Accelerating the Achievement of MDGs through BSB
Disaster Response Brigade

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
In 2008, the status and level of health in Bantaeng regency is still low. Several indicators, namely Maternal Mortality Ratio (AKI), Infant Mortality Rate (AKB), Figures on Malnutrition Cases, Incidence of Environmentally Based Diseases, and Mortality Rate reflect high figures. In addition to the poor, women are particularly vulnerable to health problems. Pregnant woman, in particular, faces high risk and requires special treatment. Prior to this initiative, the Maternal Mortality Ratio (AKI) for 2008 in Bantaeng reached 535 cases per 100,000 of mothers giving births, this is well above the MDG target of 110 per 100,000 live births for 2015. A similar incidence occurs in South Sulawesi with an average AKI rate of 248 cases per 100,000 live births. For comparison, there are several regencies in South Sulawesi with the same level of per capita income; the AKI for Sidrap Regency is 140.65 per 100,000 live births, 130 per 100,000 live births in Pangkep Regency, 81 per 100,000 live births in Gowa Regency. Health care for this group is difficult to implement due to various factors that become an obstacle. The most dominant factor is the geographical and topographical conditions of the area resulting in very minimum access to health care for the community. For sub-districts with low accessibility, the distance and travel time to the nearest health facility reaches 60-90 minutes. Meanwhile, for severe cases requiring specialist treatment, the longest travel time in Bantaeng Regency to the Regional Public Hospital (RSUD) is 45 minutes. In addition, economic and social cultural factors influence the decision making in determining health care. As a result of this condition, high risk maternal cases requiring immediate treatment also experience delays. In several maternal mortality cases, a delay in treating patients was found, the patients came when their condition was already very severe, becomes a major factor. In 2008, the percentage of maternal mortality due to delays in treatment reaches 70.59% of the total cases. This is exacerbated by home conditions which are prone to diseases such as slums and underdeveloped areas, prone to flooding and insufficient sanitation. Health cases that are caused by infection and are environmentally based such as tuberculosis, Dengue Hemorrhagic Fever (DBD) and diarrhea can easily be found.

B. Strategic Approach

 2. What was the solution?
The Disaster Response Brigade (BSB) is supported by the Head of Bantaeng Regency and Regional Government apparatus to improve the status and accelerate the achievement of the Millennium Development Goals (MDGs) in the health sector namely: 1. Eradicating poverty and hunger. One of the specific targets determined for this goal is to reduce the number of underweight/malnourished children under the age of five; 2. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate; 3. Improve maternal health; 4. Combat HIV/AIDS, Malaria and other Infectious Diseases; and 5. Ensure Environmental Sustainability. One of the specific targets set for this goal is to halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The main target group for the Disaster Response Brigade’s (BSB) health services are groups that have the greatest leverage in achieving the millennium development goals (MDGs), among others: underweight/malnourished children under the age of five, infants and children under the age of five, pregnant and maternal women, and people suffering from infectious diseases. The steps and strategies uses an outreach system to solve the issues in the form of the following initiatives: a) Bringing mobile service facilities that can reach all areas of Bantaeng Regency; b) Preparing of skilled health personnel and representative ambulance services; c) Disseminating about the availability of a mobile ambulance through communication media, community leaders, and religious leaders; d) Preparing health care facilities in the villages, sub-districts and regencies to anticipate conditions that require a direct or indirect referral process; e) Training communities through the Medical First Responder (MFR) to improve the initial response for handling emergency cases.

