public health facilities and exclusive breastfeeding in...

Seminar Presentation, TNP2K.

Jakarta, 8.04.2014

Public Health Facilities and Exclusive breastfeeding in Eastern Indonesia:

Results from the IFLS-East 2012

Maria C. Lo Bue [email protected]

Outline

First paper: “Availability and quality of public health facilities in Eastern Indonesia. Results from IFLS-East 2012”.

Second paper: “The role of demand and supply level factors in shaping optimal exclusive breastfeeding practices. Results from IFLS-East 2012”.

Availability and quality of public health facilities in Eastern Indonesia.

Results from IFLS-East 2012.

“Availability and quality of public health facilities in Eastern Indonesia. Results from IFLS-East 2012”.

I. Introduction

• Over the last decades, Indonesia has achieved significant improvements in the delivery of health care services: • Inpres program • Bidan Di Desa program • Decentralization

• Uneven progress • Substantial rise in the demand for health care services Under-supply of health services • Mixed performance in health outcomes (child and maternal health,

double burden of malnutrition) • Price of medical care


I. Introduction

• Eastern Indonesian provinces rank relatively low compared to other provinces in several health and non-health dimensions

• Data: IFLS-East 2012

• 7 Provinces: Nusa Tenggara Timur, Kalimantan Timur, Sulawesi Tenggara, Maluku, Maluku Utara, Papua Barat, and Papua

• 98 villages • 97 Puskesmas • 95 Posyandus • 76 Traditional Midwives


II. Health care supply and utilization in Eastern Indonesia: an overview

• Public Hospitals • Sub-district level: community

health centers (puskesmas) • Village level:

• mobile health clinics (pustu), • midwife clinics, • integrated health posts

(posyandu)

• Midwives (bidan) • Village midwives (bidan desa)

• Traditional providers (healers, midwives)

• Modern providers:

• private physicians , • privately-run clinics and

hospitals • polyclinics


Inpatient and Outpatient treatment in Indonesia (Source: Susenas March 2013)

PANEL A: Outpatient treatment given being sick and having treatment

Indicator in % Java and Bali Sumatra Kalimantan Sulawesi Maluku NTT, NTB

and Lombok

Papua

State hospital 5 6 8 6 9 4 19

Private hospital 5 5 4 2 2 2 3

Doctor/Polyclinic treatment 36 23 22 22 18 21 23

Health clinic (puskesmas/pustu) 28 29 40 50 55 56 60

Medical worker practice 33 41 31 23 17 19 4

Traditional treatment 3 3 2 2 2 2 1

Maternity healer 1 1 1 0 1 0 1

Other facilities and treatments 3 3 3 3 6 4 2

PANEL B: Inpatient treatment given being sick and having treatment

Indicator in % Java and Bali Sumatra Kalimantan Sulawesi Maluku NTT, NTB

and Lombok

Papua

State hospital 40 46 58 63 64 40 77

Private hospital 39 35 29 17 13 14 14

Health clinic (puskesmas/pustu) 16 6 7 19 10 44 10

Medical worker practice 8 13 5 4 13 2 3

Traditional treatment 1 1 0 0 0 0 1

Other facilities and treatments 2 2 4 1 1 2 2


III. Key findings on quantity and quality of health facilities across urban and rural areas in Eastern Indonesia

A) General Health Care Provision: Characteristics of the heads of the puskesmas

Urban Rural

Number of heads 38 59

Profession of the facility head Doctor 68.42 % 15.25 %

Not a Doctor 31.58 % 84.75 %

Heads who can speak the local language 63.16 % 77.97 %

Highest level of education complete

High school/paramedic

school 0.00 % 25.42 %

D1/Midwife 5.26 % 6.78 %

D3/Akper 13.16 % 32.20 %

College/S1 47.37 % 15.25 %

Public health 7.89 % 13.56 %

S2/S3 26.32 % 3.39 %

Other 0.00 % 3.39 %

University where education was completed

(for those who have completed D3, College,

Public Health, S2/S3)

University of Gadjah Mada 7.89 % 0.00 %

University of Airlangga 2.63 % 0.00 %

University of Diponegoro 2.63 % 0.00 %

Other state university 26.32 % 8.47 %

Private university 10.53 % 13.56 %


Total

number of

doctors

Years of

Experience

% providing

prenatal care

% providing

curative care

for children

% providing

curative care

for adults

% providing

curative care

for elderly

Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural

General

Pract. 101 54 3.93 1.93 36.63 61.11 87.13 98.15 93.07 100.00 86.14 96.30

Dentists 41 22 5.09 2.5 0.00 0.00 82.93 90.91 85.37 90.91 80.49 86.36

Nurses 509 415 8.7 5.01 12.18 19.28 81.34 83.37 93.32 90.12 85.27 75.42

Midwives 244 198 7.99 5.14 91.80 94.95 72.54 63.13 50.41 67.68 33.20 64.14

Village

Midwives 40 102 9.06 3.81 100.00 100.00 80.00 95.10 72.50 74.51 70.00 50.98

Paramedics 43 38 7.76 7.07 9.30 26.32 62.79 65.79 44.19 57.89 41.86 50.00

Specialist 2 0 2 50.00 0.00 50.00 0.00 100.00 0.00 100.00 0.00

Care provision in puskesmas


Possible interpretation:

