District Health Office, Aceh Singkil

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Although many areas of the Indonesian archipelago have undergone difficult transitions to regional autonomy, perhaps none have been as difficult as in the province of Aceh – emerging not only from 60 years of authoritarian rule but also from 30 years of civil war and the devastation of the 2004 Boxing Day Tsunami. Aceh Singkil is one of the 23 districts in the province of Aceh, and its 108,000 residents are served by 11 basic health clinics (pusat kesehatan masyarakat - puskesmas) scattered through the district’s coastal areas, hills, river-side communities. The district’s economy is primarily driven by palm oil. Before this initiative began, many babies were delivered with the assistance of traditional birth attendants (TBAs) in Aceh Singkil, especially in river-side villages. A report by Indonesia’s Central Bureau of Statistics shows that 38.28 percent of deliveries in the district were handled by traditional birth attendants in 2010. District data shows that 122 TBAs were active in child delivery services the same year. Although medically-trained midwives were available in the district, the traditions of the communities in this area were strong, and the traditional birth attendants were well-respected elders believed to possess special spiritual and medicinal powers. Their trusted positions within the community and low cost made them an attractive alternative to a large number of families from lower economic classes, low education levels, and remote areas far from health facilities. However, TBAs often lacked any kind of medical training or understanding of proper birthing procedures. As a result, they were ill-equipped to handle complications that threatened the health of mothers and their children. Because many of the deliveries they supported were at home and far from medical facilities, placing professional help beyond reach. Medically trained midwives, on the other hand, were seen by many community members as too young and inexperienced to handle deliveries properly, and their inability to speak local dialects prevented them from being able to connect to the communities they were intended to serve. A pilot project to forge a partnership between TBAs and medically trained midwives was introduced in 2012. The intention was to bring trained medical workers’ skills to bear in assisting births in line with national service standards for maternal and child health and to reduce complications with high-risk pregnancies through a culturally sensitive approach.

B. Strategic Approach

 2. What was the solution?
The health department in Aceh Singkil aimed to ensure that all births in the district were attended by trained midwives or other medical personnel. However, they have faced a number of difficulties in reaching all of the communities that needed attention. Beginning in two villages, Desa Teluk Rumbia and Desa Rantau Gedang, the district health department worked with NGO Daun, to pilot a partnership program to take advantage of the respective strengths of traditional birth attendants and medical midwifes to reduce risks to maternal and child health. For the past two years, there have been no unattended births by medical personnel in these villages due to the success of the partnership. These accomplishments have inspired five additional villages within the subdistrict to replicate the program. The strategy for successful implementation and uptake of the partnership within the communities began with mobilization of key stakeholders to discuss the problem of unskilled deliveries and the risks to mothers and their families. During these discussions the partnership between TBAs and midwives was introduced as a solution by the local health clinics and was supported by the village head, head of the local mosque, community leaders, religious leaders, local health volunteers, TBAs, and midwives themselves. There was widespread support for the initiative and a deep understanding of its importance in improving the health of the community and of the district. After a consultation with the sub-district health committee, the village head, the head of the local mosque, cultural leaders, local health volunteers, midwives, and TBAs, a local regulation was developed, legislating that every TBA would receive an honorarium from the village for their services in assisting trained medical personnel with child deliveries. TBAs were eligible under the regulation to receive additional compensation from the government health insurance fund for safe delivery (Jampersal) for sharing in the handling of the patient. This approach involved a broad variety of stakeholders, respected cultural traditions, and provided a clear incentive structure – all of which contributed to the overall success of this community-driven pilot program and significant improvements in the quality of health care delivered by the government.

 3. How did the initiative solve the problem and improve people’s lives?
This initiative creatively addressed a situation that could have been very controversial since it involved local culture, time-honored traditions, and the roles of respected elders. However, involving traditional birth attendants in the solution by inviting them to participate in a mutually beneficial partnership rather than cutting them out of the process was very successful. Pregnant women now have the benefit of both the spiritual and cultural guidance of TBAs and the skilled medical assistance of trained medical workers. It is a win-win situation. For this to happen, the TBAs and midwives signed an agreement witnessed by the village head, the head of local health clinic, and the district health department. The content of the agreement laid out the provision of locally sourced financial incentives for traditional birth attendants’ cooperation with midwives in safer delivery practices. With the support from the community, in addition to the regulation from the village head, the initiative has moved forward successfully. Community members continue to monitor the initiative and participate in its implementation.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
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.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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).
 6. How was the strategy implemented and what resources were mobilized?
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.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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.

 8. What were the most successful outputs and why was the initiative effective?
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.

