Questions/Answers

The purpose of Alert Husband Movement (most popular called Gerakan Suami Siaga /SUSI Movement in Indonesia ) is to reduce the Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR) in Lumajang Regency for vulnerable groups (women and children) living in remote areas, with MMR target from 116 per 100.000 live births (2011) to 110 per 100.000 (2019), whereas for IMR from 17 per 1000 live births (2011) to 9 per 1000 (2019). Lumajang Regency has an area of 1.790,90 km2 and population of 1.104.759 people, whereby 46% living in the mountainous region . Several sub-districts in the mountainous areas are difficult to reach using two-wheeled or four-wheeled vehicles. Majority of the people work as farmers (generally farm labors). Efforts to reduce MMR and IMR are achievable through SUSI Movement, conducted in remote areas by encouraging more involvement and roles of a husband in supporting wife’s pregnancy and childbirth as well as the care of newborns. The empowerment of husbands is conducted through the SUSI training - utilizing adults learning media, participative modules and SUSI Kit (population administration checklist, mother’s satisfactory card, delivery trust), a supporting tool of fulfilled sustainable health service indicators for mothers and babies.

The main idea of SUSI Movement is providing access to quality, sustainable and affordable health services for women and children that could be accessed by everyone, especially those living in remote areas, of low income and still hold to the belief that maternal death are something common. All along, mother and child health programs are still focusing on the responsibilities of women. Besides this, a pregnant mother is powerless in making decisions during occurrences of pregnancy and childbirth complications (patrilineal culture). Therefore, husbands as decision makers are given insights on mother and child health to ensure correct and timely decisions.

SUSI Movement is primarily intended to reduce Mortality Rate as mentioned in SDGs 3.1 and 3.2. This is conducted through integrated family empowerment, implemented through integrated counseling and pregnancy checkups, training on pregnancy, delivery, newborn care, immunization, contraception, oral dental health, environmental health and nutrition. Husbands are required to sign commitments to fulfill the needs, including nutrition fulfillment and exclusive breastfeeding, 5 Pillars of Community-Based Total Sanitation, vaccination, contraceptive, population administration, referral transportation and financing guarantees

SUSI Movement has provided a very significant impact for highly-vulnerable groups towards labor complications, namely pregnant women and babies from the poor. 100% of poor pregnant women were covered and received services in Suami SIAGA. In 2016, 1299 pregnant women from poor families received SUSI Movement services while in 2017 amounted 1452. Since 2012 these groups are reached via more adequate access through SUSI Movement, village health clinics, health volunteers and ambulances. Each village has a community health clinic with a midwife and a nurse. Since 2011, 1 ambulance is allocated in 1 village, and by 2017 are allocated to all villages in Lumajang Regency. These vulnerable groups are funded by National Health Insurance and Childbirth Guarantee. Since 2018, a Regent Regulation concerning exemption of labor costs for all groups was issued. The search for high-risk pregnancy cases is actively conducted through home visits by officers and health volunteers. High-risk pregnant women and infants with complications are prioritized and special supervision are implemented. The monitoring form of the groups’ health conditions are conducted at least once a week by . When necessary, these groups receive specialist referrals both at the sub district public office and hospital.

In general, approaches to overcome high maternal and infant mortalities involve less roles from husbands. Considering that the Lumajang Regency people still hold onto patrilineal culture whereby husbands are decision makers related to family health issues, a more innovative approach – husband empowerment in controlling health throughout pregnancy and labor – is needed. This approach is proved to reduce the MMR ration from 116 per 100.000 live births (2011) to 66 per 100.000 (2017), whereas IMR from 17 per 1000 (2011) to 9 per 1000 (2017). This effort enables husbands to make decisions quickly and correctly regarding pregnancy and childbirth.

SUSI Movement was initialized in in Gucialit Subdistrict –. Through a Focus Group Discussion, health workers and the community accepted Suami SIAGA as the answer to existing issues. Initially, 90 pairs of pregnant women were involved in Suami SIAGA since 2012, but due to their success, they were replicated to all subdistricts throughout Lumajang Regency. Husbands were requested to commit in fulfilling the nutritional needs of pregnant women, 5 pillars of Community-Based Total Sanitation, immunization, exclusive breastfeeding, contraception, blood donation, referrals and financial guarantees. They are given SUSI Kit as a monitoring and evaluation support tool.

This program is easily transferable in other regions through empowering husbands to make decisions correctly and timely. It does not require high cost, hence all similar institutions could reach funding. The technology required is very simple, making it easy to be replicated and applied anywhere. The applied training methods are equipped with husband alert participative modules, SUSI Kit, Delivery Trust, Population Administration Checklist and adult learning medium. The required human resources are available in all health institutions. All Sub distric Public Health Office in Lumajang Regency have replicated this breakthrough. SUSI Movement has also conducted socialization in several Indonesian regions.