• Rural puskesmas being relatively less available or understaffed

• Urban puskesmas having a larger pool of

medical staff which can specialize on certain services each medical professional is responsible for a narrower set of services


Practitioners‘ characteristics and working hours in puskesmas

Total number of

practitioners

Average

number of

hours per

week worked

Average number

of hours per

week

provide service

% of medical

staff absent

over the last

week

Urban Rural Urban Rural Urban Rural Urban Rural

General

Pract. 101 54 31.06 32.2 23.23 23.51 14.61 42.86

Dentists 41 22 30.86 32.68 20.66 23.26 10.00 23.81

Nurses 509 415 32.21 32.17 24.13 21.83 10.14 22.76

Midwives 244 198 31.62 32.51 24.36 21.8 7.56 18.48

Village

Midwives 40 102 33.58 28.38 24.57 21.65 11.43 28.57

Paramedics 43 38 34.34 31.31 19.81 17.69 7.89 19.44

Specialist 2 0 36.00 24.00


Government and Honoraria Employees in puskesmas Urban Rural

Government

empl. Honoraria empl.

Government

empl. Honoraria empl.

Full

Time

Part

Time

Full

Time

Part

Time

Full

Time

Part

Time

Full

Time

Part

Time

General Practioners 2.26 0.03 1.93 0.02

Dentists 1 0.03 0.19 0.05

Nurses 11.95 0.05 2.15 0.03 5.66 0.07 1.93 0.00

Midwives 5.74 0.03 0.94 0.00 2.34 0.02 1.02 0.00

Bidan desa (vill.midw.) 0.97 0.00 0.62 0.00 0.98 0.1 1.74 0.00

Paramedics 4.03 0.00 0.74 0.00 1.97 0.00 0.98 0.00

Obstetricians/gynecologist 0.00 0.00 0.00 0.00

Specialized in elderly 0.00 0.00 0.00 0.00

Public Health 1.76 0.00 0.90 0.00

Pediatricians 0.00 0.00 0.00 0.00

Assistant Nutrition Expert 0.74 0.00 0.39 0.00

Health worker 1.29 0.03 0.49 0.00

Administrative empl. 2.53 0.00 1.35 0.00 0.58 0.02 0.74 0.02

Staff 0.21 0.00 0.05 0.00


Possible interpretation: • The demand for health care services is higher than can be

satisfied by government contracted medical professionals alone.

• Limited supply with government contracted medical professionals

Medical professionals working under government contracts may have an advantageous (bargaining) position (i.e. demanding more freedom in working besides their obligations for the puskesmas as private health professionals or simply more days off).


Urban Rural

Number of puskesmas 38 59

Registration/

Waiting Room

Patient

Registration

Cards 100 % 64.41 %

Registration

Books 100 % 89.83 %

Drawer to

store files 97.37 % 79.66 %

Dirty Floor 14.29 % 18.18 %

Dirty Walls 10.81 % 15.22 %

Dirty Ceiling 10.81 % 15.22 %

Experiencing

leaks/splash/f

lood during

the rainy

season 15.79 % 32.20 %

Examination

Room

Dirty Floor 2.63 % 15.25 %

Dirty Walls 2.63 % 15.25 %

Dirty Ceiling 5.26 % 20.34 %

Urban Rural

Health

Instruments:

average

number

% in

good

repair

average

number

% in

good

repair

Stethoscope 6.08 76.64 3.39 76.11

Thermometer 3.18 92.77 2.66 87.97

Beds 3.76 98.67 2.46 97.97

Inpatient beds 2.61 85.82 2.14 86.92

Delivery Kit 1.89 85.19 1.51 90.07

Ultrasounds 2.95 98.98 1.42

100.0

0

Electrocardiog

arm 0.39 46.15 0.10 80.00

Syringes 3.08 93.18 2.69 88.10

Quality of physical equipment in puskesmas

Room conditions Disposal of health instruments


B) Maternal and Child Health Care Provision

Posyandus: services offered PANEL A: General Services

Urban Rural

Number of posyandus 38 56

Service offered:

