| 4. In which ways is the initiative creative and innovative?
The 31 TBA-midwife partnerships in Aceh Singkil were developed and implemented as follows:
1. Identification of health problems in each targeted sub-district
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 both the pilot and the replicating villages in the abilities of newly-posted medical personnel who had recently completed their midwifery courses, 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, district-level Health Committee (Dewan Kesehatan), and NGOs. Information on the results of the TBA-midwife partnerships already implemented in 2012 in other villages in Aceh Singkil was also incorporated into the discussions.
2. Public workshop to discuss the expansion of the TBA-midwife partnership project
A public workshop was held to gather midwives, TBAs, village heads, religious leaders, village health workers, community leaders, representatives of the Indonesian Midwives Association, midwife coordinators, health clinic directors, health department officials, and youth to emphasize the importance of and solidify support for the partnership program. From this workshop, the heads of each replicating village allocated village funds (alokasi anggaran desa) 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 national insurance scheme (Jaminan Kesehatan Nasional). 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).
3. Issuance of the instruction letter from the Head of Aceh Singkil’s Health Office on replication of the TBA-midwife partnership
Given that the district health office supervises community health centers, the head of district health office issued an instruction letter to ensure each clinic implements the TBA-midwife partnership.
4. Signing of the Village Head decrees on TBA incentives
To institutionalize the incentive structure that had been developed for TBAs, the village heads drafted and signed decrees for TBAs in each of the 29 replicating villages, which provided a strong, sustainable legal basis for the TBA-midwife partnership.
5. Signing of the MoUs between midwives and TBAs
After negotiating the terms the agreement, the partnership was further codified through the signing of MoUs between midwives and TBAs, and was witnessed by officials from the health department, heads of the health clinics, village heads, members of the Indonesian Midwives Association, religious elders, and community leaders.
6. Monitoring of partnerships
In the 2 pilot villages, monitoring is conducted by community oversight groups that were established alongside the TBA-midwife partnerships. In the 29 replicating villages, monitoring has so far been the responsibility of the clinics’ head midwives. The community also plays a role in informing midwives of pregnant women in the villages, in identifying problems with maternal healthcare services, and in encouraging pregnant women to get check-ups and give birth at the local health clinic rather than with a TBA.
| 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. Daun also facilitated regular discussions throughout the implementation of the initiative. Together these stakeholders conducted problem analysis, and discussed the structure and framework of the partnership agreement, including deciding on 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.
The village heads of the two pilot and 29 replicating villages were key drivers of this initiative, providing regulatory support and financial resources for the partnerships. With input from midwifes, TBAs, health clinic staff, the district health office and the Indonesian Midwifes Association, the village heads were able to draft and enact regulations 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).
In the two pilot villages, the community-based health service oversight forums conducted regular evaluations to the program and advocated the clinics and local governments when the villages encountered problems that they could not solve on their own. In the 29 replicating villages, community members are also involved in monitoring and evaluation, but on a more informal level, working directly with village midwives and the head midwives of the local clinics to report pregnancies and any TBAs working outside of the duties permitted.
| 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. The breakdown was as follows:
- Aceh Singkil Health Department (2012): IDR 56,250,000 (USD 4,634) to support implementation of the pilot TBA-midwife partnerships.
- Aceh Singkil Health Department (2013): IDR 37,577,000 (USD 3,081) to replicate the partnerships to additional villages and health clinics throughout the district.
- Aceh Singkil Health Department (2014): IDR 80,000,000 (USD 6,590) to hold a public workshop on the good practices and impacts of the pilot TBA-midwife partnerships, and to further support implementation.
- Aceh Singkil Health Department (2014): IDR 146,000,000 (USD 12,028) to increase the financial incentives offered to midwives taking part in the partnerships.
- Singkil Health Clinic (2013): IDR 25,000,000 (USD 2,059) from National Health Allocation Funds (BOK) to ensure sustainability of the partnerships.
- IMPACT-Yayasan Daun (2013): IDR 40,000,000 (USD 3,280) from an international grant to support the government in implementation.
- Yayasan Daun (2013): IDR 141,346,584 (USD 11,590) from self-sourced contributions to provide further implementation support.
- Yayasan Daun (2014): IDR 25,000,000 (USD 2,048) from an international grant to support the government in replicating the initiative.
