District Health Office, Aceh Singkil

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
As Indonesia strives to meet its Millennium Development Goal of reducing maternal mortality by 75 percent by 2015, unfortunately the number of mothers dying during delivery has been increasing. According to the 2012 Indonesian Demographic and Health Survey, Indonesia’s maternal mortality rate is 359 per 100,000 live births, while its infant mortality rate is 32 per 1,000 live births. Given the high number of mothers dying during childbirth, UNFPA has categorized Indonesia as one of the ten most dangerous countries for pregnant women. Childbirth without professional health assistance is known to be one of the drivers of high maternal mortality. Aceh Singkil, one of 23 districts in the province of Aceh, is one district where maternal death remains common. Its 110,000 residents are served by 11 basic health clinics (puskesmas) and traditional healers scattered through the district’s coastal areas, hills, and river-side communities. Before this initiative began, many babies were delivered with the assistance of traditional birth attendants (TBAs) in Aceh Singkil. A report by Indonesia’s Central Bureau of Statistics shows that 38.28% 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 are available in the district, the traditions of the communities in this area are strong, and traditional birth attendants are well-respected elders believed to possess special spiritual and medicinal powers. Their trusted position within the community, as well as their low cost, makes them an attractive alternative for many families living in remote areas far from health facilities. However, TBAs often lack medical training and understanding of safe birthing procedures. As a result, they are ill-equipped to handle complications that threaten the health of mothers and babies. Medically-trained midwives, on the other hand, were up until recently seen by many community members as too young and inexperienced to handle deliveries properly. Their inability to speak local dialects also 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 two villages in Singkil sub-district in 2012. The project aimed to bring the skills of midwives to more women than they had been reaching, in order to reduce morbidity and mortality caused by pregnancy and childbirth. Two years after the pilot was launched, the number of mothers giving birth with midwives in the two villages had increased two-fold, bringing about a significant reduction in maternal risks. Taking the success of this pilot project and utilizing public feedback, the district health office expanded TBA-midwife partnerships to 29 villages in the districts of Singkohor, Gunung Meriah, Danau Paris, and Kuta Baharu, where the proportion of women giving birth without professional assistance was still high. The intention was to provide a wider population with improved antenatal care and childbirth services.

B. Strategic Approach

 2. What was the solution?
The health department in Aceh Singkil aims to ensure that all births in the district are attended by trained midwives or other medical personnel. However, they have faced a number of difficulties in reaching all of the communities that need support. After evaluating the pilot project, the health department learned that all births in the two target villages had been attended by midwives since the beginning of the program. This was a great achievement, and it inspired the district to move forward with the initiative. Twenty nine villages signaled they were interested in implementing the TBA-midwife partnerships, as they saw it worked to take advantage of the respective strengths of both traditional births attendants and midwives. The health office decided to continue working with local NGO Daun, who had been the civil society partner during the pilot project. The strategy for introducing and implementing the partnerships in 29 new villages closely followed the process undertaken in the original pilot villages. Key stakeholders were mobilized to take part in discussions on the problem of unskilled deliveries and maternal mortality. The idea of partnerships between TBAs and midwives was presented as a potential solution to these issues during the meetings, and after discussion, it was supported by the village head, head of the local mosque, community leaders, religious leaders, and local health volunteers, as well as by TBAs and midwives themselves. Following these consultations, the partnerships were developed swiftly and with wide support. The district health office issued an instruction letter on the replicating of TBA-midwife partnerships; this provided formal support for the expansion of the initiative. Decrees were also issued by the village heads of each replicating village, and this served to further strengthen the importance of the partnerships in the eyes of the community. These local regulations legislated that that every TBA would receive an honorarium from the village for their services in assisting trained medical personnel with child deliveries. It was decided that TBAs were also eligible under the regulation to receive additional compensation from the national insurance scheme (Jaminan Kesehatan Nasional) for sharing in the handling of the patient. The next step was to develop and sign the Memorandums of Understanding (MoUs) between the traditional birth attendants and the midwives in each village. These MoUs were a very important part of the process, as they represented an official agreement between partners. The MoUs included information on the respective roles and responsibilities of TBAs and midwives, and the honorariums and compensation due to TBAs. The MoUs were all signed during public events, witnessed by the village heads and staff from the district health office. The formal event increased the importance of the partnerships from the viewpoint of the community, as community members could see for themselves the people and effort involved in developing and implementing the initiative. The events also served to raise awareness of the new partnerships and of the importance of giving birth with medical assistance. The partnerships between TBAs and midwives has ultimately led to a decrease in births assisted by TBAs in all 31 villages (2 pilot and 29 replication). Instead, as permitted by the MoUs, TBAs are now frequently involved in births at local health clinics, where they provide spiritual support to mothers during delivery. Mothers report feeling more at ease now that they can be assisted by both TBAs and medically-trained midwives, and, most importantly, no maternal deaths have occurred during births assisted by TBAs since the partnerships began.

 3. How did the initiative solve the problem and improve people’s lives?
This initiative creatively addressed a situation that had the potential to be extremely controversial since it involved local culture, long-standing traditions, and the roles of respected elders. However, by involving TBAs in the solution by inviting them to participate in a mutually beneficial partnership, the initiative 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 midwives. While partnerships between TBAs and midwives are not new in Indonesia, the manner in which they have been implemented in Aceh Singkil is different to that of many other districts. Issuing government decrees and signing the MoUs at public ceremonies give an extra degree of formality to the initiative. The composition of the MoUs are themselves also different to most MoUs developed in other areas – the critical difference is the structure of the financial incentives for TBAs participating in the partnerships, with funds coming from the district health office, the national insurance scheme, and village budget allocations. No other district in Indonesia has such a broad funding base for its TBA-midwife partnerships. All these mechanisms combined will ensure the initiative’s sustainability.