Weighing of babies/children 100 % 100 %

Provision of supplementary food 84.21 % 76.79 %

Provision of Oralit 39.47 % 62.50 %

Immunization Service 86.84 % 94.64 %

Pregnancy Examination 47.37 % 75.00 %

Provision of iron vitamin 47.37 % 75.00 %

Provision of vitamin A 100 % 98.21 %

Treatment of patients 18.42 % 50.00 %

Child development (TKA) 31.58 % 37.50 %

Mother and child health (KIA) 34.21 % 62.5 %

PANEL B: Family Planning Services

Service offered:

Oral Contraceptive 50.00 % 42.86 %

Condom (per unit) 36.84 % 55.36 %

Injectable contraceptive 15.79 % 16.07 %

Overcoming side effects (per action) 42.11 % 60.71 %

Family Planning counselling 7.89 % 10.71 %


Posyandus: disposal of health instruments

Urban Rural


Health Instruments:

Baby scales 89.47 % 96.43 %

Height measuring devices 47.37 % 55.36 %

Oral contraceptive Pills 10.53 % 19.64 %

Oralit 18.42 % 25.00 %

Iron Tablets 5.26 % 19.64 %

Vitamin A 15.79 % 26.79 %

Paracetamol 5.26 % 21.43 %

Adult Scale 63.16 % 60.71 %

Stethoscope 2.63 % 17.86 %

Thermometer 2.63 % 12.50 %


Urban Rural

Number of

posyandus

21 28

Lower

Level

Capacity

28.57 % 42.86 %

Middle

Level

Capacity

28.57 % 17.86 %

Higher

Level

Capacity

28.57 % 7.14 %

Self

sufficient

Capacity

14.29 % 32.14 %

Urban Rural


General problems:

Lack of fund 44.74 % 59.32 %

Lack of medical supply 10.52 % 28.81 %

Lack of equipment 34.21 % 47.46 %

Lack of active cadres 18.42 % 18.64 %

Lack of support from puskesmas 7.89 % 8.47 %

Lack of support from village 2.63 % 11.86 %

No permanent place 18.42 % 16.95 %

Lack of interest/participation 26.32 % 11.86 %

No problem 21.05 % 6.78 %

Problems in maternal and child health :

Lack of fund 18.42 % 40.68 %

Lack of medical supply 5.26 % 18.64 %

Lack of equipment 18.42 % 28.81 %

Lack of support from puskesmas 5.26 % 8.47 %

Lack of support from village 5.26 % 5.08 %

No permanent place 15.79 % 11.86 %

Lack of interest/participation 18.42 % 15.25 %

Lack of Kia training for the cadres 5.26 % 28.81 %

No problem 36.84 % 20.34 %

Posyandus: capacity and problems faced

Much more fluctuation

in quality for rural

posyandus


B) Maternal and Child Health Care Provision

Traditional midwives: services offered Urban Rural

Number of midwives 20 55

Service offered

Delivery

Percentage of midwives who ask for delivery charge 30 20

Fee for delivery charge (rupiah) 206250 118333.3

Postnatal care for

mothers

Percentage of midwives providing post natal care for

mothers

90 87.27

Percentage of midwives who ask for charge for mother

care after delivery

16.67 6.25

Fee for mother care after delivery (rupiah) 121426.6 7894.737

Average number of days proving mother care 14.17 12.17

Postnatal care for

babies

Percentage of midwives providing post natal care for

babies

90 85.45

Percentage of midwives who ask for charge 5.56 4.26

Fee for babies care after delivery (rupiah) 121428.6 7894.737

Average number of days providing babies' care 16.11 12.96


IV. Do poorer areas have lower levels of health care provision?

Expenditure Groups

Low Middle High

Mean expenditure (value in rupiah) 679597.3 1065333 1676764

Value of asset index -0.37 0.1 0.65

Years of schooling of the HH head 6.56 7.45 8.92

Years of schooling of the HH wife/husband 5.69 6.81 8.42

Number of communities in the urban areas 3 13 22

Number of communities in the rural areas 30 19 11

Number of communities with electricity 33 31 31

Number of communities in which electricity has become much more

available

16 19 19

Number of communities with 1450 watt of electricity available 18 12 7

Number of communities with 2.900 watt of electricity available 2 11 19

Number of communities with asphalt or cement roads 23 21 28

Number of communities with dirty roads 5 6 2

Average distance to the district capital (km) 83.51 57.17 12.77

Average distance to the province capital (km) 122.33 145.02 136.42

Average distance to the closest market (km) 35.77 37.56 7.65

Number of communities with at least one village midwife 21 20 16

Number of communities in which there even been a midwife 3 9 4

Number of communities with puskesmas 33 31 33

Number of communities with posyandu 31 31 33

Number of communities with traditional midwives 31 24 21


• Significant constraints in terms of the availability (understaffing, absenteeism) and quality (education degrees, medical training) of medical staff.

