The financing need of equitable provision of paid maternal leave in the informal sector in Indonesia: a comparison of estimation methods.

BACKGROUND: Providing an enabling environment for breastfeeding is hampered by the inequitable implementation of paid maternity leave, primarily due to perceived or actual financial costs. To estimate the real cost of paid maternity leave requires using reliable methods. We compared methods utilized in two recent studies in Indonesia. Study A estimated the financial need of providing paid maternity leave in the formal sector with a 10-year forecast at 21% coverage of eligible mothers, while study B estimated similar costs for the informal sector at 100% coverage annually. Results are critical for guiding future application of either method to inform paid maternity leave policies. METHODS: We compared number of covered mothers working informally, total annual cost, and cost per mother. We modified some parameters used in study A (method A) to be similar to study B (method B) for comparison, namely the period of estimate (annual), coverage (100%), estimate of women potentially breastfeeding, exchange rate, female labor force participation rate, the percentage of women working in the informal sector, and adding administration cost. RESULTS: The methods differ in determining the number of mothers working in the informal sector who gave birth, the minimum wage as unit cost, and administrative cost. Both studies estimated the cost at various lengths of leave period. Method A requires more macro (e.g. national/regional) level data, while method B involves (e.g. individual) micro level data. We compared the results of method A with method B, respectively: 1) number of covered mothers working informally were 1,425,589 vs. 1,147,204; 2) total annual costs including administrative costs were US$650,230,167 vs. US$633,942,726, and; 3) cost/mother was US$456 vs US$553. CONCLUSION: Certain flexibilities can be applied to both methods, namely using parameters specific to respective regions (e.g. provincial level parameters), flexible period of analysis, and the use of administrative cost. In a setting where micro data is scarce and not easily accessible, method A provides a feasible approach, while method B will be most appropriate if suitable micro data is available. Future comparison studies in other settings are needed to provide further evidence on the strengths and weaknesses of both methods.

The yearly financing need of providing paid maternity leave in the informal sector in Indonesia.

BACKGROUND: The economic cost of not breastfeeding in Indonesia is estimated at US$1.5-9.4 billion annually, the highest in South East Asia. Half of the 33.6 million working women of reproductive age (WRA) in Indonesia (15-49 years) are informal employees, meaning they are working as casual workers or they are self-employed (small scale business) and assisted by unpaid/family worker(s). No specific maternity protection entitlements are currently available for WRA working informally in Indonesia. This study aims to estimate the financing need of providing maternity leave cash transfer (MCT) for WRA working in the informal sector in Indonesia. METHOD: The costing methodology used is the adapted version of the World Bank methodology by Vilar-Compte et al, following pre-set steps to estimate costs using national secondary data. We used the 2018 Indonesian National Socio-Economic Survey to estimate the number of women working informally who gave birth within the last year. The population covered, potential cash transfer's unitary cost, the incremental coverage of the policy in terms of time and coverage, and the administrative costs were used to estimate the cost of MCT for the informal sector. RESULT: At 100% coverage for 13 weeks of leave, the yearly financing need of MCT ranged from US$175million (US$152/woman) to US$669million (US$583/woman). The share of the yearly financing need did not exceed 0.5% of Indonesian Gross Domestic Product (GDP). CONCLUSIONS: The yearly financing need of providing MCT for eligible WRA working in the informal sector is economically attractive as it amounts to less than 0.5% of GDP nominal of Indonesia. While such a program would be perceived as a marked increase from current public health spending at the onset, such an investment could substantially contribute to the success of breastfeeding and substantial corresponding public health savings given that more than half of working Indonesian WRA are employed in the informal sector. Such policies should be further explored while taking into consideration realistic budget constraints and implementation capacity.

The financing need for expanded maternity protection in Indonesia.

Background: Almost half of all Indonesian children under 6 months of age were not exclusive breastfed in 2017. Optimizing maternity protection programs may result in increased breastfeeding rates. This study aims to: estimate the potential cost implications of optimizing the current paid maternity protection program, estimate budgets needed to increase coverage of lactation rooms in mid and large firms, and explore challenges in its implementation in Indonesia. Methods: The potential cost implication of the current and increased maternity leave length (three and 6 months) as well as the potential budget impact to the government were estimated for 2020 to 2030. The cost of setting up lactation rooms in formal sector companies was estimated using the Alive & Thrive standards. Interviews were conducted in five different provinces to 29 respondents in 2016 to identify current and potential challenges in implementing both existing and improved maternity protection policies. Results: The costs of expanding paid maternity leave from three to 6 months and incorporating standardized lactation rooms in 80% of medium and large size firms in Indonesia was estimated at US$1.0 billion (US$616.4/mother per year) from 2020 to 2030, covering roughly 1.7 million females. The cost of setting up a basic lactation room in 80% of medium and large companies may reach US$18.1 million over 10 years. The three main barriers to increasing breastfeeding rates were: breastmilk substitutes marketing practices, the lack of lactation rooms in workplaces, and local customs that may hamper breastfeeding according to recommendations. Conclusions: The cost of expanding paid maternity leave is lower than the potential cost savings of US$ 1.5 billion from decreased child mortality and morbidity, maternal cancer rates and cognitive loss. Sharing the cost of paid maternity leave between government and the private sector may provide a feasible economic solution. The main barriers to increasing breastfeeding need to be overcome to reap the benefits of recommended breastfeeding practices.

