H2SMN Tangerang District
Tangerang District Health Office

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
The 2012 Indonesian Demographic and Health Survey (IDHS) shows that the Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR) in Indonesia are 359/100,000 live births and 32/1,000 live births, respectively. Until 2012-2013, Banten Province is one of the five provinces with the highest maternal and infant mortalities in Indonesia. The MCH Routine Report of the Ministry of Health (2012) shows that Banten Province ranked 4th among provinces with the highest maternal mortalities and 5th among provinces with the highest neonatal mortalities in Indonesia. Tangerang District is the second highest contributor for maternal and infant mortalities in Banten Province, with 39 cases of maternal deaths and 282 cases of infant deaths in 2013. The population size of Tangerang District in 2013 is 3,050,929 people with a growth rate of 3.402%. The number of poor people is 906,433 (29.71%). There are 64,100 pregnant women, 61,186 postpartum women, and approximately 58,273 newborns targeted for receiving health care services each year. If 10-15% of those pregnant women have high risk, 6,4109,615 pregnant women and 5,8278,741 infants will potentially experience complications, and even death, if no preparation is made during the pregnancy, delivery, and postpartum periods. The maternal and perinatal audits in 2013 show that community-related factors still strongly influence maternal and infant mortalities in Tangerang District, especially delay in recognizing danger signs leading to delayed access to health facilities. The MCH routine data of Tangerang District Health Office in 2013 suggested that 71% of women who died during childbirth only had primary and junior secondary education. Furthermore, 10% of the maternal deaths happened in a delivery assisted by a traditional birth attendance (TBA). Data on patients referred to the Tangerang District Public General Hospital (RSU Kabupaten Tangerang) in 2013 presented that substandard care from the primary level are identified in 80% of deaths. Due to the lack of referral network, “blind” referrals are often made, requiring patients to move from one hospital to another. This surely depicts an ineffective and inefficient referral system. The cause of mortalities in this district are: 1. No effective and efficient referral system available in this district due to the lack of communication and coordination as well as ambiguous roles among health facilities. 2. The emergency care for mothers and newborns in the primary health care facilities and comprehensive care in the hospitals has not been managed properly, as is evident from: Inadequate emergency response. Sub-standard capacity in stabilizing patients or giving first aid care, especially among midwives and Puskesmas (Public Health Center) and private hospital health care workers. Principle of good care is not reflected in the daily care due to the lack of standardized SOPs. Sub-standard facilities and infrastructures. 3.Community’s knowledge and understanding of danger signs during pregnancy, delivery, and postpartum period are still very low, especially among women, with very weak supports and contribution of the community to save mothers and newborns.

B. Strategic Approach

 2. What was the solution?
To address the various issues faced in Tangerang District as described in the problem analysis, the Save Mothers and Newborns Movement Team in Tangerang District has initiated Regent Regulation Number 56 of 2014 on Guideline for Maternal and Neonatal Emergency Referral. Three main activities are developed as the innovation of Tangerang District in improving its maternal and neonatal referral system, which are described broadly below: a)Strengthening the governance of the maternal and neonatal emergency referral system that includes efforts of area distribution and referral flowchart; referral system communication and information through the use of a 24-hours information technology; distribution of roles of the parties (29 parties) that include private and public parties in the referral network; referral network improvement; and Joint Agreement among all related stakeholders from the private and public sectors, as well as the community. b)Principle of Good Care implementation to improve the quality of maternal and neonatal emergency services which includes efforts for providing various SOPs and Job Aids; increasing the capability of the health care workers at the primary and referral health care facilities that use the clinical performance measurement instruments; and performing maternal perinatal audit. c)Increasing community organization’s role to empower the community which efforts include establishing a Maternal and Child Health Forum (FOPKIA) at the district and sub-district levels, creating maternal and child health motivators (MKIA) at the village level, providing guidelines and materials for FOPKIA and MKIA, and establishing Service Declaration and feedback mechanism in health care facilities.