 3. How did the initiative solve the problem and improve people’s lives?
In the implementation of health services conducted by the BSB team, the following innovation was presented: 1. The one-stop service is conducted solidly and simultaneously among three Regional Government Agency (SKPD), namely the Department of Health, the Regional Environmental Impact Management Agency (Bapedalda) and the Department of Social Services in delivering integrated emergency response services. Prior to setting up a one-stop service among 3 SKPD, the three SKPDs work on their own because the service facilities are located in each SKPD, such as BSB in the Department of Health, Fire Brigade (Damkar) in Bapedalda, Disaster Volunteer Corps (Tagana) in the Department of Social Services. Therefore when there is a social issue associated with 3 SKPDs, the coordination time for settling the issue is relatively long. With regards to this issue, the Head of Bantaeng Regency established a policy for synergizing urgent matters by positioning 3 SKPD including the Regional Disaster Management Agency (BPBD) in the form of a one-stop emergency response provider, no longer focused on each SKPD. With this initiative, emergency response coordination only takes 3-5 minutes. 2. The role of the Public Health Center (Puskesmas) can be more targeted as it can focus on the preventive and promotion aspects. 4. Meanwhile, the implementation of referral activities is taken over by the BSB at no charge. 3. The BSB acts as a traffic controller system for the referral system because the BSB team performs a triage/sorts cases. If the cases encountered in the location are categorized as mild cases, the BSB team only provides treatment at home by providing medicine, and coordinating with the nearest Puskemas to monitor the progress of the patient's health. If the cases encountered are classified as moderate, for example diarrhea with mild to moderate dehydration, the BSB team will perform an initial treatment and subsequently observe the patients in the BSB Headquarters or the Inpatient Puskemas. However, if the case encountered is classified as severe, the BSB team provides initial treatment and refers them to the hospital. 4. Emergency response is provided through the Call Center 113 for the public. Through this call center, the community can directly contact and obtain services from the BSB team with a response time depending on the location zone. The service area is divided into 5 (five) zones. If there is information from the community via Call Center 113 that operates 24 hours, the officer will respond by asking in detail regarding the patient’s location, patient’s complaints, and the condition of the patient at that time. The officer then refers the closest BSB team based on the zoning to conduct an examination on the patient. Afterwards, the doctor determines the diagnosis and performs treatment according to the case. For urban areas, the response time is only approximately 5 minutes and for long distances it is currently 10-25 minutes.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The elements of the action plan that has been developed are as follows: 1. General Emergency Life Support (GELS) training for doctors, Basic Trauma Cardiac Life Support (BTCLS) for nurses and midwifes, and Medical First Responder (MFR) for the general public. This training will result in increasing the capacity of officers in handling emergency cases and provide knowledge to the general public regarding the initial treatment for traffic accident cases; 2. Formulating Minimum Service Standards (SPM), Standard Operating Procedures (SOP), and Public Service Standards (SPP) which aims to provide a certainty of time to the community based on the zone specified referring to the response time that has been established; 3. Equipping ambulances with basic and advanced emergency kit; 4. Preparing sufficient operational costs through the Regional Government Budget (APBD). To ensure sufficient financial support for BSB operations; 5. Setting job descriptions, schedule for each officer. 6. Provide peace of work for officers by offering monthly incentives. The key steps that must be agreed upon are the commitment and integrity of the stakeholders providing health service. The service conducted by BSB is based on the vision namely to Achieve a Healthy, Independent, Good Quality Bantaeng in 2015. This vision is carried out through the mission namely: 1. Equalization and improvement of the quality of service by the Disaster Response Brigade 2. Improving the quality, facilities and infrastructure of the Disaster Response Brigade. 3. Improving the health information system. 4. Equalization and expansion of the range. In order to increase the service accountability for women and for ease in obtaining information on government programs, an information dissemination session is conducted for the public regarding the BSB program and how to contact the BSB via Call Center 113. Likewise, to ensure the continuity of services an information and communication network between the Puskesmas and its network are established with the BSB, hence a sustainable service system can be established.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
