SAKINA (Stop The Mothers and Childs Mortality
community Health centers of Sempu

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Indonesia, the country of thousands of islands, consists of 34 provinces. Banyuwangi is one of regency among 38 regencies of East Java Province and inhabited by about 1,6 million people. The maternal mortality and the childs mortality in this regency was still high. In the year 2013, there were 78 cases of mother death and 404 babies who passed away of 21.216 births. Meanwhile, point 1 and 2 of the third target of 2030 SDGs are to suppress the rate of maternal mortality to 70/100.000 of save births and the child mortality to 25/1.000 of save births Among 25 sub-districts in Banyuwangi, Sempu was the highest contributor of the high of MM and CM. In 2013, in the sub-district which is inhabited by 32,133 people, there were 16 mothers and 48 babies who passed away. The main cause of the maternal mortality were blood high tension followed by convulsion, bleeding during childbirth and anemia. Meanwhile, the main cause of the child mortality were low weight, asphyxia and anemia. The high of the mortality had strong relationship with the three factors. First of all, geographically Sempu located in the mountain remote area. It has a high rainfall (3000 cc/year) therefore the road is very difficult to be passed. Because of the condition, midwives did not jolly to stay there. The medical examination of pregnant mothers often hampered. If there was an emergency, the ambulance could not reach the area. As a result, the birth aid delivery by the paramedic often late. Because of that, the resident prefered to ask for help from traditional midwife who were cheaper and stayed in the area. No wonder than, if the childbirth which helped by medic and paramedic was only 68 % in 2013. Secondly, the relatively high of early-age marriage. The data from marriage registrar office shown that in 2013 there were 116 under 20 year old brides from the total of 576 marriages. The condition had expanded the risk of pregnancy. The young mothers had not been physically and psychologically ready to have a baby. However it is unlikely that the condition can be changed. The reason is Undang-undang RI nomor 1 tahun 1974 tentang perkawinan (The Act of Marriage) allowed a 16 year old girl to be married. The problem became more complex because of workload of the midwives. Apart the limited number, the midwives had to do an administrative which was very time-consuming. The administrative work such as treasurer, program coordinator and even head of administration. As a result their main duty as paramedic became a by job. Finally, the interaction with public was very limited. The third, the concern of husband to their wife pregnancy was very low. This condition had closed relationship with the husband’s level of education, therefore the understanding of the importancy of the pregnant examination and the birth aid delivery by the health workers is very limited. Moreover, there was a mythos that a mother who die in giving a birth would enter the paradise automatically.

B. Strategic Approach

 2. What was the solution?
a. Providing transit house b. Early detection of high risk pregnancy by the itinerant vegetables seller c. Accompaniment of high risk expectant mothers by Laskar and midwives

