| 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?
Since the beginning, all parties are involved through the Tangerang District’s to Save Mothers and Newborns Movement Team. These parties are:
•Cross-sectors/local government agencies (SKPD),
•Related Institutions (BPJS, PMI) etc.
•Community organizations and other relevant units.
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 :
•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.
•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:
•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)
•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.