ISQUA18-2088An Exploration into Universal Health Coverage’s Potential Role in Expanding Access to Immediate Post-Pregnancy Family Planning at Private Facilities in Indonesia

Abstract

Objectives: The provision of family planning (FP) following pregnancy is a life-saving intervention that prevents unintended pregnancies, but also improves postnatal outcomes for mothers and infants and perinatal outcomes in subsequent pregnancies. In Indonesia, 27% of women in their first year postpartum have an unmet need for FP, compared to an unmet need of 11% overall. Offering FP in the period immediately following delivery, before discharge from the childbirth visit, presents an opportune moment for delivery of this service. In 2014, the Indonesian Government initiated the rollout of a Universal Health Coverage (UHC) scheme. Indonesia has an active private healthcare sector, where 46% of deliveries take place and 73% of FP services are accessed. In order for UHC to be successful in reaching key indicators in these areas, inclusion of private sector healthcare interests must be considered and incorporated. Jhpiego conducted a formative assessment to understand the specific considerations required of private sector stakeholders for offering post-pregnancy FP (PPFP), particularly within the context of UHC rollout. Method(s): This mixed-methods rapid formative assessment used qualitative and quantitative data to answer the questions of interest on barriers and facilitators to private sector provision of PPFP. Data sources included key informant interviews with 11 policy makers, 4 facility decision makers, 9 facility providers, 3 focus group discussions with clients, and facility assessments at 5 private facilities in Batang and Brebes District of Central Java Province. Data collection was conducted between March-May 2017 with ethics approval from the Ethical Commission MoH RI. Result(s): Clients consider private sector services and contraceptives superior to those in the public sector. However, the primary considerations for choosing where to deliver are distance to facility, familiarity with providers, and cost. Private sector facility proprietors and providers are concerned by the reimbursement structures under UHC, particularly the possible financial advantages and disadvantages to whether and how certain services are offered in their settings. Main barriers they identify to pre-discharge PPFP service offering are: 1) pre-discharge provision of PPFP is considered part of the labor and delivery package and not reimbursed separately through the UHC scheme. Specifically PPFP is not reimbursed at hospitals as it is considered a preventative service that should be provided within primary health settings; 2) providers and proprietors had inconsistent knowledge of reimbursement rates and were therefore unable to draw confident conclusions on whether or not PPFP was a profit-bearing service offering; and 3) independent private midwives encounter fees from local facilities and health offices in order to submit reimbursement claims, further depleting potential profit margins and dissuading them from offering PPFP services. Conclusion(s): In the current context, private sector facilities in Indonesia would face barriers in the provision of immediate PPFP, particularly related to UHC rollout. Advocacy work is needed to ensure that the PPFP services are adequately covered under UHC. In addition, ensuring the good performance of private facilities, for example quality of FP services and conducive private facility enterprise management in the UHC era is also crucial.