| 4. In which ways is the initiative creative and innovative?
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"SI MIDUN KE FASKES" is a creative and innovative idea to involve key parties to achieve Sustainable Development Goals (SDGs) without getting rid of each party’s role. It creatively creates successful collaboration between shamans, who never get modern midwifery training but have local wisdom and respected by society, and midwives, who professionally trained but less trusted by public because considered young and inexperienced. The collaboration has encouraged society to utilize public health facilities.
The innovation is sustainable by incorporating native people in form of a scholarship program for 12 girls in the region, especially from mountainous and swampy ones, to be midwives and placed in their origin after graduated. It is aimed to shift the role of the shamans wisely and gradually since midwives who have been given education were come from the same area with shaman and had familial relationship.
Overall, the partnership has improved public trust to medical modern institution and at the same time has preserved traditions.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The Government of Hulu Sungai Selatan Regency, specifically the Health Department, initiated “SI MIDUN KE FASKES”. Initially, the Department designed the partnership’s substances and allocated budget for related activities. Then, by utilizing the entire Public Health Centers and Midwives Networks, the Department has conducted dissemination and coaching sessions to Shamans and Midwives regularly. In the next level, Memorandum of Understanding (MOU) and an agreement were made between shamans and midwives supervised by the village chief and other community leaders. The agreement incorporated a financial reward to shamans who encouraged expectant women to visit health facilities as a compensation for their cooperation. In addition, the government has established village health post (Poskesdes) in every village.
To ensure the program sustainability, a full scholarship program was offered to native young women, especially from mountainous and swamps' areas, to get midwifery education. Upon graduation, they will return to their villages and continue to strengthening the partnership. At this moment, twelve scholarship awardees completed their study and have worked in their own village.
The partnership between shamans and midwives was conducted one by one in all villages that have a shaman in their locality. The area covers 114 villages with the population of approximately 229.069 inhabitants in the 1, 804.94-kilometer square area. The main target is expectant women who are vulnerable due to a low level of education and dependency toward their families. Overall, "SI MIDUN KE FASKES" provided benefits to the whole society, specifically pregnant women, young women, shamans, and midwives.
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| 6. How was the strategy implemented and what resources were mobilized?
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"SI MIDUN KE FASKES" was implemented by the following steps:
(i) Identifying problem. People doubted the ability of midwives, specifically young ones who just got first assignments. On the other hand, they gave respect and trust to shamans who had assisted childbirth regularly by traditions that passed from generation to generation. The baby delivery was done at home that putting a mother and her baby at risk. The Health Department tried some approaches to improve the situation. For instance, midwives, the staff of Public Health Centers, and village chiefs had approached shamans to convince expectant women to visit health facilities, but it didn’t run well.
(ii) Proposing a solution to solve the problem. Studying the problem, the health department composed a partnership strategy between shamans and midwives by providing financial incentives to shamans who can encourage expectant women to visit a health facility.
(iii) Launching series of public workshops to discuss the partnership between midwife and shaman involving the local government, community and religious leaders.
(iv) Educating influential people about the program. Series of campaigns were launched to educate villages’ chiefs, community leaders, and public figures to understand the program. One key message was that shamans' occupation would not affect negatively. Rather, shaman's position will be strengthened and legalized by a shifting from “a birth helper” to “a childbirth companion". Furthermore, shamans earn income derived not from a pregnant woman but from the local government budget.
(v) Issuing an instruction to legalize partnership between shamans and midwives by Chief of Health Department of Hulu Sungai Selatan Regency.
(vi) Mobilizing staff of Public Health Centers and midwives to execute the partnership by inviting shamans and involving village chiefs, community leaders, and public figures. Then, the partnership campaigned massively to the public audience. Therefore, ordinary people saw the initiative as an important thing.
(vii) Signing the commitments of agreement between midwife and shaman to cooperate in conducting Partnership Strategy of Shamans and Midwives to Refer Maternal into Health Facility for this program from
(viii) Providing support for the program from the local government through the development of village health post (poskedes) in every village.
(ix) Offering a scholarship program for twelve native young women, especially from the mountainous and swampy areas to enter midwife school.
(x) Placing scholarship awardees upon graduation from midwife education was prioritized to their own areas so the midwives and shamans will work closely to ensure the program sustainability because they have relationships and familiarity in locality and family backgrounds. From the 12 newly graduated midwives, 5 from them were placed in swamps area named Pihanin Raya, Bajayau, Mandala Murung Mosque, Pakan Dalam and Hamayung, while the other 2 midwives have served the mountainous ones, Haratai and Tumingki village.
