Health Department of Hulu Sungai Selatan Regency (Dinas Kesehatan Kabupaten Hulu Sungai Selatan)

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
The mortality rate of women during pregnancy or during the 42 days of pregnancy’s termination in Indonesia is still very high. Maternal Mortality Rate (MMR) is the number of women died per 100,000 live births during pregnancy or during the 42 days of pregnancy’s termination without considering the duration of pregnancy and place of delivery, caused by the pregnancy itself or its management, and not because of other reasons such as an accident and/or a fall. Based on the Indonesian Demographic and Health Survey (SKDI) in 2012, MMR in Indonesia is approximately 359 per 100,000 live births. This number is slightly lower compared to the Demographic and Health Survey in 1991, scored 390 per 100,000 live births. However, the improvement is far below the global target of Millennium Development Goals (MDGs) number 5 that aims to reduce MMR to 102 per 100,000 live births in 2015 and the target of United Nations Sustainable Development Goals (SDGs) number 3 to achieve MMR less than 70 per live births. High level of MMR cases happened in Hulu Sungai Selatan Regency, South Kalimantan Province. The number in 2012 and 2013 was 301 and 262.2 per 100,000 live births. Geographically, and geologically, the Regency consists of mountains that extend from the east to the south; however, the west to the north part is swampy alluvial lowland. One of the main factors that cause high MMR was that the maternity aid given by shaman in a traditional way. It did not meet health standards, especially aid performed in mountainous and swampy areas. The maternity was given at home instead of a health facility. The practice led to maternal death caused by bleeding, obstructed, sepsis and eclampsia. Despite the unfavorable situation, public trust to shamans was still high, especially among the lower middle-income people that had so many difficulties to reach the health facilities. Shamans kept people's choice based on three factors. Firstly, trust factor from past events. Although Shamans delivered births naturally by simply cutting the umbilical cord without scissors, operation, and sewing, most people were familiar to Shamans intimately since their family already experienced their service for generations. Secondly, influenced by cultural and customs. Shamans assisted traditions related to pregnancy, birth and postnatal ceremony that have had very important to the people inherited from generation to generation. Thirdly, consider the education and socio-economic factors. People choose aid deliveries by Shamans because costs needed were less expensive than service delivered by a midwife or another health medical personnel, without careful consideration of health, safety, and hygiene factors. The number of shamans in the Regency was more than 120 people. Spread by the domination of 15% in mountainous and 40% in the marshes' area. Although the midwives have been placed in every village, they were not able to remove public trust toward Shamans. Although they already had adequate training and certification, the midwife considered as young, less experienced in assisting a childbirth process, and less knowledge of traditional ceremony practices.

B. Strategic Approach

 2. What was the solution?
Partnership strategy between shamans and midwives to encourage expectant women to deliver their baby in health facilities named “SI MIDUN KE FASKES” (URL: was implemented to combine traditions and modern ways in the delivery process. This program has developed four core activities namely providing incentives to shamans to encourage pregnant women to use health facilities, establishing village health post (poskesdes) in every village, recruiting qualified local residents to study in midwife schools with full scholarships, and placing scholarship awardees back to their localities upon graduation. The program was successful in empowering traditional health workers, reducing maternal death rate, and improving mothers and babies' health.

 3. How did the initiative solve the problem and improve people’s lives?
"SI MIDUN KE FASKES" is a solution to deal with causes of the high Maternal Mortality Rate (MMR) in Hulu Sungai Selatan Regency. One of its main causes is that a medical staff did not attend childbirth. People only trusted traditional practice in pregnancy process, birth, and postnatal. Therefore, they chose shamans over midwives to aid baby delivery. Technically, shamans do not receive any medical education and information on how to conduct childbirth properly. They possess skill and knowledge about baby delivery based on accumulations of experiences from generation to generation. Furthermore, the childbirth process was conducted in a high-risk location, such as a home or somewhere other than health facilities. On the other hand, a midwife is a medical personnel that has received education and curative training adequately to help the childbirth process but they do not have local knowledge. "SI MIDUN KE FASKES" program aimed to reduce MMR by improving childbirth process quality by teaming up shamans and midwives and conducting delivery in health facilities. The program has improved several aspects as the following: (i) Providing comfort and security to an expectant woman and her families, a local shaman accompanied them. The shaman gave spiritual advice and performed traditional practices during pregnancy, delivery, and postnatal; (ii) Appreciating the role of shamans as a part of local wisdom and their expertise is well known by the public for a long time. Shaman is no longer acted as a birth attendant, but as a childbirth companion. Shamans encourage and accompany pregnant women to visit a health facility. Shamans do not lose their livelihoods and still earning income provided by the government for their services; (iii) Establishing village health post (Poskesdes) in each village. Poskesdes is a health facility built by Hulu Sungai Selatan Regency Government with the existence of at least one Poskesdes in one village. Areas with difficult geographical conditions got two Poskesdes in one village. (iv) Building trust to medical modern institution represented by midwife and health facility in every stage of a maternal process: pregnancy, delivery, and postnatal. (v) Empowering the community and ensuring better synergy among all stakeholders, including community, shamans, midwives, and government through the provision of scholarships to native students for midwifery education. This makes the partnership system easier since the daughters of local residents who have become a midwife and worked at their origin could have a common area and familial relation with a shaman;

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
"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.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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.
 6. How was the strategy implemented and what resources were mobilized?
"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.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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.