• Likewise, poor physical infrastructure and

limited supply with medical equipment and medication.

Concluding Remarks:


• Strong differences between urban and rural public health care provision:

• Rural puskesmas : small number of medical

staff, higher absenteeism rates, more limitations in terms of infrastructure, medical equipment and medication and less financial endowment.

• Rural posyandus better supplied with medical

equipment/medication


• In line with the urban-rural comparison: similar differences along the village wealth gradient with poor villages showing relative worse outcomes with respect to the puskesmas and relatively better outcomes with respect to the posyandu.

Given the strong dependence/reliance of people in Eastern Indonesia to access public health care facilities, there exist significant scope to further improve public health care services

The role of demand and supply level factors in shaping optimal exclusive

breastfeeding practices. Results from IFLS-East 2012

“The role of demand and supply level factors in shaping optimal exclusive breastfeeding practices. Results from IFLS-East 2012”

I. Introduction

• Importance of breastfeeding for maternal and child health • Reduce risk of breast cancer • Reduce risk of maternal mortality • Reduce risk of infant mortality • Reduce risk of diseases (meningitis, diarrhea, respiratory infections, obesity) • Influence positively cognitive development

Breastfeeding as a cost free intervention to improve health conditions in developing countries

• WHO Recommendations: • Timely initiation (within 1 hour) • Exclusive breastfeeding for six months • Continued breastfeeding though 24 months


I. Introduction

• Long standing literature on the effects of breastfeeding but

relatively less research on the determinants of breastfeeding • Modernization hypothesis

• Virtually no research focused on the determinants of optimal infant feeding practices

• Our contribution:

• Focus on exclusive breastfeeding for six months • Considering the role of the interplay between demand and

supply side variables • Accruing current knowledge on Eastern Indonesian region


II. Data Mean/Percentage Std. Dev. Min Max

Pregnancies/child characteristics:

Duration of exclusive breastfeeding 6.62 3.63 1 12

Exclusive breastfeeding for six months 22.96%

Male children 51.90%

Order of birth 3.29 2.03 1 15

Pregnancy check ups 72.23%

Services received during pregnancy 3.45 2.80 0 8

Mother age at birth 28.53 6.33 13 47

Mothers characteristics:

Mothers' years of schooling 7.40 3.88 0 12

Mothers self-employed 25.38%

Mothers employed in the private sector or government sector 22.61%

Mothers doing casual jobs and unpaid family work 45.93%

Household characteristics:

Household Size 5.18 1.70 2 13

Asset index -0.17 1.01 -2.23 2.13

Household owing Health Card (Kartu Sehat) 35.35%

Health Care Suppliers characteristics:

Health instruments available at the posyandus 37.29 121.89 0 900

Posyandus opened in every month 94.74%

Average years of schooling of Heads and Cadres in the

posyandus 9.46 2.61 2 12

Practitioners providing prenatal care at the puskesmas 35.44 37.00 0 173.25

Working hours per week for practitioners in puskesmas 31.49 9.58 10 84

Average years of experience of health practitioners in

puskesmas 5.07 4.05 0 29

Years of experience of midwives in puskesmas 6.03 4.74 1 22.5

Village Population 3886.42 5754.08 116 62011

Sample: 972 mothers; 1372 children born over the period 2006-2012


III. Methods

• First research question: which factors affect the duration of exclusive breastfeeding at any time?

Cox Proportional Hazard (CPH) Model

• Dep. Var.: time (months) during which the child was exclusively breastfed

• Basic assumption: all the subjects (infants aged 0-12 months) are

exposed to a hazard or risk of occurrence of termination of exclusive breastfeeding;

• Estimating relative risks • Stratification across urban/rural


III. Methods

• Second research question: which factors drive the adoption of optimal exclusive breastfeeding practices?

Linear Probability Model

• Dep. Var.: dichotomous variable saying whether the child was breastfed for six months

• Robustness checks


Results: (a) Determinants of duration of

exclusive breastfeeding

(c1) (c2) (c3) (c4) (c5) (c6) (c7) (c8) (c9) (c10) (c11) (c12) (c13) (c14) (c15)

Boy 0.0219 0.0214 -0.00496 -0.0110 0.0160 -0.00611 0.000108 0.00175 0.0141 -0.00802 0.0135 -0.00803 -0.00539 -0.0260 -0.0315

(0.0579) (0.0579) (0.0580) (0.0580) (0.0600) (0.0583) (0.0585) (0.0585) (0.0614) (0.0586) (0.0614) (0.0586) (0.0585) (0.0668) (0.0697)

