Questions/Answers

In 2015 in Banyuwangi district there were 48/23,000 maternal deaths and 404/23,000 infant mortality. This district with a population of 1.6 million has an area of 5,782.66 km2. Of these mortality rate, Sempu Regency is the largest contributor with maternal mortality rate (MMR) 16/23,000 births and infant mortality rate (IMR) of 28/23,000 births. The high mortality rate is due to the lack of data on the whereabouts of high-risk pregnant women (HRPW) in Sempu sub-district. The geographical conditions of this sub-district also exacerbate the situation, because in addition to being quite large (1.8 times the size of Brussels), one-third of the Sempu area is forest and mountainous. The number of midwives at the Sempu health center, which is only ten people, is not comparable to the thousands of poor and vulnerable groups that must be served. Looking at the facts above, the Innovation of PEMBURU BUMIL RISTI (High-Risk Pregnancy Seekers/HRPS) was initiated to solve this problem targeting the poor and vulnerable groups. This innovation provides free pick-up services ranging from pregnancy checks, pregnancy assistance and delivery assistance.To do this, Puskesmas (Community Health Center) Sempu took a shortcut by recruiting groceries sellers women as “Hunters/Seekers” for early detection of high-risk pregnancies. They were chosen because every day they have high mobility and strong information networks in the community. They interact every day, making it easy to dig up information about the whereabouts of new pregnant women. The hunters are equipped with smartphones to report the whereabouts of pregnant women to the Puskesmas via WhatsApp group. For pregnant women who are at high risk, laskar (legions) are prepared as assistance until delivery. The main objective of the innovation is to provide comprehensive services to HRPW, so that in the end it can reduce MMR and IMR by up to 0%.

This innovation is in line with category one, because it prioritizes services to the poor. With comprehensive and pick-up services starting from pregnancy checks, assistance to childbirth assistance. The majority of HRPW come from poor families and they can receive these services for free. This initiative was born and focused on the characteristics of the communities it serves. So that using the help of groceries merchants who incidentally has a social network with mothers. In addition, this innovation also puts forward a participatory and collaborative approach in the community.

Since being implemented in June 2016 – June 2020, the HRPS innovation has succeeded in reducing the maternal mortality rate to zero and only 2 infant deaths. This is linear with SDG 3: ensuring a healthy life and promoting well-being for all people of all ages by 2030, especially target 3.1 reduces the maternal mortality ratio to less than 70 / 100,000 births. After this innovation, the achievement of maternal mortality until June 2020 has reached zero. Previously, 16 mothers died (48 / 23,000 births). This initiative also contributes to the achievement of indicator 3.1.2. The proportion of women whose final delivery process was assisted by trained health personnel is targeted at 92%. After this innovation reached 98.2% from the previous 78%. In addition, this initiative is also related to the achievement of targets and indicators. 3.2.2. Reduce infant mortality by at least 12/1000 births. After this innovation, the achievement of infant mortality rate is only 2 people. Whereas previously there were 28 infant mortality.

This innovation actively engages the target group. Pregnant women can provide input on the services they receive. This innovation also gave the role of traditional midwives, who was previously trusted by mothers in the process of giving birth, to become partners of the puskesmas to deliver pregnant women to trained midwives. This makes HRPS socially acceptable. Its free-of-charge nature makes the innovation also makes it economically acceptable by the poor. In addition to that, although not directly oriented towards environmental sustainability, this innovation utilizes electronic communication, thus supporting paperless services.