This initiative will involve three Regional Government Agencies (SKPD) namely the Department of Health, Department of Social Services, and Regional Environmental Impact Management Agency (Bapedalda) as a joint Emergency Response Unit. . In addition, this initiative involves several socio-religious organizations, youth organizations, community leaders, religious leaders and others. The achievement of the millennium development goals (MDGs) is inseparable from the role of civil society organizations, the private sector and others. Religious organizations and youth organizations play a role in providing counseling about the importance of nutrition for pregnant women, labor and delivery process with health professionals, healthy life style and acts as a facilitator between the pregnant women and health-care facilities. In addition to the involvement of the parties above, the operation of BSB facilities also involve several parties, namely: 1. The Japanese Government granted operational vehicles i.e. 6 ambulances equipped with fully equipped emergency care facilities. Therefore, the BSB vehicle resembles a mini Intensive Care Unit (ICU). 2. PT ASKES (Persero) granted an operational vehicle i.e. fully equipped ambulance. 3. The Public Service Center (PSC) for the Eastern region of Indonesia through cooperation to improve human resources, particularly in the emergency sector.
 6. How was the strategy implemented and what resources were mobilized?
The Regional Government in collaboration with Health Organisations, the Indonesian Doctors Association (IDI), Indonesian National Nurses Association (PPNI), and others in the mobilization of medical personnel. Operational costs required for delivering emergency services derive from Bantaeng Regency APBD II. APBD II funds the continuity of services such as vehicle operations (fuel, vehicle maintenance cost), food and drinks for the BSB duty officers, monthly incentives for BSB officers. In addition to the Banteng Regency APBD II, the BSB funding is also supported by the APBN through the National Health Insurance Program (Jamkesmas), Regional Health Insurance Program (Jamkesda) and Social Access. Health insurance is a health care payment assistance program provided by the Bantaeng Regional Government to the community. With the agreement has been established between Puskesmas under the Department of Health and BSB, that after providing health services for a patient whose health care is guaranteed by health insurance, the BSB has the right to claim payment for the services provided by the BSB Team for patients with health insurance. The proceeds of this claim is medical services reserved for all health care providers in the BSB, ranging from doctors, nurses and non-nurses.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Within 4 years since the Disaster Response Brigade (BSB) was formed, 2008-2012, the BSB has successfully improved the health services for the community particularly women as the most vulnerable group. Several health indicators in Bantaeng Regency display significant improvement: 1. Maternal Mortality Ratio Since 2008, the Maternal Mortality Ratio (AKI) in Bantaeng Regency is as follows: there are 17 maternal deaths of which 12 cases (70.59%) were caused by four delay factors, i.e. late discovery, late diagnosis, late treatment and late referral. Through BSB operations in providing services for the referral for pregnant and maternal women, the delay factors have successfully been anticipated, therefore at the end of 2012, the number of maternal mortality cases has been reduced to zero. 2. Infant Mortality Rate Based on data from the health survey held in 2008, the infant mortality rate (AKB) in Bantaeng Regency occurred in 38 cases, the presence of the Disaster Response Brigade (BSB) with its trained and skilled personnel managed to reduce infant mortality to 11 cases in 2012. 3. Number of Malnutrition Cases The health condition in Bantaeng Regency in 2008 is still relatively low. This is reflected by the existence of malnutrition cases. Based on the health survey of that particular year, there were 16 malnutrition cases. The BSB collaborated with a number of parties associated with the issue, primarily through consultation and information dissemination sessions. As a result Bantaeng Regency had eradicated malnutrition cases in 2011. 4. The Incidence of Environmentally Based Diseases Decreases Based on the health survey in 2008, 2.7% of the total population Bantaeng Regency i.e. 172,849 people experienced diarrhea; and 0.09% of the total population or 256 cases experienced dengue hemorrhagic fever. The figure above obliviously becomes a problem in the health sector particularly in the effort to eradicate infectious diseases. Through promotion and preventive activities that synergize with the Public Health Center (Puskemas), community leaders, religious leaders, and other public components, in 2012, the incidence of environmentally based diseases can be reduce. IN 2012, diarrhea cases affected 1.7% of the total population and Dengue Hemorrhagic Fever of only 0.003% of the total population or 6 cases. 5. Increased Life Expectancy. In 2008, the life expectancy in Bantaeng Regency was 67.9 years. After the BSB commenced its operations, the health problems in Bantaeng Regency decreased each day. This condition obviously provided security and comfort for the community, particularly in terms of the availability of good quality health services in Bantaeng Regency. This plays an important role in increasing life expectancy in Bantaeng Regency to 72.5 years in 2012.