- 5 health clinics via the National Health Insurance Scheme (2014): IDR 50,000 (USD 4.20) per delivery per TBA for deliveries referred to the clinics.
- 31 villages via the Village Allocation Funds (2013-2014): IDR 50,000 (USD 4.20) per month per TBA participating in the partnerships.
Human resources involved in implementing the partnerships between midwives and TBAs are as follows:
- Head of the Aceh Singkil Health Office
- District community-based health service oversight forum (Dewan Kesehatan)
- Heads and midwife coordinators from 5 health clinics
- Midwives in 2 pilot and 29 replicating villages
- TBAs from 2 pilot and 29 replicating villages
- Village health volunteers
- Public service specialists and governance specialists provided technical support via local and international organisations.
All resources listed above played an active role in supporting and encouraging the implementation and expansion of the initiative in Aceh Singkil. The strong commitment to the partnerships was built over two years 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 residents, health workers, and the government, creating buy-in from all partners to ensure 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. An instruction letter (Surat Keputusan) from the Head of Aceh Singkil Health Office No. 441/1515.a/2013 was issued, instructing health centres in 4 sub-districts to replicate the TBA-midwife partnerships in order to improve maternal and child health.
2. Village head regulations (SK Kepala Kampong) were issued in each of the 2 original and 29 replicating villages on the partnership.
3. Memorandums of Understanding (MoUs) were signed in a total of 31 villages between midwives and TBAs to formalize their ongoing working relationship.
4. Emergency contact cards were created and distributed to all 31 villages so that pregnant women and their families can contact health workers to request an ambulance or a midwife.
5. A public workshop was held to discuss the results of the initial pilot project, and was widely attended by the community. This workshop was a key part of gaining the local communities’ support in expanding the TBA-midwife partnerships to 29 additional villages in 4 sub-districts.
| 8. What were the most successful outputs and why was the initiative effective?
To better understand the implementation of the initiative and to overcome any issues, regular monitoring and evaluation of the TBA-midwife partnership is conducted in Aceh Singkil.
Each of the five health clinics involved in the program are responsible for ensuring the partnerships work effectively and smoothly. The midwife coordinator from each clinic conducts monthly field visits to each village with a TBA-midwife partnership to monitor adherence to the MoUs and to compare achievements against planning documents. The coordinating midwife also records data of all pregnant women, post-natal women, and babies in her clinic’s area.
The district health office compiles data from all health clinics to conduct annual evaluations of the TBA-midwife partnerships. This data includes the number of births attended by midwives and the percentage of pregnant mothers who attend all four recommended antenatal checkups.
Complementing the evaluation from the local government, the district-level community health service oversight forum (Dewan Kesehatan) also conducts field visits and discusses the progress of the initiative with the village TBAs and midwives. The district health office incorporates the forum’s recommendations into their work plan.
One example of how monitoring and evaluation findings have already had an effect on the program is the creation of the emergency contact cards for each sub-district. The cards were created as a response to the communities’ desire to be able to contact the village head, the village midwife, the health clinic, and the health service oversight forum more easily. The cards ensure that pregnant women and their families have the ability to request emergency services such as ambulances and midwives as soon as they are required, as well as being able to put complaints and concerns to the oversight forum.
| 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 and programs; however, the impact on changing health-related behaviors had been minimal. Traditions, such as the preference to give birth at home or the belief that telling others about one’s pregnancy during the first trimester 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 ante-natal care, safe delivery practices, or post-natal care. The inability of many village-based midwives to speak local languages compounded this, as they their lack of language skills prevented them from challenging these traditions with evidence-based examples.
However, the community-based approach taken by the two pilot and 29 replicating villages in the implementing TBA-midwife partnerships presented an opportunity to meet with pregnant women and their families, as well as influential community and religious leaders, to discuss the importance of the new initiative for the health of families in the community. The incorporation of TBAs in the formation of a ‘new tradition’ of giving birth at health clinics helped to mitigate resistance to change, while also respecting their trusted position within society and providing access to modern medical birthing assistance as well as pre- and post-natal healthcare and counseling.
At times, midwives’ commitment to the new arrangement waned, but the monitoring and evaluation efforts of the 31 villages and the district health department helped to maintain buy-in and to overcome issues as they arose.