indonesia, that education about Jewish history is poor and that there is no voice for Jewish people in Indonesia, I doubt many Indonesians are exposed to the Israeli side of the conflict. The fact that Schindler's list was banned under President Soeharto illustrates the points of the prior sentence. This is upsetting to me. I am not pro-israel or pro-palestinian, but I'm a supporter of historical education about the conflict and working towards a solution that prioritizes human security over religious-right.

I don't yet have a solid understanding of the public's opinion of the conflict or religious education in Indonesia. But this is an important topic because Indonesia is involved. There were 12 Indonesians aboard the Marmara. The Indonesian government was very concerned with those passengers, and the Jakarta globe followed the state of the Indonesian passengers in a few articles:

Still No Concrete News on Indonesians Aboard Ship to Gaza
One Indonesian Injured, 11 Others Detained After Israeli Military Attack on Aid Flotilla: Government
Yudhoyono Confirms Release of 10 Indonesians Aboard Ship to Gaza

As far away from the Middle East as Indonesia seems, it's important to remember that countries like Indonesia play a role in the conflict. If there is to be any movement in the direction towards peace, leaders in the conflict and in the mediation process should take this into consideration. I would personally like to see a movement to include accurate historical education about Jewish history and the formation of Israel in Indonesian schools. The fact that Indonesians are generally uneducated about Jewish history doesn't bode well for progress.