 3. How did the initiative solve the problem and improve people’s lives?
This initiative increases the access and quality of services for pregnant women, women in delivery, post-partum women, and newborns in Tangerang District including for poor people, especially those in the northern area. The number of women in delivery in the northern area of Tangerang district who receive services in 2015 is 1,638, which increases into 2,680 in 2016. The service improvement is performed through the implementation of the following strategies: a)Strengthening maternal and neonatal emergency referral system governance: Organize a comprehensive referral system at the primary and referral health care facilities that guarantee the people of Tangerang District that they will receive effective and efficient referral services. A map of hospital capabilities is also available to make sure that patients can be referred to the appropriate facility. Provide hospital capability map and referral flow to facilitate the health care workers to refer patients to the facility that can provide appropriate care. Establish referral communication and information system through the use of information technology that is available 24 hours a day and 7 days a week, which is integrated to the Public Safety Center (PSC) at the Health Office. With this system, the communication between the referrer and the referral facility can be established and the referral facility can remind and provide guidance for the management that can be performed by the referrer and prepare for receiving the referral. b)Application of Principle of Good Care" for improving the quality of Maternal and Neonatal Emergency Services: •BEONC Puskesmas and CEONC hospitals function 24 hours 7 days, making it easier for the community to access services. •Implementation of “clinical governance” in daily services makes the management of Health Care facilities becomes more accountable. •Health care workers have adequate competencies and work according to the standards or SOPs; hence, their self-confidence in managing emergency cases improves. •The ability of health care workers in the primary and referral becomes better, which ensures the provision of quality maternal and neonatal services for the community. •Emergency responses and ability to do stabilization at the primary level and referral level have improved. c)Increased role of Civil Society Organizations for community empowerment: •High risk pregnant women and their family who live in the village are facilitated by the Maternal and Child Health Motivator (MKIA) in their respective village. •Maternal and Child Health Forum (FOPKIA) performs facilitation to the community including for the financial aspect (National Social Security Board/BPJS, Local Government Health Insurance/Jamkesda, or other financing scheme) which makes a clear financial solution available earlier. •Civil Society Organizations give actual contributions in saving mothers and newborns by actively facilitate problem solving for various problems that arise between health care providers and care recipients. •Implementation of Service Declaration as a real effort of Tangerang District Government to comply with the Law on Public Services and provides access to the community to give feedbacks/critics to service providers regarding the services they received.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
a)Tangerang Regent Regulation is the first regulation that comprehensively regulates Maternal and Neonatal Emergency Care governance in Banten Province, and in Indonesia. b)The signing of the Joint Agreement for the Movement to Save Mothers and Newborns in Tangerang District by 29 parties including both public and private stakeholders, such as Indonesian Red Cross (PMI), National Social Security Board (BPJS), Indonesian Society of Obstetrics and Gynecology (POGI), Indonesian Medical Association (IDI), Indonesian Pediatric Society (IDAI), Indonesian Midwife Association (IBI), and Maternal and Child Health Forum (FOPKIA), reflects the commitment of all parties in Tangerang District. c)Clinical governance in managing emergency care in primary level (BEONC Puskesmas) and referral hospitals (CEONC hospitals) is a real action to improve service quality. d)The use of information technology (SMS Gateway, mobile android, WhatsApp) and 24/7 call center supported by all health facilities facilitates the monitoring of all referral communication. e)Promulgation of Service Declaration Law No. 25 of 2009 encourages all health care facilities to make a Service Declaration and implement a feedback mechanism. f)Open the biggest opportunity possible for community organizations and public to contribute on saving mothers and newborns in Tangerang District.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
To save mothers and newborns movement is coordinated by the Health Office and is performed together with stakeholders who are jointly committed to implement Regent Regulation, including Primary Health Care Facilities (FKTP), Referral Health Care Facilities (FKRTL), BPJS, PMI, FOPKIA, and professional organizations, i.e. IBI, POGI, IDAI and IDI. The roles are: •Health Office is responsible for referral system implementation from FKTP level to FKRTL level and gives technical assistance and supervision on referral network implementation. •FKTP gives first response or stabilizes patients in maternal and neonatal emergencies and communicates with the referral facility as per SOPs. •FKRTL answers and receives referrals, performs comprehensive management based on appropriate SOPs, improves and maintains service quality and give technical assistance together with the