| 4. In which ways is the initiative creative and innovative?
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The midwife-TBA partnership initiative was implemented according to the following strategy and action plan:
1. Identification of health problems in each targeted health clinic
One of the first steps in implementation of the action plan was to hold a focus group discussion with government and non-government stakeholders to identify health problems and identify solutions. One of the main problems related to safe delivery was a lack of public trust among the residents of Teluk Rumbia village in the abilities of newly posted medical personnel, who had recently completed their midwifery courses and had little practical experience and could not speak local dialects. A wide range of stakeholders attended the discussion, including health clinic directors, midwife coordinators, village midwives, health volunteers, village heads, religious elders, community leaders, representatives of the midwives association, youth representative, media, and NGOs.
2. Informal coordination
To follow up the results of the FGD, the main issues discussed were shared with key officials in the health department and the heads of health clinics in Singkil. As a result, the health department decided to endorse the TBA-midwife partnership and sought advice from related stakeholders on how to facilitate a participatory process to implement the program.
3. Joint understanding between sectors regarding the TBA-midwife partnership
A mini workshop was held to gather midwives, TBAs, village heads, religious leaders, village health workers, community leaders, representatives of the midwives association, midwife coordinator, health clinic directors, health department officials, and youth to emphasize the importance of and solidify support for the partnership program. From this workshop, the village head of Teluk Rumbia allocated village funds (alokasi anggaran desa or ADD) in the amount of IDR 50,000/month for each TBA as a “base salary”, and an agreement was reached to provide an additional incentive of IDR 50,000 per delivery from funds in the government health insurance scheme (Jampersal). During this workshop stakeholders agreed upon the rights and responsibilities of midwives and TBAs prior to delivery and during the delivery later codified in the MOU for partnership between midwives and TBAs).
4. Signature of the Village Head decree on TBA incentives
To institutionalize the incentive structure that had been developed for TBAs, the village head drafted and signed a decree for TBAs in Teluk Rumbia, which provided a continuing legal basis for the TBA-midwife partnership.
5. Signature of the MOU between midwives and TBAs
After negotiating the terms the agreement, the partnership was further codified through the signature of an MOU between midwives and TBAs, and was witnessed by officials from the health department, the heads of the health clinics, village head, Indonesian midwives association, religious elders, and community leaders.
6. Regular meetings of the subdistrict health committee (K3) and health clinic evaluation of the partnership between midwives and TBAs
The subdistrict health committee (Komite Kesehatan Kecamatan or K3) held monthly meetings to evaluate the TBA-midwife partnership. During these meetings, the health clinic head suggested that the partnership program be replicated in an additional three villages (Peumuka, Pea Bumbung, and Selok Aceh) since there were still many deliveries proceeding without trained medical personnel in these areas. The program was successfully replicated in these three villages through an identical joint commitment between midwives, TBAs, and the village heads.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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Daun, a local NGO provided capacity development and advocacy support for health governance, in conjunction with local health volunteers, village leaders, and health office officials facilitated regular discussions throughout the implementation of the initiative. Together these stakeholders conducted the problem analysis, and discussed the structure and framework of the partnership agreement including appropriate incentive structures. Daun also supported the related stakeholders to conduct monitoring and evaluation activities to measure the impact of the partnership and opportunities for further improvement.
For the technical elements of this initiative, the village head was a key driver of this initiative, providing regulatory support and financial resources for the TBA-midwife partnership. With input from midwifes, TBAs, health clinic staff, the district health office and the Indonesian Midwifes Association (IBI), the village head was able to draft and enact a regulation that proved foundational for this initiative’s success.
Local cultural and religious leaders provided outreach support for the initiative to ensure accurate information about the partnership was distributed among trusted local channels, including religious and informal community gatherings. These efforts were also supported by the village branch of the Organization for Women’s Empowerment and Family Welfare (PKK).
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| 6. How was the strategy implemented and what resources were mobilized?
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To implement the TBA-midwife partnership in Aceh Singkil, different stakeholders provided funds to support this initiative:
- Health Department Aceh Singkil 2012 IDR 56,250,000 (USD 4,625) for TBA-midwife partnership activities.
- Health Department Aceh Singkil 2013 IDR 37,577,000 (USD 3,100), including funds for the replication of this initiative to additional health clinics.