(xi) Hulu Sungai Selatan Regency Government has funded the whole program started from planning, coaching activities, provision of incentives to shamans, the establishment of village health posts, and scholarships. Similarly, the government has involved the technical and human resources from the Health Department, Public Health Centers, and the network of midwives. From the total of 144 villages, the program has invited the participation of 144 village chiefs, 21 midwives coordinators, and 144 midwives with the distribution of 1 midwife in 1 village who has done the partnership with 126 shamans spreading over all villages.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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This initiative was conceived and designed by the Health Department of Hulu Sungai Selatan Regency with the main purpose to lowering Maternal Mortality Rate (MMR).
Furthermore, the implementation of "SI MIDUN KE FASKES" program was involving the Health Department, head of wards, head of districts, head of Public Health Centers, midwives, shamans, village chiefs, volunteers of Family Welfare Development organization (PKK), public figures, community and religious leaders.
Shamans were the key stakeholders that indispensable t the partnership. They were willing to shift from a childbirth attendant to be a childbirth companion because offered an attractive financial scheme. Midwives were trained to accommodate shamans while performing their duty. To make the program more accessible, the health village posts were established and designed as the basecamp for midwives. In addition, village chiefs, head of wards, and head of districts were influential in convincing people and shamans to utilize health facilities for a baby delivery. Religious leaders were also important to provide information and support to the program ideas and benefits.
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| 8. What were the most successful outputs and why was the initiative effective?
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The outputs generated by SI MIDUN KE FASKES programs were:
(i) The main objective of this initiative is to reduce MMR, in line with the 3rd target of SDGs that is to ensure healthy lives and promote well-being for all at all ages, By 2030 reduce the global maternal mortality ratio to less than 70 per 100,000 live births. Since SI MIDUN KE FASKES program implemented, the reduction of MMR from 2012 to 2016 consecutively as follows: 301, 262.2, 208.4, 136.3, and 108.8 per 100.000 live births. It showed, significantly; that MMR in 2016 is getting closer to the global target of SDGs number 3 which expects MMR in 2030 to be lower than 70 per 100,000 live births.
(ii) The increasing of childbirth aid in health facilities by a qualified healthcare professional. This is in line with government regulations that require childbirth aid to be done in health facilities by medical assistance. It can be seen from the increasing output of childbirth aid in health facilities than at home.
(iii) Empowerment and commitment between midwives and shamans endorsed by the village chief. This initiative, effectively, has overcome conventional local practices, involving customs, hereditary, and tradition that refers to childbirth aid by a shaman. However, this program is not conducted by eliminating the role of shaman, rather it is empowering shamans to mutually participate in the form of partnership between midwives and shaman.
(iv) The establishment of village health post (Poskedes) in each village. At the moment, 96 Poskesdes is being built spreading over 144 villages and 4 wards.
(v) The placement of 12 midwives from the scholarship program for native young women in their origin areas. In the end, all parties stepped together for the maternal assistance in health facilities to save them from death risk.
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| 9. What were the main obstacles encountered and how were they overcome?
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The main obstacle in the implementation of “SI MIDUN KE FASKES” program was the resistance of both the villagers and the shamans. The objection came from the villagers because the tradition of childbirth with shaman’s assistance is a hereditary tradition that has been running long before modern medicine was introduced. It has deeply rooted in people’s custom; hence subsequent rejections occurred at the beginning of the initiative. Moreover, shamans felt that their livelihood will be significantly reduced. Therefore, the habitual transformation has been done through the following approaches:
(i) Approaching shamans personally and continuously about the program benefits. It was done through promotion and dissemination about the importance of childbirth carried out in health facilities with the help of medical personnel and how it declines the mortality rate.
(ii) Giving aid to the village board, community, and clergy. This approach encourages a better welcome towards the ideas that may bring positive changes. Additionally, since the intensity of religious aspects has greater dominance in the social life, approaching the religious leaders holds a great role in influencing public behavior. The clergy could deliver better the suitability of the program according to the norms of religious affiliations.
(iii) Shifting the role of shamans from childbirth helper into childbirth companion. This action does not try to decrease the social status and ignore shamans’ role. In contrast, it tries to stay involving them during delivery. Therefore, it does not eliminate Shaman’s livelihood because they still get incentives from local government. The main idea is to replace the role as well as the income.
(iv) Providing scholarship in midwifery education for the native young women. After graduating, the graduates will be assigned as a midwife in their origin area; hence, it may improve the public trust towards medical personnel, especially for the villagers.
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