District Facilitative Supervision Team to the health facilities under its network. •BPJS facilitates community’s access to the national social security board (BPJS), expand cooperation network with health facilities, and receive and follow up complaints related to financing by BPJS. •PMI is responsible for providing access to 24-hour information on availability of blood and 24-hour blood availability. •Professional organizations (IDI, POGI, IBI, IDAI) develops medical care standards according to their profession, supervises and nurtures their members and gives recommendations on member deployment distribution and policy making. •FOPKIA is responsible for empowering the community and community organizations to save mothers and children through facilitation to pregnant women, especially high risk, to get appropriate standardized care, and encouraging the poor to gain access to quality health care and health financing. The beneficiaries of this program include 64,100 pregnant women and 58,273 infants per year in Tangerang District; network members that include 44 Puskesmas, private midwife practices, 21 hospitals, Health Office, BPJS, PMI, and FOPKIA; and other professional organizations such as IBI, POGI, IDAI, and IDI.
 6. How was the strategy implemented and what resources were mobilized?
The movement to save mothers and newborns are implemented through the following strategies and action plan: a.Conduct Movement to Safe Mothers and Newborns Team regular meetings for monitoring and evaluating the implementation of the Movement to Safe Mothers and Newborns in Tangerang District at least once every 6 months. b.Perform dissemination to health care workers in Puskesmas, hospitals, and private midwife practices on clinical governance and the appropriate referral system standard and reporting and recording system. c.Build a call center as the coordination center for maternal and neonatal emergency referral that is integrated with the Public Safety Center (PSC-119) which serves 24 hours a day, 7 days a week. d.Create social media groups as a mean of communication between health care workers and relevant stakeholders in order to ensure that the referral system runs well. e.Improve the ability of Puskesmas (public health center) in managing labor and delivery 24 hours a day, 7 days a week through increasing the number of Puskesmas with BEONC capability, providing technical assistance to the newly established BEONC Puskesmas, performing facilitative supervision on the clinical and referral performance, BEONC on-the-job training and emergency response simulation as well as the use of BEONC dashboard. f.Update hospital maternal and neonatal emergency capability map periodically. g.Implement a feedback mechanism through customer satisfaction surveys. h.FOPKIA collects data and gives facilitation to high-risk pregnant women, pregnant women who do not have identity card, and poor pregnant women, as well as establishing blood donor groups, monitoring maternal and child health services, and performing maternal and child health advocacy. i.Update standard procedures and Regent Regulation for maternal and neonatal emergency management for midwives and Puskesmas workers. j.Enter into a cross-border cooperation agreement with neighboring districts and cities regarding cross-border maternal and neonatal emergency services. Resources used are: Human resources: human resources include 35 people from various local agencies (SKPD) of Tangerang District; Directors and their managerial and technical staff from 21 hospital which gives a total of 147 people; 4 CEONC Teams from Tangerang District Public General Hospital, Balaraja Local Public General Hospital, Siloam Hospital, and Ciputra Hospital which gives a total of 115 people; 36 BEONC Puskesmas Teams that gives a total of 432 people; members of FOPKIA and MKIA of 330 people, and related stakeholders from BPJS, PMI, IDI, POGI and IBI of 15 people. Funding for the movement to safe mothers and newborns in Tangerang District comes from Tangerang District Budget through Health Office budget of US$185,150 (excluding employee’s salary), Banten Provincial Budget through provincial financial assistance of US$238,000, foreign aids in the form of technical assistance of US$ 61,500, contribution of private hospitals in financing their maternal and neonatal emergency services, and community funding for maternal and neonatal emergency services. Clinical and referral performance instruments, register books, standard operating procedures for maternal and neonatal emergencies, and referral system information and technology system.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Stakeholders involved: a.Design Phase Since the beginning, all parties are involved through the Tangerang District’s to Save Mothers and Newborns Movement Team. These parties are: •Cross-programs, •Cross-sectors/local government agencies (SKPD), •Related Institutions (BPJS, PMI) etc. •Professional organizations, •Community organizations and other relevant units. b.Implementation Phase In the effort to save mothers and newborns in Tangerang District, the following parties have contributed to the implementation of the Regent Regulation No.56/2014 and the Joint Agreement on Guidelines for Emergency Maternal and Neonatal Referral: •Tangerang District Health Office, •Public and private primary health care facilities, •Advanced referral health care facilities (all public and private hospitals), •Related Professional Organizations (IDI, POGI, IDAI, IBI), •Other related supporting units (PMI, BPJS), and •Maternal and Child Health Forum (FOPKIA) of Tangerang District as the representative of the community.