SUSI Movement requires human resources comprising medical doctors, dentists, MCH-PB (Mother and Child Health – Planned Family) program officers, immunization coordinators, environmental health officers, nutrition officers, health advisors, midwives and nurses. Facilities and infrastructures needed are SUSI Participative Module, projector, display tool, flipchart, food models, handwash utensils, Dental Phantom, banners, brochures and leaflets, trust form, mother and child health book and Suami Siaga Kit. Husband alert is allocated a Health Operational Assistance amounting Rp. 405.000.000 annually, whereas for SUSI Kit is allocated Rp50.000.000 annually.

Since its presence in 2012 in the pilot project region, husband alert became compulsory throughout Lumajang Regency due to its development. A MMR and IMR reduction roadmap for short term (1-2 years) and long term (until 2030) is prepared to ensure that these activities are conducted consistently and continuously. In 2015 a Regent Circular was issued, appealing all regions in Lumajang Regency to implement SUSI Movement. To further convince the sustainability of husband alert, the Lumajang Regent Regulation concerning Safe Labor is issued. The success of husband alert in reducing MMR-IMR and improving access to health services are proven and the benefits are felt by the community. They felt that they own and need this breakthrough. The health financing guarantee in universal health coverage, targeted nationwide in 2020, was accelerated by the Lumajang Regency Government through a Lumajang Regent Regulation concerning Labor Relief Fees Exemption. With this, there are no more concerns in labor costs. Sustainability assurances are also obtained through institutional strengthening of the husband alert team formed by the Regency Government to accelerate the replication of husband alert throughout all Lumajang Regency regions.

Yes

Gerakan Suami Siaga has been evaluated internally and externally. Internal evaluation was conducted by the Ministry of Health through periodic supervision and monitoring once every 6 months. Results of this evaluation are summarized in the form of Regional Head Performance Report. On the other hand, external evaluations are conducted through community satisfaction survey once a year.SUSI Movement is also evaluated on its activities each quarter-yearly through scoring system and questionnaires.

Indicators used in the SUSI Movement evaluation are mentioned in the Regency Health Service Minimum Standards (SPM) as stipulated in the Indonesian Minister of Health Regulation Number 741/MENKES/ER/VII/2008, including coverage on active birth control participants, malnourished children, and villages with Universal Child Immunization. Whereas scoring system and questionnaire contain similar indicators as SPM, equipped with Maternal and Infant Mortal Rate, coverages on exclusive breastfeed milk coverage, access on clean latrines and water. Among external evaluation indicators through community satisfaction survey are service requirements, procedures, operating hours, information and product; charges/tariffs, committee competencies and behaviour; complaints, suggestions and feedback handling.

SUSI Movement has succeeded in reducing MMR from 116 per 100,000 live births (2011) to 66 per 100,000 (2017) and IMR from 17 per 1000 live births (2011) to 9 per 1000 (2017). Participation in active KB acceptors increased from 79.9 % participants (2011) to 81.7% (2017), while delivery coverage among health workers increased from 99.15% (2011) to 99.5% (2017). The number of malnourished children under five in Lumajang Regency decreased from 8.86% (2011) to 8.32% (2017). In environmental health, latrine ownerships increased from 159.776 (2011) to 198.156 (2017)

Suami Siaga was initiated through the collaboration various parties within Government and community participation. This collaboration was done since 2013 with the Population Civil Registry Office and Post Office in issuing birth certificates. Collaboration with Indonesian Red Cross was established in 2015 through the Water and Sanitation Hygiene (WASH) program in efforts to improve clean water access and handwashing behavior. Whilst through the blood transfusion unit, collaboration in the provision of blood stocks for needy mothers began in 2017. The rise of public understanding on environmental health in SUSI Movement has motivated rural Governments in providing clean water access through the collaboration of Community Drinking Water program since 2014, manufacturing of communal septic tanks in 2015 and a sanitary latrines provision program from 2016 until present. Village Community Meeting is conducted by health volunteers every quarter-yearly to increase community participations in the early detection of high risks of pregnant women. When a pregnant mother is found at high risk and with complications, a home visit is conducted by SUSI team.

SUSI Movement has taught us to be creative in applying new approaches in saving mothers and babies. The involvement of husbands and knowledge equalization between husband and wife produce huge impact on improving family health. Changes in community mindsets are not only about mother and child health, but there are contributions in caring for handwashing habits, fulfillment of nutrition among pregnant women and toddlers, fulfilling the 5 pillars of Community-Based Total Sanitation, increasing contraceptive acceptors and complete basic immunization coverage. The cross-sector collaboration initiated through a sustainably-conducted SUSI Movement brings a positive culture to strengthening bureaucratic governance in the Government.