 8. What were the most successful outputs and why was the initiative effective?
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.

 9. What were the main obstacles encountered and how were they overcome?
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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The main impacts of "SI MIDUN TO FASKES" program are to increase public awareness on the importance of maternal health and to conduct childbirth in health facilities by competent healthcare personnel. If previously, the childbirth process was done traditionally at home and assisted by shamans; now the maternal delivery process is done mostly at a health facility and conducted by a midwife as a proficient medical personnel. According to the data from the Health Department of Hulu Sungai Selatan Regency, the number of childbirth assisted by shamans tends to decline in the last 5 years. It was only increased in 2014 before dropped significantly in the following years. The number of childbirth process helped by shaman as compared to total deliveries since 2012 to 2016 are provided as follows. In 2012, there were 124 out of 4015 childbirths done by the Shamans. The number of deliveries by shamans was decreased in 2013 as of 55 from 3327. During 2014, the number of deliveries was almost doubled (93 out of 3931), although it was declined considerably in the next two years, which were 69 out of 3677 and 29 out of 3667 deliveries respectively. Another indicator that strengthens the benefit of the program was shown by the negative trend of Maternal Mortality Ratio (MMR). Using the same period from 2012 to 2016, the figure exhibits a consistent decline in the number of mortality ratio per 100.000 live births. In 2012, the ratio was 301 and further decreased by 13% and 20% in the following years. The ratios were 262.2 and 208.4 in 2013 and 2014 respectively. The mortality rate dropped by 34% in 2015, after the mortality rate reached 136.3. The ratio continued to decrease in 2016 with 108.8 deaths per 100.000 births. Consequently, the maternal mortality caused by Shaman delivery decreased from 2 to 1 during 2013-2014 periods. Furthermore, there was no maternal death caused by Shaman delivery in the following years. These impacts have been statistically measured using data set taken within the last 5 years since "SI MIDUN KE FASKES" program implemented in 2012.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
"SI MIDUN KE FASKES" program has encouraged transparency and accountability in delivering public health services in Hulu Sungai Selatan Regency, particularly in maternal treatments. Besides its original goal to improve the quality of childbirth and to reduce the maternal mortality rate, the system was built to provide a fair incentive system towards shaman. This approach is successfully proven to enhance collaboration between shamans and midwives and increase the number of patients who utilize health facilities for pregnancy, childbirth and postnatal dramatically. Moreover, by implementing rigorous Standard Operating and Procedures, the opportunity of being extorted is diminished. Each of health facility has a foundation of financial regulation and general procedures, hence; the business process be clearer, transparent, and accountable. All preparation and realization stages of the "SI MIDUN KE FASKES" program are clearly stated and built according to applicable regulations of the Ministry of Health, Regional Regulation, District Regulation, and other policies.

 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 is specifically intended to optimize the benefits towards women, young women, and children through the following ways: (i) The program aims to reduce maternal mortality rate that is consistent with SDGs number three. In particular, the initiative intends to ensure that no more women died due to childbirth, including newborn babies. (ii) Involving shamans as the success key of program implementation. Most shamans are women whose existence must be appreciated. Thus, the empowerment of shaman should be done continuously in assisting the process of childbirth along with midwives. Shaman inherited the noble ideas and local wisdoms in customs practices that should be preserved for future generation. (iii) Providing Midwifery Education Scholarship Program. The government of Hulu Sungai Selatan Regency proposed special education program for native young women, particularly for those who live in the mountains and swamp area. This scholarship program is meant to empower young women, by giving them opportunity to pursue their study, hence, one day they will give the benefits back to the society. This initiative eventually kept the young women to stay longer in the school.

Contact Information

Institution Name:   Health Department of Hulu Sungai Selatan Regency (Dinas Kesehatan Kabupaten Hulu Sungai Selatan)
Institution Type:   Local Government  
Contact Person:   Siti Zainab
Title:   Head of Health Department of Hulu Sungai Selatan  
Telephone/ Fax:   +6282149059059 / Fax.051721017
Institution's / Project's Website:  
Address:   Jl. Jenderal Sudirman No.29 Kandangan
Postal Code:   71211
City:   Kandangan
State/Province:   South Kalimantan

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