Birth order 0.0212 0.0208 0.0214 0.0189 0.00955 0.0219 0.0210 0.0214 0.0148 0.0209 0.0162 0.0206 0.0183 0.00486 -0.00369

(0.0217) (0.0218) (0.0219) (0.0223) (0.0230) (0.0221) (0.0220) (0.0220) (0.0231) (0.0221) (0.0230) (0.0221) (0.0222) (0.0249) (0.0262)

Mother age at birth 0.00567 0.00571 -0.00159 -0.000308 0.000230 -0.00295 -0.00241 -0.00234 -0.000689 -0.00213 -0.00125 -0.00211 -0.00136 -0.00111 0.000398

(0.00583) (0.00584) (0.00590) (0.00582) (0.00614) (0.00597) (0.00593) (0.00593) (0.00613) (0.00596) (0.00613) (0.00596) (0.00599) (0.00678) (0.00708)

Household size -0.0338 -0.0339 -0.00776 -0.000913 -0.00392 -0.00697 -0.00893 -0.00968 -0.00453 -0.0102 -0.00513 -0.00993 -0.00914 -0.0243 -0.0218

(0.0214) (0.0215) (0.0211) (0.0211) (0.0218) (0.0212) (0.0212) (0.0212) (0.0220) (0.0213) (0.0220) (0.0214) (0.0213) (0.0244) (0.0249)

Mothers years of schooling 0.00394 0.00366 -0.0202* -0.0257** -0.0214* -0.0221** -0.0210* -0.0213** -0.0237** -0.0226** -0.0230** -0.0225** -0.0232** -0.0258** -0.0233*

(0.0102) (0.0103) (0.0106) (0.0105) (0.0110) (0.0107) (0.0107) (0.0107) (0.0111) (0.0107) (0.0111) (0.0107) (0.0107) (0.0123) (0.0129)

Asset index 0.00980 0.0104 -0.0275 -0.0294 -0.0175 -0.0274 -0.0215 -0.0240 -0.0188 -0.0190 -0.0216 -0.0191 -0.0109 -0.00632 -0.0468

(0.0443) (0.0444) (0.0448) (0.0447) (0.0463) (0.0453) (0.0451) (0.0453) (0.0471) (0.0458) (0.0471) (0.0458) (0.0456) (0.0525) (0.0561)

Mother self employied -0.104 -0.104 -0.107 -0.102 -0.138* -0.108 -0.104 -0.102 -0.123 -0.114 -0.118 -0.114 -0.111 -0.205** -0.152*

(0.0747) (0.0747) (0.0746) (0.0742) (0.0783) (0.0748) (0.0748) (0.0748) (0.0791) (0.0750) (0.0792) (0.0752) (0.0751) (0.0873) (0.0907)

Mother employed in gov/priv 0.0798 0.0812 0.0124 0.0181 -0.00298 0.0114 0.0117 0.0172 -0.00803 0.000379 -0.0159 -0.00187 0.00377 -0.0814 -0.107

(0.0932) (0.0935) (0.0934) (0.0920) (0.0951) (0.0938) (0.0934) (0.0937) (0.0962) (0.0942) (0.0966) (0.0948) (0.0943) (0.105) (0.108)

Health Card 0.0111 -0.0618 -0.0973 -0.0539 -0.0571 -0.0584 -0.0605 -0.0657 -0.0676 -0.0630 -0.0673 -0.0587 -0.0782 -0.0454

(0.0630) (0.0634) (0.0633) (0.0657) (0.0638) (0.0637) (0.0638) (0.0669) (0.0637) (0.0669) (0.0638) (0.0641) (0.0738) (0.0779)

Pregnancy Services 0.133*** 0.137*** 0.134*** 0.135*** 0.141*** 0.137*** 0.134*** 0.0859** 0.131*** 0.135*** 0.132*** -0.0141

(0.0117) (0.0121) (0.0117) (0.0117) (0.0152) (0.0124) (0.0118) (0.0400) (0.0171) (0.0119) (0.0134) (0.0217)

Pregnancy checkup 1.104*** 1.309***

(0.0757) (0.140)

Pos.opened every months -0.163 -0.452***

(0.137) (0.174)

Village Population 4.86e-06 1.53e-05*

(6.95e-06) (8.28e-06)

Pos. health instruments 0.000129 -6.39e-05

(0.000231) (0.000244)

Pus. Practitioners prenatal care -0.00101 -0.000243 -0.00161*

(0.000824) (0.00135) (0.000964)

Pregnancy services *Pus. Practitioners prenatal care -0.000194

(0.000272)

Pos.Years of schooling of heads 0.0205 0.000924 0.0318**

(0.0136) (0.0199) (0.0161)