 3. How did the initiative solve the problem and improve people’s lives?
SAKINA initiative which was started in the earlier of 2014 had successfully overcame three prime factors which caused the high of maternal and child mortality in Sempu. First of all, geographic obstacle was solved by the “jemput bola” (proactive) strategy which aim to increase the service access to the people. Once a month, the SAKINA team which consisted of doctors, midwives and trained citizen by renting a truck go to remote area to do medical pregnant examination. This method, the regular pregnant examination in that area could reach 100 %. Team and the citizen at the edge of forest’s provided transit house. Transit house actually owned by the citizen which located in the side of main road therefore can be reached by the ambulance. Several days before giving birth, the pregnant mother who live in remote area is stayed temporarily in the transit house. An ambulance is freely prepared and ready to evacuate the pregnant mother to the Puskesmas. The team embraced the traditional midwives. The dukun will be given Rp.100.000 (US$7,48) as rewar for picking-up a pregnant mother who will shortly give a birth to the Puskesmas. The traditional midwives are still involved in bathing and caring the umbilical cord of the babies. Therefore they will not be lost their income. The second, the team had empowered the itinerant vegetables seller to be the hunters of high risk expectant mothers. The sellers selected because they had a high mobility. They have been recognized and welcomed by the public, especially the women. The itinerant vegetables, who are in Banyuwangi recognized by mlijo, previously were trained in understanding of high risk pregnant indication. They were also equipped with a smartphone for reporting via android. Everyday, the hunters come in and go out from the villages for selling their merchandises. During selling, if they find a high risk expectant mother, they will report this finding to the server in PUSKESMAS. The content of the report included the name of pregnant mother, her age, her address, her photograph and her husband’s name. The report will appear in the monitor screen in PUSKESMAS and the head of PUSKESMAS will immediately response by sending his field officer to chek the validity of the report and to handle the expectant mother. The third, SAKINA team collaborates with Laskar who consist of local women leaders. This laskar accompanied by the midwives actively campaigned and socialized the healthy pregnant and birth. One of the method is by avoiding the early-age marriage. The laskar also lists all of pregnant mothers in their areal service. If they can find under 12 weeks pregnant mother, they will be given a reward of rp.50.000(US$3,74). The laskar also visit the husband of the pregnant wives to suggest them to be more care to their wives in term of routine examination and planning of her labor. More importantly, the laskar and the midwives would accompany all of the high risk pregnant mother who found by the hunters until they give a birth. Sticker is used by SAKINA team as one of disseminator of information. The sticker contained the telephone number of head of Puskesmas, the head of the team, the driver of the ambulance and the indication of earlier labor. The sticker is adhered in the house of the high risk pregnant mother. The collaboration of the SAKINA team and the hunters, the laskar and the midwives got a very good result. Until December 2016 the initiative could successfully saved 1.514 mothers and her babies. It means that amazingly, the maternal and child mortality could suppress to be zero.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The transit house was freely lent from the resident. The empowerment of the vegetable seller as the hunters was the successful strategy to overcome the limitation of the number of midwives. Within hours, as a result of using smartphone application, the hunter’s finding can directly be managed and executed by the laskar and midwife in charge. Another uniqueness, of this initiative is the obligation of the hunters to educate the community about the high risk pregnancy. The container of the vegetables, besides fully contained with the merchandises is also written with the information of high risk pregnancy. Might be, this type of innovation, is the one and only in Indonesia Together with the midwives, the Laskar’s duty is to accompany the high risk expectant mother who previously founded by the hunters until the mothers had a birth. Since the SAKINA initiative started to be activated, the traditional midwives duty was reduced to only accompany the pregnant mother to go to the Puskesmas. The empowerment of the hunters, the Laskar and the traditional midwives actually was a simple collaboration, however, the collaboration have effectively solved the critical problem of maternal and child mortality of Sempu.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The spearheads of this initiative are the itinerant vegetables sellers. The empowerment of the vegetable sellers as the hunters of high risk expectant mothers was very strategic. It can be ascertained that in every villages in Banyuwangi, there are many itinerant vegetable sellers who starts their activity at 03.00 in the early morning and finishes at 10.00 AM. Equiped with the knowledge of the characteristic of a high risk pregnant, it had been proven that the hunters can easily detect the fragile pregnant. This fact, clearly shown that the itinerant vegetables seller are able to be not only the reliable and accurate hunters. The other key actors are the Laskar who are recruited from the women local figures who have strong influence in the society. The traditional midwives also play an important role. Like in the competition, to get the reward they had competed each other to escourt as many as possible of the expectant mothers to the Puskesmas. The more number of the expectant mothers, the more they will get the reward. Behind the successful collaboration among the three actors, there are very important roles by the Team of PUSKESMAS Sempu not only as the coordinator. Therefore, in the last three years, there was no maternal dan child mortality at all. The early age marriage of under 20 year old girls could also be suppressed. Previously from all of the marriage, 20 % were the early age marriage, in the last three years the percentage could be reduced to 9,2 %. This decreased of the early age marriage had an important contribution in reducing the number of high risks pregnant mothers. This initiative has specifically covered 10.020 poorest who are isolated in the middle of the forest with the income far under the average income of Indonesian citizens.
 6. How was the strategy implemented and what resources were mobilized?
The initiative was legalized by issuing the Camat of Sempu decree with number 445/143/KEP/429.519/2014 3 January 2014. SAKINA is directly lead by the head of PKK of Sempu. The concrete programs that had been executed were : • A MOU also signed with the head of the office of Religion Affair of Sempu to ensure that all candidates of the brides must attend the consultation in healthy reproduction, contraception and nutrition. Including pregnant examination and the healthy childbirths. • The recruitment of the hunters by the midwives. The requirements for the hunters are : woman, energetic, communicative and able to operate a smartphone. From 39 applicants there were 10 applicants who have been selected to be the hunters. The hunters are equipped with smartphone, waistcoat with the logo “Pemburu Bumil Risti” (The hunters of high risk pregnant mother) and booth shoes. The training of the hunters is conducted regularly with the subject of the indication of the high risk pregnancy. The report by using the smartphone also was given in the training. • The training for 23 members of the Laskar covered the indication of the high risk of pregnancy, the signs of childbirths, dangerous alert of childbirth, dangerous indication of newborn baby, reference system, recording and reporting. The duty of the Laskar is together with the midwives, accompany pregnant mother until giving a birth. The other duty are to adher the sticker in the house of the high risk Expectant Mothers and to socialize the transit house. • Built an android application. Every information from the hunters will appear in the monitor screen in Puskesmas. In the screen, there is an areal service map of Puskesmas includes the villages. Every information that had been sent by the hunters will be converted to be a red dot in the screen. If the red dot clicked, in the screen will automatically appear the name, the age, the address, the name of the husband of the pregnant mother, the picture of her house and also her symptom of high risk pregnant. This type of presentation method via visualization is relatively new in Indonesia. • Administrated a specific Village Regulation. The regulation mentioned that the every hunter and Laskar get IDR.100.000,-(US$ 7,48) plus IDR 60.000,- (US$ 4,49) from Banyuwangi health department as transportation cost. • Monitoring and evaluating of the initiative became the responsibility of the areal midwives assisted by the PKK which consists of the wives of officials village. The public took part in giving the information about the high risk expectant mother who did not observed by the team. The human resources who actively involved in the initiative are the Head of Puskesmas, doctors, midwives, traditional midwives, the driver of ambulance, the laskar, the hunters, head of Public Health Office of Banyuwangi, head of sub district of Sempu, head of Marriage Administrative Office of Sempu, Religious Preach, Cultural figures, PKK and Head of Villages. Financial: Banyuwangi health department 2014-2016 IDR 71.280.000 (US$5.335) As the transport fo the hunters and the laskar. The village budget allocation 2015 – 2016 IDR 79.200.000,- ( US $ 5.928) as the incentive for the hunters and the laskar. The initiative got the grant of US$ 7500 from Deutsche Fuer Internasionale Zusammenargeit (GIZ) . The grant, was given as a reward to the uniqueness of the idea of the hunters in the event of URUN IDE Jawa Timur 2016 which managed by GIZ in collaboration with Pulsa Lab Jakarta. The grant was used to buy the smartphones, built the application, buy the weistcoats, revitalization of the vegetables box and procurement of the huntters’booth shoes.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The Head of the public health office of Banyuwangi as the initiator and the person in charge of public health in Banyuwangi. He has to provide the budget to fund the program and the transportation for the hunters and the laskar. More over, he has to have commitment to increase the budget for the initiative every year. The head of Sub-district of Sempu as the head of the region had issued the decree as the legal basis of the initiative. The Head of PKK of Sempu as the Head of initiative. Her duty beside responsible in successing of the initiative, also to stimulate the members of PKK in the village level to actively involve in supporting the initiative. She had also involved in designing and initiating of the initiative. The Head of PUSKESMAS besides as the initiator and the Team Secretary, he also as the motor of the initiative. He must also directly command the hunters, the Laskar include the traditional midwives. He kept the unity of the three important pillars include the ambulance’s driver. Since the existency of them is the spearhead of the initiative. the head of Marriage Registrar Office of Sempu is the fasilitator of consoling for the candidate of brides in Puskesmas. The head of the villages, issued the regulation of the village to allocate the village budget to monthly give incentive to the laskar and the hunter. Religious and cultural figures actively involved in dissemination of the initiative. Their involvement of the key figures, especially the religiuos leaders, have made the public easily directed to use the health service rightly . Even, there were the resident who voluntarily lend his house to be the transit house.