 8. What were the most successful outputs and why was the initiative effective?
The system used to evaluate this activity, are as follows: 1. For mother and child activities through the Local Maternal and Child Health Monitoring (PWS-KIA), Local Nutrition Monitoring (PWS Gizi) which is performed every month in the Department of Health by inviting pediatricians and obstetricians from the Prof. H.M. Anwar Makkatutu Regional Public Hospital; 2. Perform monthly monitoring and evaluation of the Disaster Response Brigade (BSB); 3. Conduct monthly Regency level coordination meeting to discuss the program in the Puskemas, in synergy with the Disaster Response Brigade activities; and 4. Hold annual Regional Health Meeting (RAKERKESDA).

 9. What were the main obstacles encountered and how were they overcome?
The BSB health services implementation, includes some geographically challenging/difficult to reach areas, such as mountains, valley, and others. For topographically flat urban areas, geographical problems are not an impediment factor. However, the prolonged decision making process often causes a delay in the delivery of services. To overcome this problem, we will implement the following strategies: 1. For home visits, we equip the BSB team with 1 doctor, 2 nurses and 1 driver, so they can provide answers to all the questions from the community about the state of the patient and this will foster public confidence to immediately make a right and quick decision. 2. In overcoming this problem, we work closely with the civil society and religious organizations. The organization serves as a motivator to invite people to use the health facilities and participate and provide input in the decision making process. 3. Provide certainty of cost, time, and healthcare personnel. In areas with mountainous topography which requires a response time of more than 20 minutes, the government will build new quarters for the BSB in Uluere Sub-district located in Loka Mountain. Therefore, decreasing the response time for the surrounding three sub-districts to less than 15 minutes. In 2014, new quarters for the BSB will be built in Tompobulu which has a response time of over 20 minutes, hence the response time for the 3 surrounding sub-districts will hopefully be shorter.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Since commencing its operations in December 2009, the BSB has provided health services for the whole community in Bantaeng Regency. The number of cases resolved or handled by BSB experienced an escalating yearly trend. This illustrates that the people of Bantaeng Regency that previously had no access to health services, can now have equal access to good quality health services. Specifically for obstetric or maternal cases, out of the 631 cases served, 87 cases were treated in a mobile ambulance. In other words, mothers facing difficulties during labor (obstructed labor) can be assisted by the BSB team and deliver their babies in the ambulance. This is due to the readiness of the medical personnel and equipment to assist the labor and delivery on the ambulance. With the presence of the emergency response services, particularly the BSB which is a leading innovation, there have been significant changes in the Bantaeng Regency. This is reflected by the change in health status indicators prior to the BSB operation and after the BSB operation. This condition will certainly affect the achievement of the MDGs. The health status prior to and after the Disaster Response Brigade (BSB) operation are as follows. The maternal mortality rate experiences a significant decrease from 17 cases in 2008 to 0 (zero) cases in 2012, the infant mortality rate decreased from 38 cases in 2008 to 11 cases in 2012. The number of malnutrition cases in 2008 i.e. 16 cases was eradicated in 2011. Likewise, the incidence of environmentally based disease declined, resulting in the increasing life expectancy of the Bantaeng society from 67.9 years in 2008 to 72.5 years in 2012. Without undergoing a relatively lengthy training and information dissemination session, changes and empowerment in the health sector has taken place in the community. When the community encounters issues related to the health sector, they will spontaneously contact Call Center 113 to ask for help. They no longer seek shaman, healers and other community leaders. This is a very crucial and difficult change as it alters the attitude and mindset of the community.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
1. Program sustainability requires the establishment of regulations, planning as well as the allocation of resources e.g. finance, institutions and human resources. In connection with that matter, the Regional Government of Bantaeng has stipulated that the BSB institution will still be under the coordination of the Bantaeng Department of Health as one of its technical implementation units. Similarly, to maintain continual synergy between 3 related SKPD, the Regional Government of Bantaeng issued the Regent’s Decision Letter No. 430/595/XII/2009 on the Establishment of an Emergency Service Team for Bantaeng Regency. The Bantaeng Regency Disaster Response Brigade (BSB) is not only a health care facility for the Bantaeng Regency, but has been recommended by the Ministry of Health of the Republic of Indonesia as a destination for work visits by other Regencies/Municipalities in all of Indonesia. The Regencies/Municipalities that have visited the BSB since 2010 till now, among others: 1. Sinjai Regency, South Sulawesi 2. Makassar, South Sulawesi 3. Bekasi, West Java 4. Bulukumba Regency, South Sulawesi 5. Padang, West Sumatera 6. Palopo, South Sulawesi 7. Gunung Kidul Regency, DIY 8. Polman Regency, West Sulawesi 9. Mamuju Regency, West Sulawesi 10. Bombana Regency, Southeast Sulawesi 11. Ponorogo Regency, East Java 12. Wajo Regency, South Sulawesi 13. Selayar Regency, South Sulawesi 14. Kupang, East Nusa Tenggara (NTT) 15. Yogyakarta, DIY 3. In addition to being visited by health elements from various Regency/Municipality in Indonesia, the BSB also becomes a place for work study, field observation and research for students and several domestic and international non-governmental organizations, among others: NGO from Thailand, Master students from various Private Universities in Makassar, and others. This visit is particularly related to the public services management. 4. As a learning facility and applied public services in the health sector in the form of field visits by the participants of the disaster communication equipment training held by the Health Crisis Center of the Ministry of Health of the Republic of Indonesia. 5. This initiative has been replicated by the Department of Health of Palopo, Pangkep Regency, Yogyakarta (plan), Kupang (planned for January 2014).

