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.