 8. What were the most successful outputs and why was the initiative effective?
Firstly, the availability of the two transit houses. The location is in the main road therefore can be reach by the ambulance easily. The mortality of the mother often occurred because of the late of birth aid delivery by the midwive. That is the result of the mountain road which can hardly be reached. By providing the transit houses, as the temporary house for the expectant mothers, the aid delivery can be conducted faster therefore the mortality can be avoided. Secondly, the establishment of simple but effective collaboration among the hunters, the laskar and the traditional midwives. the finding by the hunters, as a result of application system, within hours, can be followed up by the laskar and midwives until the expectant mother give a birth. With the system, the head of Puskesmas will be able to monitor the high risk expectant mother via monitor screen easily. The traditional midwives, who previously always helped labor, after the activation of the initiative, changed their function to be only escourt the expectant mother to go to Puskesmas. The third, sticker of emergency contact, as a mean of fast aid. The stickers were adhered at the house of the expectant mother. Therefore, if she need an emergency aid, the neighbor can contact the midwives or ambulance’s driver that standby 24 hours via the number in the stickers. The fourth, the issued of village regulation which ruled the incentive to the hunters and the laskar. Added by the budget that prepared by the public health office of Banyuwangi for funding the program. The fifth, the involvement of the key figures in the society. The key figures, especially religious and cultural figure include the traditional midwives as the role models. Because of the key figures, the public can be easily directed to used the healthy services. The position of the figure in Indonesia is noble and what they say will become the reference. The five output clearly become the key factor of the initiative in reaching the third target of SDGS point 1 and 2 that are to suppress the maternal of mortality by 70/100.000 save birth and the child mortality by 25/1000 life birth. Even in the last three years, the out put could save 1.514 mothers and their babies. And the peak was, until Desember 2016 the mortality became zerro.