- Singkil Health Clinic with National Health Allocation (BOK) funds 2013 IDR 25,000,000 (USD 2,065)
- IMPACT-Yayasan Daun from international grant IDR 40,000,000 (USD 3,304)
- Daun from own-source contributions IDR 141,346,584 (USD 11,675)
- Funds from the Safe Delivery Fund (Anggaran Jaminan Persalinan) at IDR 50,000 for each delivery assisted together
- Village funds from Teluk Rumbia and Rantau Gedang villages in the amount of IDR 50,000/month/TBA
Human resources involved in implementation of the partnership between midwives and TBAs are as follows:
- Head of the Health Clinic
- Subdistrict Health Committee (K3)
- Midwife coordinator and midwives in Teluk Rumbia and Rantu Gedang villages
- TBAs from Teluk Rumbia and Rantu Gedang villages
- Village health coordinators
- Technical assistance from public service specialists and governance specialists provided by local and international NGOs
All resources listed above played an active role in supporting and encouraging the implementation of the initiative in Aceh Singkil. This commitment was developed through a series of discussions in the form of FGDs, coordination meetings, and workshops. These discussions, held in an open and public manner, were crucial in building a common understanding among area residents and strengthening buy-in for the success of the program.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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The concrete outputs achieved by the TBA-midwife partnership include the following:
1. Village head regulation (SK Kepala Kampong Teluk Rumbia No. 35/VII/IV/2012) in Teluk Rumbia on incentives for TBAs under partnership structure.
2. Village head regulation (SK Kepala Kampong Rantau Gedang No. 01/07/2012) on incentives for TBAs under partnership structure.
3. MOU in Teluk Rumbia between area midwives and TBAs to formalize their ongoing working relationship.
4. MOU in Rantau Gedang between area midwives and TBAs to formalize their ongoing working relationship.
These outputs have contributed to the achievement of the following:
1. Improved coverage by medical workers and a decrease in number of births only assisted by TBAs. Collaborative communication developed between midwives and TBAs in Teluk Rumbia and Rantau Gedang villages provided an avenue for earlier referrals to professional medical help and pre-natal counseling. This helped to address the myth among the community that providing information to medical professionals during the early stages of a pregnancy may have adverse effects. First trimester examinations have risen to 100% of all known pregnancies in the TBA-midwife partnership area.
2. Improvements in coverage contributed to a complete elimination of TBA-assisted births in the area surrounding Singkil Heath Clinic by the year 2013 – an extraordinary achievement considering the practice remains common in other subdistricts.
3. Community members in Teluk Rumbia and Rantau Gedang villages and other partner villages began to trust medical personnel for the first time.
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| 8. What were the most successful outputs and why was the initiative effective?
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To better understand the implementation of the initiative and to monitor and evaluate the progress on a regular basis.
The Singkil Health Clinic, which oversees the initiative, conducts routine monitoring and evaluation activities to measure the effectiveness of the TBA-midwife program. Midwife coordinators from the health clinic conduct monthly field visits to the partnering villages to monitor adherence to the MOUs that were previously signed and to compare achievements against planning documents.
The district health office compiles data from the health clinic to conduct an annual evaluation of the initiative in both villages. The district health office also conducted an evaluation of the coverage of attended births each year, providing additional oversight of the TBA-midwife partnership.
In addition, a hotline mechanism at Singkil Health Clinic is available to document the number of complaints from users regarding the service of midwives and TBAs in partner villages. This hotline has been used in order to ease access to and improve government responsiveness to community health-care needs. For example, pregnant mothers have used the hotline to request emergency services such as ambulances or midwife services.
In response to monitoring and evaluation findings, the Singkil Health Clinic has begun to develop an emergency delivery card with the contact numbers of the health clinic head, midwife coordinator, village midwife, village head, and the subdistrict health committee.
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| 9. What were the main obstacles encountered and how were they overcome?
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The main challenges encountered during implementation were the embedded nature of traditional customs and community members’ resistance to change. Health clinics in several parts of Aceh Singkil had previously conducted several health promotion and health outreach campaigns, activities, and visits; however health behavior rarely changed. Traditions such as the preference to give birth at home or the belief that sharing information regarding the early stages of a pregnancy with medical personnel could leave the baby vulnerable to “dark magic”, remained entrenched.
The continuation of these practices was due in part to the fact that TBAs had only a cursory understanding of medical aspects of pre-natal care, safe delivery practices, or post-natal care, and the inability of many midwives to speak local languages prevented them from challenging these traditions with evidence-based examples.
However, the community-based approach taken by Singkil Health Clinic in the implementation of the TBA-midwife partnership presented an opportunity to meet with pregnant women and their families, as well as influential community and religious leaders to discuss the importance of its new initiative for the health of families in the community. The incorporation of TBAs in the formation of a “new tradition” helped to mitigate resistance to change, while respecting their trusted position within society and providing access to modern medical birthing assistance as well as pre- and post-natal counseling.
At times, midwives’ commitment to the new arrangement waned, but the monitoring and evaluation efforts of the Singkil Health Clinic and the district health department helped to maintain buy-in and overcome issues as they arose. The clinic’s collection of impact-related data from the program’s beneficiaries requires further strengthening, which has already been included in the plan of action for next year.
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