The annual cost of not breastfeeding in Indonesia: the economic burden of treating diarrhea and respiratory disease among children (< 24mo) due to not breastfeeding according to recommendation.

BACKGROUND: In Indonesia, 96% of children (< 24mo) are breastfed. However, only 42% of children (< 6mo) are exclusively breastfed, as per World Health Organization recommendations. Breastfeeding provides protective benefits such as reducing the risk of morbidity and mortality associated with diarrhea and pneumonia/respiratory disease (PRD). This study estimates the potential economic impact of not breastfeeding according to recommendation in Indonesia based on infants suffering from attributable diarrhea and PRD. METHODS: A cost analysis examined both the healthcare system costs and non-medical costs for children (< 24mo) with diarrhea and PRD. Data collection took place between 2015 and 2016 and healthcare expenditures were assessed in 13 facilities, in five sites including Bandung and Tomohon City. Costs from a provider perspective were estimated using healthcare records and 26 interviews with healthcare workers. A discount rate of 3% was used. A cross-sectional survey with caregiver-child pairs (n = 615) collected data related to out of pocket costs such transportation and opportunity costs such as wage loss. These figures were combined with the national disease prevalence rates from Indonesia Demographic and Health Survey 2012, and the relative risk of disease of not breastfeeding according to recommendation from literatures to extrapolate the financial burden of treatment. RESULTS: The healthcare system cost due to not breastfeeding according to recommendation was estimated at US$118 million annually. The mean healthcare system cost and out of pocket costs was US$11.37 and US$3.85 respectively. This cost consists of US$88.64 million of provider costs and US$29.98 million of non-medical patient costs. CONCLUSIONS: The cost of not breastfeeding according to recommendation is potentially high, therefore the Indonesian government needs to invest in breastfeeding protection, promotion and support as the potential healthcare system cost savings are significant. As suggested by other studies, the long term cost due to cognitive losses of providing not breastfeeding according to recommendation should also be taken into account to provide a complete understanding of the economic impact of not breastfeeding according to recommendation.

HIV Patients Drop Out in Indonesia: Associated Factors and Potential Productivity Loss.

AIM: this study reported various factors associated with a higher probability of HIV patients drop out, and potential productivity loss due to HIV patients drop out. METHODS: we analyzed data of 658 HIV patients from a database in a main referral hospital in Bandung city, West Java, Indonesia from 2007 to 2013. First, we utilized probit regression analysis and included, among others, the following variables: patients' status (active or drop out), CD4 cell count, TB and opportunistic infection (OI), work status, sex, history of injecting drugs, and support from family and peers. Second, we used the drop out data from our database and CD 4 cell count decline rate from another study to estimate the productivity loss due to HIV patients drop out. RESULTS: lower CD4 cell count was associated with a higher probability of drop out. Support from family/peers, living with family, and diagnosed with TB were associated with lower probability of drop out. The productivity loss at national level due to treatment drop out (consequently, due to CD4 cell count decline) can reach US$365 million (using average wage). CONCLUSION: first, as lower CD 4 cell count was associated with higher probability of drop out, we recommend (to optimize) early ARV initiation at a higher CD 4 cell count, involving scaling up HIV service at the community level. Second, family/peer support should be further emphasized to further ensure treatment success. Third, dropping out from ART will result in a relatively large productivity loss.

The cost of not breastfeeding in Southeast Asia.

Rates of exclusive breastfeeding are slowly increasing, but remain suboptimal globally despite the health and economic benefits. This study estimates the costs of not breastfeeding across seven countries in Southeast Asia and presents a cost-benefit analysis of a modeled comprehensive breastfeeding strategy in Viet Nam, based on a large programme. There have been very few such studies previously for low- and middle-income countries. The estimates used published data on disease prevalence and breastfeeding patterns for the seven countries, supplemented by information on healthcare costs from representative institutions. Modelling of costs of not breastfeeding used estimated effects obtained from systematic reviews and meta-analyses. Modelling of cost-benefit for Viet Nam used programme data on costs combined with effects from a large-scale cluster randomized breastfeeding promotion intervention with controls. This study found that over 12 400 preventable child and maternal deaths per year in the seven countries could be attributed to inadequate breastfeeding. The economic benefits associated with potential improvements in cognition alone, through higher IQ and earnings, total $1.6 billion annually. The loss exceeds 0.5% of Gross National Income in the country with the lowest exclusive breastfeeding rate (Thailand). The potential savings in health care treatment costs ($0.3 billion annually) from reducing the incidence of diarrhoea and pneumonia could help offset the cost of breastfeeding promotion. Based on the data available and authors' assumptions, investing in a national breastfeeding promotion strategy in Viet Nam could result in preventing 200 child deaths per year and generate monetary benefits of US$2.39 for every US$1, or a 139% return on investment. These encouraging results suggest that there are feasible and affordable opportunities to accelerate progress towards achieving the Global Nutrition Target for exclusive breastfeeding by 2025.