 9. What were the main obstacles encountered and how were they overcome?
The prime obstacle were the living mythos among the people that the death in giving a birth was the insurance to enter the paradise and the strong reluctance of the public to change. The believe that if they inform the paramedic about their pregnancy their fetus would easily be attacked by the black magic. However, an intensive and embraching approach by the team supported by the key actors as the agent of change had reduced the cultural and the tradition obstacles. The areal service of Puskesmas of Sempu mainly located in the remote area with road which was very difficult to accessed by an ordinary vehicle. The geographic obstacle was solved by renting truck to provide jemput bola (proactive) services in the area. Because only the truck that is able to stab the hard field of mountain area. To pay attention on the problem and to avoid the late birth aid delivery, the team provided the transit house located in the edge of the forest and the main road therefore could easily be reached by the ambulance. In the beginning, this initiative was only known by the member of Puskesmas and few people. This problem was overcame by printing the sticker to be adhered in the house of the expectant mothers. If the public need an emergency help, the can contact the telephone number which is contained in the sticker. In addition, the team had also printed the leaflet contains all of initiative’s activities to be distributed to the public. The last was psychology obstacle, the hesitation to be success. The head of PUSKESMAS of Sempu had continuously ascertained the people that building of the strong collaboration from all of elements will become the key success of this initiative.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The prime benefit that could be felt was the significant reduction of the mortality. In 2013, there were 16 expectant mothers and 48 babies passed way. The data until Desember 2016 shown that the initiative had successfully saved 1,514 mothers and her babies. The mortality coud be suppressed to be Zero, this is because all of the expectant mothers (100 %) had been handled by the medic and paramedic. The success had influenced the data in the level of regency, the maternal mortality from 78 to be only 20 and the child mortality from 404 to be 193. The next advantage was the behavior change of the public. It could clearly be sen especially among the mother who previously less paid attention to their pregnancy. That was proven that until Desember 2016 all of the pregnant examination (100 %) were tackled by midwives. to be more proud, because of the laskar, the concern of the husband to their pregnant wives increased drastically. The health registration book shown that the pregnant medical examination that accompanied by the husband reached 88 %. Previously the percentage was only 36 %. The initiative affected directly to the women group and the poor. The women felt be respected and their dignity were glorified. It had been proved, all of public elements had given special appreciation therefore the existency of the women no more be underestimated. Meanwhile, after operating of the initiative , 10.020 poor residents who are isolated in the middle of the forest, monthly get the free proactive health services. Another important benefit was the decreased of the early age marriage. Before the initiative the premature marriage reached 20% of all marriages in Sempu. After operating the initiative the number reduced to only 9,2 % (in 2016). The decrease was influenced by approaching effort by the Laskar, religious and cultural figures to the public in socializing the medically health marriage. The initiative also sharply increased the number of acceptor KB, especially post-partum acceptor. As are result are better birth spacing and planed pregnancy. The improvement was the result of the effort by midwives who patiently spread understanding of the importance of planning the future to the husbands when they accompanied their pregnant wives. Previously, post-partum acceptor was only 18 mothers (2013). The number increased significantly to be 288 acceptor until December 2016. The next advantage was the improvement of the public involvement of the health development. The collaboration of the hunters, the laskar and the traditional midwives was the form of the direct participation of the public. Because of the participation, the data of pregnant mothers became more complete, because of transit house, the pregnant mother in the remote area could be helped faster. Public satisfaction on the health service by Puskesmas was also increased. The survey that conducted regularly in every six months shown that in 2014 the index of public satisfaction was 78,3 %. in 2016 the public satisfaction index reached 92,4 %.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
This initiative is addressed to save mother and child. Therefore, all stake holders must have a high integrity and sincerity. The data of condition of the pregnancy must be valid therefore there would not be a mistake in decision making. In the beginning, beside socializing the initiative, the team also informed to the public that all of the services were totally free. The jemput bola services was not only focused only the pregnant mother but also provided to all of the resident especially in the remote area who previously because of the hard condition did not had health service access. The initiative had given optimal result with a very minimal budget. The resource of the budget was clear and the budget’s utilization was transparent. The amount of the budget was far more cheaper compared to the problems which had to be solved. Therefore, the budget’s utilization was very open to be known by the public and the possibility to be manipulated was very small even nearly impossible. Meanwhile the utilization of the grant from GIZ had also been audited by GIZ and Pulse Lab Jakarta. The majority of receiver of the benefit of the initiative were the poorest who lived in the remote area. Among of them are young girls who have had a baby, some of them had to work hard as a rubber tapper with hold their babies. This initiative shown that the government present in the middle of the poor. In Sempu there were 10.020 poor people who were isolated in the middle of the forest who used to be far away from health facility. Because of the initiative, the public, especially the poorest and the women, had felt cared.