C. Execution and Implementation

 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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Information uncovered during the health clinics’ monthly monitoring and evaluation visits to the villages participating in the TBA-midwife partnership have so far revealed the following impacts: - 1,047 births were attended by midwives in the initiative’s five sub-districts between January and the end of August 2014. If extrapolated based on delivery trends so far this year, it is predicted that 1,570 women will give birth with a midwife in 2014; this represents a small but significant increase of 61 deliveries over 2013, when 1,509 deliveries were assisted by midwives. - Statistics managed by Singkil Health Center (the health center for the pilot program) show a decrease in the number of births attended only by TBAs in the area around the clinic 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. No births have been assisted by only TBAs in Singkil sub-district so far in 2014, but TBAs have been involved in providing spiritual support at the health center, as encouraged by the MoU. - Collaborative communication developed between midwives and TBAs in the 29 replicating villages provided an avenue for earlier referrals to professional medical help and ante-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, such as leaving the baby vulnerable to black magic. TBAs have proved crucial in encouraging pregnant mothers to undergo at least one pre-natal check-up at proper medical facilities, and the number of women doing so has risen dramatically since 2012. Based on 2014 data from January to August, it is expected that by December, 1,739 women will have undergone at least one prenatal check-up at the 5 health clinics implementing the TBA-midwife partnership, compared to 1,649 in 2013 and 1,603 in 2012. - 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 has made their jobs easier, as the midwives were now solely 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 head 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. - The partnership program identified logistical challenges that created barriers to health care. For example, when it was found that the community felt it was sometimes hard to contact the health clinic, it 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 linguistic bridge to village communities, midwives who have migrated to Aceh Singkil for work are now able to more effectively communicate with their patients. - Public discussions and workshops have led to an increase in public awareness in partnership villages about the importance of ante-natal visits and seeking medical assistance for a 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 sub-districts.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Since the pilot program began in 2012, the TBA-midwife partnerships in Aceh Singkil have become stable and sustainable. One of the major challenges experienced throughout Indonesia in developing such partnerships is the fact that the TBAs often feel their income is being taken away from them if they encourage pregnant women to seek health care at clinics. Aceh Singkil has created a unique way of overcoming this issue, through providing a ‘base salary’ from the district health department every month and allowing for additional and unlimited wage ‘top-ups’ for referring pregnant women to the clinics and assisting deliveries through village funds and the national insurance scheme. TBAs report being very happy with the new arrangements, as it not only provides them with a reasonable income but reduces their workload and improves health outcomes for mothers and babies in their villages. Formalizing the relationship between TBAs and midwives in the form of an official MoU is a critical step in ensuring sustainability. Both partners in the agreement consequently have a clear understanding of their roles and responsibilities, and can refer back to the document if needed. It also means that if the terms of the MoU are not followed, the TBAs in question will not receive their salary nor any other incentives. The government has actively supported the initiative. Although the partnerships have been developed in many areas throughout Indonesia, unfortunately most local governments leave the initiative to midwives and health centres to implement and monitor. In Aceh Singkil, the district health office has not only provided financial incentives for TBAs, but it has also issued important letters and decisions on the partnerships. These types of letters have high status and importance in Indonesia, and play a significant role in encouraging both the community and the health workers to participate in the initiative. The initiative also receives good support from the communities. Mothers now receive modern health care from the midwives at the health centres without losing the spiritual and emotional support provided by TBAs. This often helps overcome family barriers where a mother would prefer to give birth in a health centre, for example, but her mother, grandmother or mother-in-law believes she should follow tradition and use a traditional birth attendant. Women can now do both, and ensure they receive good medical and spiritual care. The initiative’s success in blending traditional practices and modern healthcare not only has implications within the province of Aceh but also for national health policy as the Ministry of Health continues its efforts to meet MDG commitments on maternal and child health. It proves that traditional belief systems can be changed over time through culturally-sensitive approaches and the provision of appropriate incentive structures. The innovative form of TBA-midwife partnerships implemented in Aceh Singkil could easily be replicated throughout Indonesia, as it provides a clear structure, including incentive mechanisms, that is simple to implement yet also has clear benefits. Aceh Singkil plans to continue replicating the partnerships throughout the district over the next few years.

 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 has been and continues to be successful as a result of the commitment from the local government and key community leaders. Without this cooperation, the initiatives 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 has proved essential. - Public participation is crucial to success. Strong commitment from all stakeholders including health department, health clinics, midwives, TBAs, and village heads was key to successful implementation. Without active participation and a sense of ownership, the community would not have understood or accepted the initiative as well or as quickly as they have. - Trust between 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. Through a partnership with midwives, their position is respected, appreciated, and integral to reducing maternal and infant mortality rates. Similarly, highlighting midwives as a resource rather than a threat to TBAs’ livelihoods allowed for each partner to perform their duties more effectively. - Appropriate incentives are needed for any behavioral change. Clear regulations, defining and protecting the roles and responsibilities of each party, were a significant boost in the success of this program. The inclusion of financial incentives in the MoUs helped to institutionalize the initiative and formalize the TBA-midwife relationships. The identification of appropriate incentives and their sources was also crucial, as TBAs have often become disinterested in participating in partnerships in other areas of Indonesia when incentives are too low and do not provide an adequate income. - Constant communication is needed to maintain working relationships. Monthly community visits by clinic staff and the provision of an emergency assistance contact card 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 the role and responsibilities of TBAs was the appropriate strategy to attempt these changes in recognition of their societal status 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.

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, Aceh Singkil
Postal Code:   24785
City:   Aceh Singkil
State/Province:   Aceh

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