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Indonesia’s cash transfer programs are valuable, Stanford health fellow finds

Indonesia’s cash transfer programs are valuable, Stanford health fellow finds

Nursing students in training. Yogyakarta, Indonesia. Project HPEQ. Photo: Nugroho Nurdikiawan Sunjoyo / World BankNearly forty-four percent of Indonesia’s population is living on less than $2 a day, making it near impossible for some to seek proper health treatment. One way to reduce this situation is through Indonesia’s conditional cash transfer (CCT) program, Margaret Triyana, PhD, says.

The CCT program, first piloted by the World Bank in 2007 and expanded from 2009–10, encourages Indonesia’s most destitute to pursue health-seeking behaviors by reducing barriers to health care through cash incentives. Payment is given for receiving treatments at a local clinic. Essentially, the poor are reimbursed simply for “showing up” for health services.

Triyana, a Jakarta native and postdoctoral fellow in the Asia Health Policy Program, has been in residence at the Shorenstein Asia-Pacific Research Center (APARC) in the Freeman Spogli Institute for International Studies studying the effects of the CCT program on Indonesia’s poor. She has been evaluating the household CCT program’s two-year implementation, focusing on the maternal and child health initiatives.

She plans to produce multiple papers that focus on issues related to CCT interventions and its impact on mothers and children. Triyana will continue this research after leaving Shorenstein APARC this July, accepting an academic teaching position at Nanyang Technological University in Singapore.

Recently, Triyana discusses her research.

What types of health initiatives does the CCT program sponsor, and for whom?

The CCT program targets Indonesia’s most poverty-stricken by selecting approximately the bottom 30 percent of the poorest households, with preference toward households with pregnant women or school-aged children. Eligibility depends on socioeconomic factors per district such as expenditure, education and asset ownership. The program stretches the rural-urban divide, covering people in and off Java (this is the main island where 60 percent of the population resides). Many initiatives in the household CCT program are focused on child and maternal health. For mothers, they include a series of prenatal care visits, an iron tablet prescription, childbirth assistance and postnatal care. For children, they cover vaccinations, monthly height and weight measurements at the clinic and vitamin A pills. It is a combination of poverty reduction and human capital investments – attempting to induce good behavior that instills long-term health in low resource settings.

Who is the typical primary care provider in Indonesia?

The primary care provider is often a midwife. This is because Indonesia doesn’t have enough trained doctors to support the growing demand. Clinics operate at the sub-district level, which comprise 10-15 villages each. Every village is assigned one midwife. Midwives can perform most procedures just short of surgery. For example, midwives offer typical delivery services but refer patients to a district-level hospital for a Caesarean section. This system, for the most part, functions well, but midwives do have an expanded scope of care that can be unsettling. Children have their cuts taken care of by midwives; adults can get antibiotics through them. This diffused system is perhaps more efficient, but it can call into question the legitimacy of their authority. Midwives receive only three years of training for their certification. This is something the Indonesian government intends to inspect and will likely restructure.

What behavior changes do you see as a result of the CCT program?

My initial findings show there is increased utilization of health care programs. The CCT program incentivizes certain behaviors – attending the clinic for a test or retrieving medication – which then, in theory, leads to better health. “Showing up” doesn’t automatically correlate with improved health, but if we think about the population at hand, it would in most cases. People who weren’t using health services before now are. Everyone that was offered the program signed up. Monthly attendance to CCT-linked programs is reported at a rate of 85 percent. In particular to maternal health, I noted a 10 percent increase in delivery fees. This trend follows what we would expect to see – because of increased utilization, there is a natural rise in price for the service. On the demand-side, I found a 40 percent increase in the use of midwives, and a rise in fees paid to providers for maternal and child services. These factors indicate with a high level of certainty that the CCT program lowers barriers to health care.

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Cancer, Global Health, Stanford News, Women's Health

Stanford fellow addresses burden of cervical cancer in Mongolia

Stanford fellow addresses burden of cervical cancer in Mongolia

Mongolian clinic - smallCervical cancer is the third most common cancer among women worldwide, and Mongolia has one of the highest incidence rates in Eastern Asia. Prevention and early detection programs are essential to counteract its prevalence, especially in developing countries.

However, women encounter barriers to knowledge and access to cervical cancer screening services in Mongolia – a country with low population density. The urban–rural divide, lagging healthcare reform, and cultural differences are cited as core factors leading to lack of awareness and treatment.

To address the rising burden, a national cervical cancer screening program was implemented in August 2012 by Mongolia’s Ministry of Health (MOH) facilitated by a grant from the Millennium Challenge Corporation.

Gendengarjaa Baigalimaa, MD, the 2013-14 Developing Asia Health Policy Fellow at Stanford’s Walter H. Shorenstein Asia-Pacific Research Center in the Freeman Spogli Institute, has been evaluating the effects of that program. She serves as a gynecological oncologist at the Mongolian National Cancer Center (NCC). Her early findings show that awareness of cervical cancer has increased, and more women and girls are now getting screened. Gendengarjaa recently talked about her research.

What does your “typical” patient look like at the NCC and how has your work informed your research?

Patients typically arrive at the NCC with an advanced stage of disease – 70 percent of these women have progressive forms of cervical cancer. Of course it is not easy to work with patients who are this far along, especially if we are unable to offer full palliative services. As the only cancer center in the nation, just 10 gynecological oncologists are available to take on the high demand for treatment services. Healthcare providers and policymakers designed the Mongolian Cervical Cancer Program to address the alarming incidence rate. My research analyzes behavioral change before and after the introduction of the national screening program, bearing in mind my experiences with my own patients.

What does the national cervical cancer screening program facilitate?

Before the program was implemented, regular cervical cancer screening did not exist in Mongolia. The program diffused and strengthened primary care screening services (Pap test) as well as prevention programs. Gynecological doctors from the NCC were systematically dispatched to the 338 soums or districts throughout the nation. They trained local doctors and midwives on how to administer the Pap test. The program coordinated two initiatives: a pilot HPV vaccination program for girls aged 11-15 years from four select areas and a Pap test program for women aged 30-60 years. The women and girls who participated are urged to get screened every three years thereafter. Health education campaigns were also broadcast on select television and radio programs targeted at women and girls.

Comparing a survey taken at the program’s outset in 2010 to your survey at the program’s conclusion in 2013, what behavioral changes have been observed?

Our preliminary results have shown increased knowledge about risk factors and screening services. Women in both rural and urban areas are now more informed about cervical cancer risk factors. Awareness of the need for a Pap test increased from 15.3 percent in 2010 to 45.3 percent in 2013. The respondents also reported being more educated about the suggested frequency of visiting a doctor, and the availability of services outside of Ulaanbaatar. Due to increased knowledge, 54.2 percent of the women surveyed confirmed that they had attended cervical screening services.

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