So far, the poor and vulnerable groups have experienced many obstacles in accessing public services. This initiative is here to bring change which involves collaboration between community elements through empowering mobile vegetable sellers as HRPS. They are at the forefront of finding data on pregnant women, especially those at high risk, so that data on the whereabouts of pregnant women are more complete. This innovation also recruits female neighbors as a volunteers for high-risk pregnant women in collaboration with traditional midwives. These volunteers, then, can fill the shortage of midwives. The result of these efforts is an increase in the trust of pregnant women in health center. This is evidenced by visits to trimester I and trimester IV of antenatal care as well as delivery assistance by midwives. Health center also prepares special services area for pregnant women that are comfortable, fast, without queuing and are free. One shelter is also prepared for transit for pregnant women who want to give birth from remote areas, so that the midwives can easily reach them. This shelter was initiated by the village police. All of these efforts are to ensure public services that can be accessed by all groups, especially the poor.

This innovation is focused on providing services to high-risk pregnant women who are generally a marginalized group in society because they come from poor families. Women play an important role in this initiative. From the planning stage to the evaluation, starting from the groceries merchants as HRPS, the laskar as a assistant, and even pregnant women who also contributed to provide input regarding the services provided. On the other hand, this innovation also erodes some husbands 'indifference to their wives' pregnancies by involving them in the pregnancy monitoring process.

The main targets are HRPW, namely those who are pregnant at the age of less than 20 years or more than 35 years, have had an abortion, have had a C-section, have a height of ≤140cm, have a history of multiple pregnancies, or have chronic diseases (heart, kidney, tuberculosis, hypertension, diabetes militus). Data for HRPW were obtained from records carried out by groceries merchants who act as HRPS through their interactions with mothers in the village. Prior to the innovation, data on HRPW did not yet exist, making monitoring by midwives difficult. In 2015, only 72% of antenatal care was achieved and birth assistance by midwives was only 78%, the rest was assisted by traditional birth attendance. As a result, there are frequent deaths, even three times the death on the way in the pickup truck. After the innovation is running, there are significant changes. The empowerment of vegetable sellers is starting to show results. Awareness of first trimester pregnancy examinations rose sharply to 92.6% and fourth trimester examinations rose from 73.2% to 94.3% as of June 2020. The midwives' assistance increased from 78% to 98.2%. During the period 2016-June 2020, hunters have found 398 HRPW.

This innovation was born through a workshop initiated by Sempu Health Center. The forum was attended by village heads, traditional, cultural and religious leaders. The village police, representatives of women leaders and several vegetable sellers were present. The forum explained the causes and number of maternal and infant deaths. Finally, on 24 June 2016 the forum agreed to the birth of the HRPS innovation. This innovation also involved GIZ Germany, because it had won first place in the ideathon organized by them. This innovation puts forward a ball pick-up service with a vegetable seller as the spearhead. There are 10 vegetable sellers who are empowered as agents of change. They are specially trained on high-risk pregnancies and are equipped with smartphones, red vests, vegetable baskets, boots and helmets. When the HRPS found new pregnant women or at high risk, they immediately took photos, recorded the names and addresses and names of their husbands, then reported them to the puskesmas via WhatsApp group whose members consist of hunters, laskar, midwives and heads of puskesmas. Furthermore, 23 pregnant women who live in the villages were prepared. In addition to using monitoring via the WhatsApp group, this innovation conducts periodic monitoring and evaluation. First, through an internal evaluation every month at the puskesmas by inviting all elements involved in this innovation. Second, in the form of monthly reports that are routinely sent to the health office. Third, supervision from the health office is carried out every month, so that the development of this innovation will be monitored on an ongoing basis.

Transportation becomes an obstacle as many HRPW live in remote, forest areas. As a result, HRPW risk dying on the way. To avoid this incident, with the support of the Police Department, a shelter was built and a police patrol car was prepared to evacuate pregnant women who were about to give birth. In addition, husbands previously paid less attention to their pregnant wives. This have been followed up by forming a coffee community with the husbands of high-risk pregnant women. As a result, husbands are now more concerned with the development of their wives' pregnancies.

The involvement of vegetable sellers as hunters is one of the novelties of this initiative. They are specially trained to dig up information and operate smartphones for reporting. The police, who are law enforcers, are also directly involved in building shelters and picking up pregnant women who are about to give birth. This collaborative governance model is something that is rarely done in Indonesia.