 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)
Since operating, a lot has been learned related to the provision of health services for the public, among others: 1. Labor and Delivery Assistance in ambulance. During its operation, there have been 87 cases of Labor and Delivery Assistance in ambulance. This is due to referral from the village and sub-district to the hospital, mostly diagnosed as obstructed labor. In the journey to the hospital, the BSB team performed certain treatments, so the baby can be delivered in the ambulance. Therefore, pregnant women that were previously instructed to undergo operation, can have a normal birth. This is all due to the availability of sufficient facilities in the ambulance, which has a similar standard with a mini ICU and skilled and trained BSB personnel. 2. Decreasing Number of Head Injury Cases The treatment for head injury patients is performed by doctors, nurses, and the general public that has received emergency training. Therefore, the failure rate in the evacuation process of head injury patients can be reduced. 3. Treat Inter-Regency Referral Patients The health service provided by the BSB is given without considering geographical boundaries. When required by neighboring Regency, the BSB is ready to help by providing referral services to the Regional Hospital in South Sulawesi. Recommendations related to this initiative are as follows: 1. We recommend the formation of the BSB in all Regency/City in Indonesia, particularly in disaster prone areas. 2. A commitment from the health personnel, regional government and community are required in the BSB operations. 3. A complete and representative ambulance is required to treat all health related problems.

Contact Information

Institution Name:   Disaster Response Brigade
Institution Type:   Public Agency  
Contact Person:   Andi Ihsan
Title:   Mr  
Telephone/ Fax:   +62 413 23353
Institution's / Project's Website:  
Address:   Jl. A. Manappiang
Postal Code:   92441
City:   Bantaeng
State/Province:   South Sulawesi

          Go Back

Print friendly Page