Tuesday, June 28, 2011

Destination: Karawang

Our second field visit, destination Karawang. Karawang is in Java, just east of Jakarta about one and half hours. Since its so close, we left very early on Tuesday morning to beat the traffic. Karawang is one of Jhpiego’s cervical cancer sites and that’s about all I know. I’m not sure what they’re doing in terms of cervical cancer, but I’m happy to know that the health systems are at least equipped to tackle cervical cancer, which is more than I can say about a lot of countries where basic health needs are barely being met. We started our visit with the obligatory visit to the District Health Office and then traveled to the puskesmas where we would be basing our village visits. I’m still constantly surprised about how big places are. I don’t know the square mileage of Karawang, but it seemed as if we could drive at least an hour in any direction and still be in Karawang. After we found the puskesmas, we picked up the midwife coordinator and headed to a small village, Dukuh Kariya, to begin our interviews. I was already pretty tired at this point, I only slept like 4 hours the night before, so the thought of interviewing 15+ women was not getting my pumped about the day. We met at one of the village health worker’s houses where the posyandu takes place. By the time we arrived, the posyandu was already finished, but she was able to go and call and bring some of the women back to talk with us.

Midwife Coordinator, Ibu Yuli, who was very awesome and very maternal.

Posyandu sign in Dukuh Kariya

Our interviews went pretty well, and we were learning a lot about services in this village. I previously talked about jampersal, a governmental program that will pay women to deliver in facilities. There are some challenges around it because the government will only reimburse the midwives 350,000 RP, when they might normally charge 700,000 RP or more. So, I think it’s a good program to get women into facilities, but I think its limiting midwives and creating a situation where they can start to corrupt the system (which we’ve already seen) by telling women that it costs only 100,000 or 150,000 Rp instead of 700,000 Rp and then they’re pocketing the 150,000 and getting the 350,000 Rp reimbursement from the government. Confused? Just read it again. The bottom line is that there are still kinks to work out and since the government hasn’t (and can’t) implement jampersal nationally, it’ll take awhile for the individual districts to work out the problems. That said, Dukuh Kariya took jampersal in a whole new direction. The private midwife who lives and works in the village is a government employee who also works at the puskesmas and earns a monthly government salary. Based on this, it appears that it wasn’t so much her decision to implement jampersal in the village as it was decided for her. We then learned that jampersal is accepted at her private facility as well as for HOME BIRTHS. That’s right, home births. The whole idea of this program is to get women to a safer facility, and now we’re offering them to stay at home and deliver for free. Problematic, for sure, but I had to remind myself – as I have to almost daily – that we’re not here to change things, we’re just here for data. This news was the biggest of the day because it was so odd. Since Indonesia decentralized, which I don’t know much about, the districts have more power than the national government and therefore decide what to use their money on. That’s why we see that Karawang has implemented jampersal and Minas, for example, hasn’t. Apparently the districts use the money for infrastructure instead of health, which isn’t exactly surprising. So, it was good to know that Karawang took the leap and started providing free deliveries for women, but it doesn’t sound like it was executed the best way.

Posyandu, filled to the brim with women and their children

Concerned mother with her newborn, talking to the midwife and village health worker about the progress of her baby's health

As I mentioned, our interviews went well with the exception of one woman who made me lose confidence in this research. She was in her mid-thirties, dressed to a T, wearing a satin dress with gorgeous embroidery and a beautiful hijab. Her features were striking, her skin not too light and not too dark, her eyes dark and seemingly full of life. I had high hopes as she walked into the room and sat down. She was pregnant and told us that her plan was to deliver at a private midwife’s clinic because she thought it was safer for her and her baby. These are the women that make me jump up and down with joy. But, as the interview continued she slipped up and told us that she actually wanted to deliver at home because it was more comfortable, and that she lied to us because she was scared. My frustration comes in that, is this happening often? Are we getting responses because women are scared or are the telling us what they think we want to hear? How many respondents are doing this? And what do I do with this woman’s interview? My initial feeling is to throw it away, which is probably what I’ll do, but it’s frustrating to think that more of our responses might have this problem and we don’t know about it.

The gorgeous landscape and rice fields of Karawang