This model initiative is the first in Indonesia. This step is a portrait of local wisdom and becomes the original characteristic of rural communities. No references or news have been found regarding the use of vegetable sellers as hunters for high-risk pregnant women. Because of its uniqueness, this initiative has inspired other regions to follow suit. HRPS is often presented at various seminars both locally and nationally. It even became a concern in front of representatives of 79 countries in the Asia Pacific Regional Meeting forum in South Korea. Through a poll, this innovation was declared the most interested innovation

For quick response, this initiative has become digital. The Puskesmas created a WhatsApp group whose members were vegetable sellers, laskar, midwives and the head of the puskesmas. This group is also used as a means of monitoring and evaluation as well as discussing developments in innovation in the field. Meanwhile, pregnant women who have smartphones are also given 24-hour access to their pregnancy consultations with midwives. This digital use is new, especially for vegetable sellers. Thus, a side effect of this is of course increase in the the ability to use information technology for rural women

This innovation has been upscaled by the Banyuwangi Regency Health Office with the branding CARE AND QUICK RESPONSE. On 12 January 2018 the Regent of Banyuwangi issued instructions to all puskesmas in banyuwangi (45) to replicate the HRPS. This was reinforced by an order from the Head of the Health Service on January 26, 2018, which contained the same contents. The incessant coverage of HPRS from various TV stations, print media, and online media has also invited institutions both regency and provincial levels in Indonesia to take a close look by conducting an appeal study. UNDP (United Nation Development Program) and GIZ Germany representatives also visited Sempu Health Center on 24 September 2017 and 4 April 2018 for monitoring and evaluation. Before the Covid-19 pandemic, this innovation was visited by 68 agencies from all over Indonesia.

This innovation is very easy to be adopted/adapted because it only relies on intensive communication with stakeholders and is low cost. There are hundreds of vegetable sellers in Banyuwangi. Every village always has vegetable sellers who go around from morning to noon. The possibility of replication is even bigger for regencies in Indonesia, because the existence of a vegetable seller is ubiquitous in Indonesian society. This innovation can also be an inspiration for other countries, especially developing countries. For example, empowering garbage men or other informal workers for early detection of social problems in the community, including HRPW.

a. Finance: 1. From GIZ Germany: Rp 26,000,000. This budget was used at the beginning of the innovation for training of vegetable sellers and assistants as well as equipment for smartphones, vests, boots, helmets. 2. The annual budget from the ministry of health at Rp. 48,000,000 as cost-recovery for legions and vegetable sellers as well as monthly evaluations. 3. Within a year, Banyuwangi Health Office provided budget in the amount of Rp 7,000,000,000 for childbirth insurance for poor families. b. Human Resources: 23 legions, 10 hunters, and 14 new midwives. c. 1 unit of public Ambulans vehicle.

The source of finance comes from the routine budget of the Ministry of Health and the Banyuwangi regency health office, so that the sustainability is guaranteed. This innovation is low on cost but high on impact. This innovation was born from a workshop that was attended by various elements of society. It was followed by the signing of a joint commitment including volunteers to maintain sustainability. Meanwhile, midwives are state civil servants, so they tend to work permanently. This innovation was legalized by Regent’s order and decision letter of the head of Health Center.

Yes

External evaluation carried out by GIZ on 2018 bearing in mind that GIZ participated in funding the emergence of this innovation. Evaluation is also carried out by LIPI (Indonesian Institute of Sciences) in the form of research. The goal is to see the quality of services. Internal evaluation is carried out at the end of each month at the Puskesmas. The evaluation was led by the head of the Health Center by inviting ten regional midwives, the Hunters and the laskar. The agenda is to discuss the development of innovation. Internal evaluation is also conducted by the Health Office monthly.