 8. What were the most successful outputs and why was the initiative effective?
•Joint Agreement document that is signed by 29 parties involved in MMR and IMR reduction efforts in Tangerang District: Health Office and all Puskesmas, 21 hospitals, PMI, BPJS, POGI, IDAI, IBI, IDI and Maternal and Child Health Forum (FOPKIA) of Tangerang District to implement Regent Regulation number 56/2014 that has been revised into Regent Regulation number 128/2015 on Guideline for Maternal and Neonatal Emergency Referral in Tangerang District. •The availability of well-established maternal and neonatal referral system with area distribution and maternal and neonatal emergency referral path supported by an information-technology-based referral information system (SMS Gateway, android mobile and maternal-neonatal emergency referral call center in health office that runs 24 hours a day, 7 days a week) to avoid hospital touring. •Availability of Clinical SOPs, Indonesian Red Cross (PMI) SOP, referral information and communication system utilization SOPs, Financing SOPs, and Community Empowerment SOPs. •Establishment of FOPKIA in all sub-district (29 sub districts) and availability of 330 Maternal and Child Health Motivator (MKIA) in all villages (274 villages) in Tangerang District. •Improved normal delivery and delivery with complication management both in primary health care facilities and referral health care facilities. The numbers of normal deliveries and deliveries with complication in BEONC Puskesmas are 1,953 and 668, respectively. In 2016, the numbers are 5,801 and 1,335 respectively. The number of babies with complication managed in 2015 is 228 while the number for 2016 is 313. In Tangerang District Public General Hospital in 2015, the numbers of normal deliveries and deliveries with complication are 2.602 and 2,566, respectively. In 2016, the numbers are 1,715 and 2,235, respectively. This reduction in the number of normal deliveries in this hospital is caused by the implementation of effective referral system. Meanwhile, the numbers of neonatal complications managed are 6,896 and 4,911 in 2015 and 2016, respectively.