 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)
1. The instruction of Bupati of Banyuwangi number 445/040/429.114/2015 and the decree of the Head of Health affair of Banyuwangi number 445/191/429.114/2015. The contents is all of Puskesmas must transfer the initiative. In term of that the maternal mortality and the child mortality in Banyuwangi is still high. 2. Recorded and involved the poorest and the vulnerable including the high risk pregnant mother in the health insurance paid by the government. The legal standing of the policy is The Bupati’s Regulation number 41 year 2016. 3. The decree of the Head of PUSKESMAS Sempu number 188.4/10.B3/429.114.35/2015 about finding and accompanying for poorest and vulnerable including the high risk expectant mother. 4. All of candidates of brides must attend the consoling in Puskesmas. The certificate of consoling become one of the requirement before marriage. This policy is amplified with the MOU between PUSKESMAS and marriage registrar office number 445/508/429.114.43/2014. 5. The instruction of the head of PUSKESMAS number 444/41/429.114.35/2015 about distribution of blood buster for all of young girl via the school every month. The aim is to earlier preparation to avoid the blood deficiency when the girls pregnant and will give a birth.

Contact Information

Institution Name:   community Health centers of Sempu
Institution Type:   Local Government  
Contact Person:   hendy setiyantoro
Title:   head of initiative  
Telephone/ Fax:   +6281358644600
Institution's / Project's Website:  
E-mail:   pkm_sempu@yahoo.co.id  
Address:   jl Kalisetail no 170 Sempu
Postal Code:   68468
City:   banyuwangi
State/Province:   east java
Country:  

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