Pus. Practitioners years of experience 0.00418 0.00259 -0.0271

(0.00796) (0.0109) (0.0219)

Pregnancy services*Pos.Years of schooling of heads 0.00557

(0.00412)

Pregnancy services*Pus.Practitioners Years of experience 0.000557

(0.00257)

Pus. Practitionners working hours -0.00430 3.71e-05

(0.00321) (0.00363)

Years of experience of midwives -0.00426 0.00252

(0.00763) (0.0126)

h0(0) rural 0.91 0.91 0.92 0.95 0.92 0.92 0.92 0.92 0.94 0.93 0.93 0.92 0.91 0.91 0.94

h0(0) urban 0.91 0.91 0.93 0.95 0.92 0.93 0.93 0.93 0.95 0.93 0.94 0.93 0.92 0.91 0.94

Observations 1,203 1,203 1,203 1,203 1,127 1,188 1,188 1,188 1,081 1,179 1,081 1,179 1,179 916 857


Determinants of duration of exclusive breastfeeding

• Maternal education associated negatively and significantly with the risk of termination of exc. bf.

• Pregnancy Checkup and Number of pregnancy

services associated positively and significantly with the risk of termination of exc. bf.

• No significant role played by the supply

variables


Determinants of duration of exclusive breastfeeding

• Non linearities affecting the results

Length of

exclusive

breastfee

ding

(months)

Mothers years

of schooling Asset Index

Observat

ions Mean St.Dev. Mean St.Dev.

0-1 140 7.18 3.96 -0.214 1.08

1-2 88 6.9 3.61 -0.084 0.93

2-3 67 8.14 3.97 0.075 1.03

3-4 133 6.98 3.76 -0.044 1.05

4-5 116 8.42 3.75 0.000 0.99

5-6 77 5.85 4.14 -0.613 0.96

6-7 311 8.5 3.42 -0.070 0.96

7-8 60 7.2 3.48 -0.382 0.87

8-9 36 6.55 3.73 -0.306 0.94

9-10 16 5.75 2.88 -0.546 0.7

10-11 10 5.4 3.8 -0.423 0.93

11-12 303 6.83 4.12 -0.254 1.04

Number of

services

received

Pregnancies

Mothers

average years

of schooling Asset Index

Mean

St.

Dev Mean

St.

Dev

0 29.45% 5.42 3.99 -0.59 0.98

1 3.43% 6.88 3.28 -0.61 0.73

2 5.54% 5.65 3.46 -0.48 0.79

3 10.86% 7.24 3.40 -0.15 0.95

4 11.15% 7.77 3.37 -0.07 0.90

5 11.44% 8.44 3.62 -0.11 1.03

6 9.84% 8.94 3.30 0.19 0.93

7 9.18% 9.70 2.89 0.44 0.91

8 9.11% 9.57 3.15 0.34 0.98


Results: (b) Determinants of optimal

exclusive breastfeeding practices

(c1) (c2) (c3) (c4) (c5) (c6) (c7) (c8) (c9) (c10) (c11) (c12) (c13) (c14) (c15)

Rural 0.00474 -0.00156 0.0142 -0.00766 0.0247 0.00790 0.0205 0.0185 0.0362 0.0141 0.0398 0.0111 0.0191 0.0361 0.0295

(0.0379) (0.0382) (0.0371) (0.0373) (0.0379) (0.0419) (0.0375) (0.0375) (0.0401) (0.0379) (0.0403) (0.0381) (0.0378) (0.0415) (0.0496)

Boy -0.0103 -0.0116 -0.0226 -0.0194 -0.0211 -0.0245 -0.0260 -0.0271 -0.0136 -0.0203 -0.0137 -0.0195 -0.0217 -0.0296 -0.0205

(0.0241) (0.0241) (0.0235) (0.0236) (0.0245) (0.0237) (0.0237) (0.0237) (0.0250) (0.0238) (0.0250) (0.0238) (0.0238) (0.0275) (0.0286)

Birth order -0.0148 -0.0160* -0.0125 -0.0136 -0.0151 -0.0144 -0.0130 -0.0132 -0.0145 -0.0136 -0.0143 -0.0129 -0.0121 -0.0202* -0.0217**

(0.00931) (0.00934) (0.00908) (0.00912) (0.00966) (0.00918) (0.00914) (0.00914) (0.00966) (0.00919) (0.00967) (0.00921) (0.00922) (0.0106) (0.0110)

Mother age at birth0.00345 0.00357 0.00124 0.00190 0.00102 0.00141 0.00104 0.00108 0.00112 0.000856 0.00104 0.000795 0.000607 0.000508 0.000795

