Indonesia’s vast geography and sociocultural diversity shape the delivery of reproductive, maternal, newborn, child and adolescent health (RMNCAH) services in ways that are both enabling and challenging. Across provinces, significant variation has been observed in how services are planned, resourced, and delivered. These variations in service standards and quality are felt daily in the lives of women, newborns and adolescents.
Despite these challenges, progress is visible. National estimates show a drop in maternal mortality ratio, from 331 to 140 per 100 000 live births since 2000, signaling improvements in care quality and access. Fertility has stabilised and contraceptive use has grown, yet unmet reproductive health needs persist, and adolescent pregnancies continue to reflect early marriage and limited access to youth-friendly services.
To better understand how Indonesia’s health system has evolved under decentralisation, the Ministry of Health, supported by World Health Organization (WHO), United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), IPAS and the Asian Development Bank (ADB), conducted a joint external review of RMNCAH programmes. This review draws on multiple sources of evidence, including existing literature, policy documents, national health system data, as well as field visits to six selected provinces to represent Indonesia’s geographic and administrative diversity.
During the field visits, review teams observed service delivery in health facilities, spoke with health workers and local leaders and met mothers and families to understand how RMNCAH policies are operationalised.
One of the challenges identified was the management of low birthweight (LBW) infants, a major contributor to neonatal deaths, under resource constraints. One midwife described a severe case of extremely LBW twins, one stillborn and the other died after three days of care. She recalled how the surviving infant struggled to swallow and may not have received breast milk, while simultaneous emergencies required the team’s attention, affecting the care provided to the infant.
A subsequent review of the case by the district health office revealed insufficient antenatal care, fragmented maternal medical history due to population mobility, referral delays, limited provider capacity in neonatal intravenous access and a heavy workload that constrained proper newborn monitoring. These insights informed recommendations to strengthen both system-wide and service-level responses.
Since the early 2000s, Indonesia’s decentralisation initiative has given much of the responsibility for funding, staffing and managing health services to regional governments. While the Ministry of Health sets national clinical standards, daily management of public health facilities falls under regional authorities through the Ministry of Internal Affairs. While this arrangement allows services to be tailored to local needs, it also depends heavily on local capacity for planning, budgeting and management. Health facilities and district health offices are better positioned to translate national priorities into local action when they have access to consistent technical support, helping health workers manage resource constraints and infrastructure gaps.
The complexity of Indonesia’s health system governance is no easy feat to navigate. Understanding these dynamics is essential to strengthening policy, improving coordination and ensuring more equitable access to services across Indonesia. Under the leadership of Ministry of Health, recommendations from this exercise will be key in guiding the nation’s roadmap to an equitable and quality health system for RMNCAH.
Written by Edit Oktavia Manuama, National Professional Officer (Maternal, Newborn, and Child Health), and Jessie Yunus, National Professional Officer (Gender, Rights, Equity, and Disability Inclusion)