1. Maternal mortality rate is 0%. and 0% infant mortality. 2. Pregnancy examination of First trimester is 100% and fourth trimester is 100%. 3. The percentage of delivery assistance by midwives is 100%. In addition to these indicators, evaluation is also carried out by recording problems and achievements in the cohort book (register) and monthly reports to the Regency Health Office.

From the external evaluation, it is found that there are not enough midwives. With a ball pick-up service, the 10 midwives have to be mobile every day. Meanwhile, the puskesmas also provides other services. So that in May 2019, the Puskesmas proposed for an additional 4 midwives. Further, in January 2019, the Health Center prepared a special area for pregnant women with one-stop fast service starting from medical records, doctor consultations, laboratories, pregnancy checks and drug services. This service only takes 20-30 minutes. The results of the internal evaluation show that the MMR has been successfully eliminated, but the IMR is still 2 deaths. The first trimester examination reached 92.6% and the fourth trimester reached 94.3%. Delivery assistance by midwives reached 98.2%. There are 18 births that are still being assisted by traditional birth attendants. Traditional midwives are desperate to help deliveries because of the pressure of economic needs. From this situation a policy was adopted to make the dukun a partner to deliver mothers who wanted to give birth to health facilities for a certain fee. The results of the public satisfaction survey in June 2020 reached 93.7%. Before this innovation, the value was only 77.8%.

One indicator of the success of development in the health sector is the MMR and IMR. This area is the responsibility of the Ministry of Health. So that this innovation becomes the main task and function of the Heath Center as an extension of the Ministry of Health. This innovation has been upscaled by the health department with the CARE AND QUICK RESPONSE branding through a warrant from the Regent of Banyuwangi. This warrant is also equipped with guidelines for implementing the HRPS. As a result, Kembiritan Health Center replicated the HRPS and other puskesmas replicated the mentoring strategy for high-risk pregnant women by utilizing mothers as paramilitary troops. This inter-agency collaboration was strengthened by the MoU (memorandum of understanding) with Sempu Health Center to directly guide the implementation process. The police who are law enforcers also show their empathy for pregnant women. They built a shelter on the edge of the forest to transit pregnant women who will give birth from remote areas. This commitment from law enforcers reflects two agencies with different functions, which can be united in the interests of saving the lives of mothers and babies.

The forefront of this innovation is mobile vegetable sellers. Their job is to find HRPW, then report to the puskesmas via WhatsApp group. The results of these findings, immediately received assistance from trained midwives and legions until delivery. Meanwhile, traditional midwives are used as partners to deliver pregnant women who want to give birth to health facilities. Village police also play a strategic role. This concern that is beyond the expectations of the institution is manifested by building a shelter on the edge of the forest for transit for pregnant women who want to give birth. They also prepared patrol cars to evacuate pregnant women who were about to give birth. It is a collaboration across professions brought together in common interests. For internal evaluation, it is held at the end of each month with the head of the puskesmas, midwives, Hunters and legions to discuss developments in innovation. Meanwhile, the external evaluation was carried out by GIZ Germany and the Indonesian Institute of Sciences (LIPI). Pregnant mothers are also involved in implementing this innovation.

The key to the success of this innovation is commitment and courage to carry out bureaucratic reform. This "free pick-up ball" is a form of bureaucratic reform in the field of public services that is able to solve all the obstacles of the poor and vulnerable groups. This makes it easier for this group to get access to quality health services. In addition to ball pick-up services, the Puskesmas also provides a “one-stop fast service” for pregnant women. This service without queuing is free, from medical records, antenatal care, doctor consultation, laboratory and drug services. This service only takes 20-30 minutes. Whereas previously it took 2-3 hours. This innovation has demonstrated collaborative steps between elements of society. Various professions are united in a common commitment, how to save the life of a mother who gave birth to all of us and contains future generations. Currently, the development of initiatives is also being carried out by preparing the formation of a community whose members are former HRPW. They will be used as motivators for HRPW who will face childbirth. In addition, new shelters will also be added to facilitate access for pregnant women, especially those living in remote areas.