 9. What were the main obstacles encountered and how were they overcome?
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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Anecdotal and testimonial evidence uncovered during Singkil Health Clinic’s monthly monitoring and evaluation visits to the villages participating in the TBA-midwife partnership reveal the following impacts: Impact on Quality of Service: - Health statistics reveal that the maternal mortality at Singkil Health Clinic fell to zero in 2013. In 2012 there was one maternal death. - Similar statistics managed by Singkil Health Center show a decrease in the number of births attended by TBAs only in the clinic’s coverage from 17 in 2011, to eight in 2012, to just two in 2013. It is worth noting that the two deliveries supported by TBAs in 2013 occurred in villages outside of the pilot program area. From January 2012 to October 2013, a total of 214 births have been assisted through the new partnership between TBAs and midwives. - Focus group discussions show that trust between midwives and TBAs has improved in the pilot program areas. Both parties have noted that the partnership provides a clearer delineation of duties and responsibilities. TBAs feel the partnership had their jobs easier since the midwives were responsible for clinical aspects and they could rely on them when complications occurred. Similarly, midwives mentioned that TBAs helped talk to the mothers and families and comfort them during the delivery process, handling important non-medical aspects. - The director of the Singkil Health Clinic said that, through its expanded network of TBAs, the clinic was better positioned to learn about new pregnancies in the clinic’s coverage area. Since TBAs now share information with the clinic, potential high-risk pregnancies and impending deliveries are more readily identified. Impact of Access to Health-Care Services: - TBAs have proven crucial in encouraging pregnant mothers to undergo pre-natal check-ups at proper medical facilities, leading 113 mothers to undergo first trimester exams in 2012, and an additional 109 as of October 2013. - The partnership program identified logistical challenges that created barriers to health care, which in turn triggered the creation of the Singkil Health Clinic’s hotline service for emergency services. Through this hotline, mothers going into labor could order ambulances and water ambulances for emergency transport to the clinic. This service has not only affected pregnant women, but has had a far broader impact on the surrounding community. - Because of the partnership, mothers are now able to access professional health-care services in a language that they understand. With TBAs serving as a bridge to village communities, midwives are now able to more effectively communicate with their patients. Impact on Public: - Focus group discussions have led to an increase in public awareness in partnership villages about the importance of pre-natal visits and seeking medical assistance with safe delivery. - Focus group discussions have created new opportunities for partnering villages to participate in the overall development of health services. Many of its direct beneficiaries have become outspoken advocates for its broader adoption and further replication in other villages and to new subdistricts.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
To ensure the sustainability of the partnership between midwives and TBAS in Singkil health clinic and Aceh Singkil district as a whole, the following steps have been taken: 1. Singkil Health Clinic allocated IDR 6 million for evaluation of the partnership between midwives and TBA in its plan of action and 2014 budget. 2. Singkil health clinic developed monitoring and evaluation mechanism for partnership between midwives and TBAs. 3. Head of the Aceh Singkil health department issued Head of Health Department Decree No. 441/1515-a/2013 regarding TBA-midwife partnerships to replicate the initiative in all health clinics throughout the district 4. Head of the Aceh Singkil health department allocated funds for replication of the partnership between midwives and TBAs initiative through the health department budget line item for the Family Health Division’s 2014 budget in the amount of IDR 938.6 million 5. Enactment of a village head regulation (SK Kepala Kampong Teluk Rumbia No. 35/VII/IV/2012) in Teluk Rumbia on incentives for TBAs under partnership structure. 6. Enactment of a village head regulation (SK Kepala Kampong Rantau Gedang No. 01/07/2012) on incentives for TBAs under partnership structure. 7. Establishment of an MOU in Teluk Rumbia between area midwives and TBAs to formalize their ongoing working relationship. 8. Establishment of an MOU in Rantau Gedang between area midwives and TBAs to formalize their ongoing working relationship. This initiative began as a pilot program to reduce the maternal and infant mortality rate in two villages to test its potential for replication. Follow its success in Rantau Gedang and Teluk Rumbia, it has already been replicated in five additional villages (Teluk Ambon, Takal Pasir, Pea Bumbung, Selok Aceh, and Pemuka). Based on the success of the TBA-midwife partnership, the district health department prepared a policy in 2013 for its full-scale implementation throughout the entire district beginning in 2014. This program’s success as a local initiative that blended traditional community figures in the adoption of modern medical practices not only has implications within the province of Aceh but also has implications for national health policy as the Ministry of Health continues its efforts to meet Millennium Development Goals (MDGs) on maternal and child health. It proves that traditional belief systems can be changed over time through careful and culturally sensitive approaches, and the provision of appropriate incentive structures.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
This initiative was successful given the commitment from the local government and key community leaders. Without this cooperation the initiatives from the health department would not have been accepted by the public nor would behavioral change have occurred so quickly. An approach emphasizing public participation to increase ownership and accountability for results proved essential. Lessons Learned from the Partnership between midwives and TBAs: - Public participation is crucial to success. Strong commitment by stakeholders including health department, health clinics, midwives, TBAs, and village heads was the key to success for implementation of the partnership initiative. Without their active participation, levels of awareness and commitment to overcoming the problem would be unlikely. - Trust between development partners is a precondition to success. Recognizing TBAs as a tremendous community resource and a major agent of change for maternal and child health outcomes became a significant factor in the success of the initiative. Similarly, highlighting midwives as a resource rather than a threat to TBA livelihoods allowed for each partner to perform their duties more effectively. - Through a partnership with midwives, their position is respected, appreciated, and integral to the maternal and infant mortality rates of the community. - Appropriate incentives are needed for any behavioral change. Clear regulations, defining and protecting the role of each party, were a significant boost in the success of this program. - Constant communication is needed to maintain working relationships. Monthly community visits by clinic staff and the 24-hour hotline help to maintain open lines of communication that were key in identifying and resolving challenges as they arose. - Changing cultural traditions that have been maintained for decades, perhaps even centuries, is not easy and requires a strategy and approach in line with the customary practices of the community. In the case of the partnership between midwives and TBAs, strengthening of the TBAs was the appropriate strategy to attempt these changes in recognition of their strategic role at the village level. Their importance in the cultural fabric of the community positioned them well to influence behavior and promote wider coverage of safe delivery practices. As the elders in the community who are well respected by their community, the partnership approach was appropriate for the cultural context.

Contact Information

Institution Name:   District Health Office, Aceh Singkil
Institution Type:   Government Agency  
Contact Person:   Edy Widodo
Title:   Chief of District Health Office  
Telephone/ Fax:   +6265821202 / +6265821203
Institution's / Project's Website:  
Address:   Jalan Bahari No. 55, Pulo Sarok,
Postal Code:   24785
City:   Aceh Singkil
State/Province:   Aceh

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