(0.00249) (0.00249) (0.00243) (0.00244) (0.00255) (0.00246) (0.00245) (0.00245) (0.00255) (0.00247) (0.00255) (0.00247) (0.00247) (0.00284) (0.00296)

Household size-0.00428 -0.00462 0.000804 -0.000100 0.00147 0.00115 0.00224 0.00240 0.000810 0.000776 0.000540 0.000243 0.000238 0.00576 0.00611

(0.00890) (0.00890) (0.00867) (0.00871) (0.00903) (0.00875) (0.00873) (0.00873) (0.00915) (0.00877) (0.00915) (0.00879) (0.00879) (0.0103) (0.0106)

Mothers years of schooling0.0235*** 0.0227*** 0.0154*** 0.0168*** 0.0137*** 0.0150*** 0.0146*** 0.0148*** 0.0137*** 0.0154*** 0.0138*** 0.0153*** 0.0155*** 0.0139*** 0.0119**

(0.00423) (0.00426) (0.00423) (0.00423) (0.00443) (0.00428) (0.00429) (0.00429) (0.00446) (0.00429) (0.00447) (0.00429) (0.00430) (0.00503) (0.00521)

Asset index -0.0269 -0.0255 -0.0409** -0.0391** -0.0324* -0.0403** -0.0438** -0.0423** -0.0299 -0.0354* -0.0309* -0.0350* -0.0402** -0.0294 -0.0263

(0.0181) (0.0181) (0.0177) (0.0178) (0.0185) (0.0179) (0.0179) (0.0179) (0.0187) (0.0181) (0.0187) (0.0181) (0.0181) (0.0210) (0.0220)

Mother self employied-0.00727 -0.00867 -0.000964 -0.00201 0.0891** -0.00199 -0.00329 -0.00402 0.0851** 0.0860** -0.00315 -0.00252 0.0864** -0.00548 0.0839**

(0.0308) (0.0308) (0.0299) (0.0301) (0.0365) (0.0301) (0.0301) (0.0301) (0.0369) (0.0359) (0.0323) (0.0303) (0.0359) (0.0358) (0.0411)

Mother employed in gov/priv-0.0672* -0.0637* -0.0884** -0.0727* -0.0892** -0.0853** -0.0891** -0.0904** -0.0870** -0.103**

(0.0386) (0.0387) (0.0377) (0.0378) (0.0379) (0.0378) (0.0380) (0.0391) (0.0383) (0.0430)

Health Card 0.0368 0.00513 0.0118 0.00598 0.00248 0.00223 0.00318 0.00392 0.00263 0.00546 0.00160 0.000238 -0.0123 -0.0135

(0.0263) (0.0258) (0.0258) (0.0270) (0.0261) (0.0260) (0.0260) (0.0274) (0.0261) (0.0275) (0.0261) (0.0261) (0.0307) (0.0322)

Pregnancy Services 0.0408*** 0.0422*** 0.0406*** 0.0407*** 0.0358*** 0.0437*** 0.0409*** 0.0281 0.0459*** 0.0407*** 0.0438*** 0.0323***

(0.00478) (0.00499) (0.00481) (0.00480) (0.00639) (0.00507) (0.00485) (0.0174) (0.00706) (0.00490) (0.00554) (0.00879)

Pregnancy checkup 0.220*** 0.101*

(0.0283) (0.0536)

Mother doing casual/unpaid work 0.0894** 0.0891** 0.0897** 0.0895** 0.0883**

(0.0387) (0.0391) (0.0382) (0.0382) (0.0447)

Pos.opened every months 0.0111 -0.00341

(0.0554) (0.0709)

Village Population -9.25e-07 -3.63e-07

(2.68e-06) (3.30e-06)

Pos. health instruments -0.000115 -0.000136

(9.42e-05) (0.000101)

Pus. Practitioners prenatal care 0.000586* 2.53e-05 0.000608

(0.000341) (0.000594) (0.000401)

Pregnancy services *Pus. Practitioners prenatal care 0.000141

(0.000122)

Pos.Years of schooling of heads 0.00489 -0.000879 0.00139

(0.00532) (0.00815) (0.00656)

Pus. Practitioners years of experience -0.00481 -0.00182 -0.00286

(0.00303) (0.00433) (0.00916)

Pregnancy services*Pos.Years of schooling of heads 0.00167

(0.00179)

Pregnancy services*Pus.Practitioners Years of experience -0.00104

(0.00107)

Pus. Practitionners working hours 0.00107 0.000328

(0.00124) (0.00139)

Years of experience of midwives -0.000603 -0.000733

(0.00313) (0.00504)

Constant 0.0519 0.0520 -0.00250 -0.0298 -0.0893 0.0162 -0.0190 -0.00172 -0.142 -0.0502 -7.96e-05 0.0309 -0.106 0.0272 -0.112

