RCA at the frontline: multiple realities in Indonesia's health sector
Reality Check Approach (RCA) is a unique qualitative research method that places significant importance on learning from the contextual experiences of local individuals and communities. By triangulating the rich perspectives and realities of multiple stakeholders, RCA can help improve policies and the targeting and design of services for the poor. Since 2010, Palladium has promoted the use of RCA in Indonesia and has conducted a number of studies including for DFAT, the World Bank, BAPPENAS, and Indonesia’s National Team for the Acceleration of Poverty Reduction (TNP2K). Two of RCA’s latest studies include Frontline Health Service Providers and Hygiene & Nutrition, conducted in parallel to better understand barriers and opportunities in Indonesia’s public health system, and to inform appropriate policies.
RCA in action
Service delivery in Indonesia’s health sector continues to undergo improvements, with the implementation of strategies, blue prints and regulations at a national level. How these improvements are understood and applied at the frontline of health service delivery remains an immense challenge. To better tackle this issue, RCA conducted two parallel studies in three Indonesian provinces, with the aim of capturing diverse perspectives and realities from both sides of the health system: people providing and accessing health services. With its unique approach involving experiential research, people-led agenda setting, living with rather than visiting communities, and conversations rather than interviews, RCA was ideally suited to uncovering and understanding diverse realities and opinions. Specifically, it explored the impact of certain factors on health service delivery, including rural and peri-urban regions; coastal, river and inland landscapes; as well as the perceptions of locals and newcomers.
‘RCA is quite a simple idea. It’s about listening to people in their own context- which sounds quite simple, but is actually surprisingly difficult to do well. It’s an opportunity to spend quality time and understand what people think, and the context in which they are living’- Dee Jupp, RCA Senior Technical Adviser
Through its unique research elements, RCA uncovered a suite of key learnings for health service delivery. Across the study locations, it found that medicine supply has become a vast logistical challenge, more so in the eastern region of Indonesia. Insights gathered from village health centres (puskesmas) indicated that a change in budget priorities of local government, limited and irregular stocking, as well as difficult access are amongst the underlying causes. Consequently, despite the supposedly free or cheaper access to medicines at the puskesmas, communities prefer to buy their own medicines at kiosks or markets. Specifically, community perception of self-procured medicines points to a preference for choice, diversity and immediate results. Substituting appropriate medicines with vitamins or other drugs due to puskesmas’ limited stock continues to exacerbate community perception that puskesmas-sourced medicines are of inferior quality.
Next steps: improving health service delivery
In taking the learnings from these RCA case studies and informing policy improvement, valuable insights were recorded:
• Villagers want to see continuity and ever-readiness of service from frontline health providers, with a strong emphasis on being approachable and trustful.
• Civil-servant health staff, be it doctors, nurses or midwives, mostly prefer assignment in peri-urban villages as they remain close to all the ‘perks’ in town.
• Government-contracted health professionals undertake up to three years’ assignment in remote areas with adequate incentive. Once they leave, continuity of service is disrupted until the next professional arrives.
• Ever-readiness, approachability and trustfulness of a frontline provider depend more so on the individual’s character and ‘chemistry’ with the community, and are thus hard to standardise.
• Ultimately, the motivations of frontline health providers assigned to villages are often at odds with the needs of rural and remote people.
The findings of both studies were recently presented to key commissioning bodies, including the World Bank and DFAT funded Governance for Growth (KOMPAK) program. More broadly, research conclusions and recommendations have been put to BAPPENAS and the Ministry of Health. Suggested discussion points, including the improvement of service attitudes of health providers in local communities, will now be taken forward by key stakeholders. Ultimately, RCA learnings can help inform the broader policy discussion regarding contextual community engagement with health providers.
In a complex sector such as this, RCA insights provide decision makers with an understanding as to how and why people make choices. The relatively swift turnaround of an RCA study ensures rapid and high quality evidence and insights, while timely updates ’from the field’ contribute to responsive policy making and program designing. By helping relevant governments, donor agencies, NGOs and development programs better understand the realities of the poor and the front line service providers that support them, RCA can contribute to positive impact in the long term.
RCA will hold a ‘Meet the RCA’ event on 9 May in Jakarta, followed by RCA International Practitioners Conference on 10 – 13 May. To read more about RCA past and present studies, RCA Community of Practice, and contributions to evidence based policy, click here.