 9. What were the main obstacles encountered and how were they overcome?
a)Community Level : Obstacles encountered: •Awareness on maternal and neonatal emergencies is still lacking and there are still delays in making the decision to bring the patient to the health facility. •There are still many people who do not have Citizen ID Card, making it difficult for further facilitation. Methods to overcome the obstacles: •Improve FOPKIA’s role in increasing awareness among community members on maternal and neonatal emergencies and decision making to bring the patient to health facilities. •Provide a guideline for MKIA on how to do facilitation for community members who have problems with their Citizen ID Card. b)Puskesmas Level: Obstacles encountered: •The number of health care workers, facilities, and health care workers’ compliance to SOPs is still not optimum yet. Methods to overcome the obstacles: •Meet the need for HR, facilities, and infrastructures up to the standard for BEONC Puskesmas •Routine technical assistance or facilitative supervision on clinical performance implementation and referral performance in Puskesmas. c)Private Midwife Practice and Private Clinic Level: Obstacles encountered: •Low service quality and competencies of private midwife practices and private clinics. Methods to overcome the obstacles: •Collaborate with professional organizations (IBI, POGI, IDAI and IDI) to do monitoring and provide technical assistance. d)Advanced Referral Service Level (Hospital) Obstacles encountered: •Variations in terms of available facilities, infrastructures, and HR capabilities among private hospitals. •Private hospitals’ compliance in reporting and recording. Methods to overcome the obstacles: •Technical assistance, standardization of report format, and clinical and referral mentoring for public/private hospitals by the mentor team from Tangerang District Public General Hospital.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
•A maternal and neonatal referral network and a 2-way communication system between primary and referral health care facilities are implemented. •Case screening is running optimally using the clinical SOPs for maternal and neonatal emergencies. If a patient is referred to the hospital, she is stabilized first at the BEONC Puskesmas. •Increased number of BEONC Puskesmas from 14 in early 2014 to 27 in 2015 and 36 in 2016. •Increased number of deliveries in BEONC Puskesmas from 2,621 in 2014 to 4,370 in 2015 and 7,136 in 2016. •Since the first year of innovation (2014) until 2016, the number of obstetric cases managed by Tangerang District Public General Hospital decreases from 8,454 (2014) to 7,678 (2015) and to 4,933 (2016). This means that the “overload” issue in Tangerang District Public General Hospital has been addressed by providing certain services at the primary health care facilities or BEONC Puskesmas. In addition, referral cases are now distributed evenly to other CEONC hospitals in Tangerang District. Testimony from the Deputy Director of Medical Services of Tangerang District Public General Hospital: “The results that we’ve achieved through this innovation are very beneficial, especially for Tangerang District Public General Hospital, because we witness a reduction in the number of cases referred to this hospital which is almost half of the number when the innovation was started. This means that we have opportunities to improve the quality of service towards better and higher quality services. Furthermore, the cases that we received now are real referral cases because the basic emergency cases are managed at the primary care level” - DR.dr. Shirley Moningkey, M.Kes. •Increased maternal pre-referral management of patients referred to Tangerang District Public General Hospital (50.4 % of the total cases in 2015 to 73.5% in 2016) •Documentation and facilitation of high-risk pregnant women or pregnant women with financial issues by MKIA have increased from 81 cases in 2014 to 115 cases in 2015 and 390 cases in 2016. Testimony from a post-partum woman from Pasir Nangka Village, Tangerang District: “I live in Sudirman housing complex with my husband who works at a worker in a factory. During my second pregnancy, Ms. Iin, who is the MKIA cadre, often reminded me to check my pregnancy routinely so that I could have my delivery in Puskesmas Pasir Nangka. After my baby was born, my placenta could not be delivered for a long time that the midwife said to my husband that I had to be referred... My husband and I were confused, because we didn’t know what to do with our baby as I don’t have any relative here. But Ms. Iin convinced us that she would take care of my baby during my treatment in the hospital. Finally, I was treated in Selaras Hospital. I really thank the MKIA cadre, Ms. Iin, because now my baby is healthy and he is already 7 months old” - Ms. Nurholifah, 33 years old.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
•The various efforts that have been performed are proven to be able to increase health care service integrity, especially in the increasingly improved response time in emergency case management or referral in Tangerang District. The data can be accessed publicly through the referral system dashboard at http://banten-dashboard.rujukan.net. •The implementation of Service Declaration and feedback mechanism in Puskesmas and hospitals is a reflection of the preparedness of all health care facilities to implement the Law on Public Service. •The results from the customer satisfaction survey in MCH clinics of 9 accredited Puskesmas in Tangerang District during the period of October - December 2016 with a total number of respondents of 4,431 reveal the fact that 93 % of the respondents are satisfied with the MCH services. •The customer satisfaction survey in Obstetric and Gynecology installation of Tangerang District Public General Hospital in 2016 shows an increased Community Satisfaction Index to 75.86 % (criteria: good) •Assessment of program indicator achievement through the Government Institution Performance Accountability System (Sistem Akuntabilitas Kinerja Instansi Pemerintah, SAKIP) in 2016 results in a B score.

 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)
•With the issuance of the Standard Operating Procedures as a part of the Regent Regulation, there is a guarantee from the Tangerang District Government that each maternal and neonatal emergency case management by Midwives and Puskesmas health care workers will be performed using the same procedures for all mothers/infants, including those who are poor. •In zoning or regionalization of Tangerang District into the Southern, Western, and Northern regions, it is apparent that the northern region is the region with the highest ratio of poor people when compared to the western and southern regions. The number of BEONC Puskesmas in the northern region in 2014 is 4, which increased to 7 in 2015 and to 10 in 2016. The number of deliveries in the northern region in 2015 was 1,638 deliveries, which increases to 2,680 deliveries in 2016. The amount of funding provided to poor people from the northern region for deliveries is US$ 5,709.

Contact Information

Institution Name:   Tangerang District Health Office
Institution Type:   Local Government  
Contact Person:   Sri Indriyani
Title:   Community Health  
Telephone/ Fax:   +628128324678, +62215990535 (fax)
Institution's / Project's Website:  
E-mail:   indriyanisri92@yahoo.co.id  
Address:   Jalan Abdul Hamid 2, Kadu Agung, Tigaraksa, Tangerang, Banten
Postal Code:   15720
City:   Tangerang
State/Province:   Banten

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