(0.0803) (0.0802) (0.0782) (0.0790) (0.0955) (0.0837) (0.0806) (0.0820) (0.108) (0.0876) (0.117) (0.0825) (0.0912) (0.0929) (0.143)

Observations 1,203 1,203 1,203 1,203 1,127 1,188 1,188 1,188 1,081 1,179 1,081 1,179 1,179 916 857

Adjusted R-squared0.029 0.029 0.085 0.075 0.086 0.084 0.086 0.086 0.090 0.087 0.090 0.087 0.085 0.088 0.095


Determinants of optimal exclusive breastfeeding practices

• Male and high order-children are negatively associated with exclusive breastfeeding. • Gender bias in parental preferences (see Ralston, 1997) • Rise in the opportunity cost of time

• Mother’s age at birth is positively associated with the probability of exclusive breastfeeding: • “Experience” effect



• Mothers who are employed in the formal sector (Gov./Priv.) are less likely to practice exclusive breastfeeding for six months • clear competition between maternal employment and

breastfeeding

• Mothers living in wealthier households are less likely to practice exclusive breastfeeding for six months • Modernization hypothesis • Easy access to breast-milk substitutes



• More educated mothers are more likely to adopt optimal infant feeding practices.

• Part of the positive effect of maternal education is channeled by mothers’ demand for prenatal health services.

• Positive and significant effect of pregnancy services • More interaction with health practitioners affecting

mothers knowledge


Conclusion

• Major contribution is on our focus on optimal breastfeeding.

• Low cost intervention for reducing rates of morbidity/mortality for infants and mothers.

Main Findings and Policy implications: • Education policies: mothers with more education tend to

adopt optimal breastfeeding practices (confirming the findings from Akin et al. 1981). • Education campaign, for all women, irrespective of

education (i.e. mass media promotion or advertising material exposed at health posts), may help to positively influence women’s attitudes towards breastfeeding.


Conclusion

• Supply and quality of health infrastructure seem to be not important in affecting exclusive breastfeeding practices but the advice from health professional received during pregnancy can influence breastfeeding decision strongly. • Moreover, part of the effect of maternal education is channeled by mothers demand for health care services. • A policy recommendation therefore would be to increase access to pregnancy services.

Terima Kasih!

Appendix first paper

Reasons for being absent (%) : Urban Rural

1.Off duty 12.22 1.71

2.Vacation 1.11 0.57

3.No longer work there 28.89 36.57

4.Sick 7.78 5.14

5.Family, member is sick 3.33 2.86

6.Other authorized absence 41.11 26.29

7.Late 2.22 20.57

8.Unauthorized absence 3.33 5.71

Appendix first paper

Urban Rural

% of puskesmas/pustu which received Health Operational Assistance (BOK) program 97.37 81.35

Amount of the budget derived from the BOK for the last year's budget (rupiah) 180,000,000 112,000,000

Amount of the budget derived from the BOK for the current year's budget (rupiah) 183,000,000 132,000,000

% of puskesmas/pustu which recently have finished Budget Year 2011 97.37 89.83

% of puskesmas/pustu which recently have finished Budget Year 2011/2012 2.63 10.17

% of puskemas which did not send budget proposal Local Gov. (Dinas Kesehatan) for the

past budget year 68.42 67.80

% of puskemas which sent specific budget proposal to Local Gov. (Dinas Kesehatan) for the


Budget proposed by puskesmas to Local Gov./Dinas for the past budget year (rupiah) 445,000,000 206,000,000

Budget of the puskesmas for the last budget year (rupiah) 410,000,000 232,000,000

% of the budget comprised from:

Assistance from regional government 44.39 22.28

Assistance from central government 21.05 43.97

Claim from Jamkesmas/Jamkesda 19.68 35.47

Patients 4.85 1.89

Askes 7.32 3.05

Other Assistance 0.31 0.17

% of puskesmas that did not receive any revenue/patient target from Dinas Kesehatan for


% of puskesmas that received revenue/patient target from Dinas Kesehatan for past budget

year 19.44 28.21

Target of revenue from patients set by Local Gov./Dinas (rupiah) 23,100,000 15,100,000

Appendix second paper

Full Breastfeeding

Exclusive

breastfeeding 5-7

months

Probit

Baseline Extended Baseline Extended Baseline Extended

Mother

Education 0.0145*** 0.0103* 0.0140*** 0.0197*** 0.0568*** 0.0397**

Pregnancy

Services 0.0416*** 0.0304*** 0.0588*** 0.0321*** 0.144*** 0.0948***

public health facilities and exclusive breastfeeding in...

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