USAD
FROM THE AMERICAN PEOPLE
EVALUATION OF THE HEALTH
SERVICES PROGRAM (HSP)
IN INDONESIA:
Taking Stock and Looking Forward
DISCLAIMER
The authors' views expressed in this publication do not necessarily reflect the
views of the United States Agency for International Development or the United
States Government.
This document (Report No. 08-001-118) is available in printed and online versions. Online
documents can be found in the GH Tech web site library at
www.ghtechproject.com/resources.aspx. Documents are also made available through the
Development Experience Clearinghouse (www.dec.org). Additional information can be obtained
from
The Global Health Technical Assistance Project
1250 Eye St., NW, Suite 1100
Washington, DC 20005
Tel: (202) 521-1900
Fax: (202) 521-1901
info@ghtechproject.com
This document was submitted by The QED Group, LLC, with CAMRIS International and Social
& Scientific Systems, Inc., to the United States Agency for International Development under
USAID Contract No. GHS-I-00-05-00005-00.
ACKNOWLEDGMENTS
The evaluation team extends its thanks and enonnous appreciation to the Health Services Program and
USAID staff who made our visits in Jakarta, Malang, Deli Serdang, and Sumedang such a great success.
We also are extremely appreciative ofthe warm welcome we received in the many Indonesian
governmental offices, nongovernmental organizations, public and private health facilities, and homes and
clinics of midwives in the districts we visited.
HSP staff did an excellent job of organizing and presenting a large amount ofinfonnation, which greatly
facilitated our work. We are also very grateful for the wonderful support and valuable input we received
from the USAID Basic Human Services Office.
Ibu Maria Syamsudin ofHSP and Ibu Ria Wardani of USAID deserve special recognition for their
superior management of a constantly changing schedule of appointments and travel. We would also like
to thank Ibu Heryanti Umiyarsi, who did a heroic job as interpreter.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
ii EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
ACRONYMS AND TRANSLATIONS
ADB
AMTSL
APN
Askeskin
AusAID
BAPPEDA
BCC
BEONC
BHS
Bupati
CA
CEONC
CHC
COP
CRS
CSO
CTO
Desa SiAGa
DHO
DPRD
DTPS
EIBF
GO!
GTZ
HSP
IBF
IBI
IDAI
IDHS
IMCI
IR
JICA
JNPK
JSI
LGSP
MCC
MDG
MenkoKesra
M&E
MMR
Asian Development Bank
Active management ofthe third stage oflabor
Basic delivery care
Health insurance for the poor
Australian Agency for International Development
Regional Planning Board
Behavior change communication
Basic essential obstetric and neonatal care
Basic Human Services
Elected executive official at the district level
Cooperative agreement
Comprehensive emergency obstetric and neonatal care
Community Health Committee
Chief of Party
Catholic Relief Services
Civil society organization
Cognizant Technical Officer
Birth preparedness and complication readiness program-now referred to as P4K
District Health Office
Local House ofRepresentatives
District team problem-solving
Early initiation of breastfeeding
Government ofIndonesia
Deutsche Gesellschaft fUr Technische Zusammenarbeit
Health Services Program
Immediate breastfeeding
Indonesian Midwives Association
Indonesian Pediatrician's Association
Indonesian Demographic and Health Survey
Integrated management of childhood illness
Intermediate result
Japan International Cooperation Agency
National Clinical Training Network
John Snow, Inc.
USAID Local Government Support Program
Millennium Challenge Corporation
Millennium Development Goal
Coordinating Ministry for People's Welfare
Monitoring and evaluation
Maternal mortality ratio
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA iii
MNCH
MNH
MOH
MPS
Musrenbang
NGO
OP
P2KS/P
P4K
PC
Perda
PHO
PKK
PMP
PNPM
POGI
Polindes
POPPHI
Posyandu
POUZN
PPP
PromKes
Puskesmas
Pustu
RFA
RH
SBA
SDM
SMFPA
SNL
SPM
STARH
TA
UNICEF
UNIFEM
UNFPA
USAID
WHO
iv
Maternal, neonatal, and child health
Maternal and neonatal health
Ministry ofHealth
Making Pregnancy Safer
Bottom-up planning process
Nongovernmental organization
Operational plan
RegionallDistrict Clinical Training Centers
Birth preparedness and complication readiness program)
Program Coordinator (HSP regional office staff)
District law
Provincial Health Office
National women's organization
Performance Monitoring Plan
National community development/cash transfer program)
Indonesia Obstetrician and Gynecologists Association
Community birthing facilities
Preventing Postpartum Hemorrhage Initiative
Integrated Service Post
Point-of-use (POU) water disinfection and zinc treatment
Public-private partnership
MOH health promotion unit
Subdistrict Community Health Center
Community Health Center (below the puskesmas)
Request for application
Reproductive health
Skilled birth attendant
Studio Driya Media (local NGO partner of HSP)
Safe Motherhood Family Planning Assistance
Saving Newborn Lives
Minimal Service Standards
Sustaining Technical Achievements in Reproductive Health
Technical assistance
United Nations Children Fund
United Nations Fund for Development of Women
United Nations Population Fund
United States Agency for International Development
World Health Organization
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
CONTENTS
ACKNOWLEDGMENTS i
ACRONYMS AND TRANSLATIONS iii
EXECUTIVE SUMMARY vii
I. INTRODUCTION 1
METHODOLOGy 1
OVERVIEW AND STRUCTURE OF THE REPORT 3
II. ASSESSMENT OF HSP 5
OVERVIEW OF HSP OBJECTIVES AND ACCOMPLISHMENTS 5
THE CHALLENGES OF THE PROJECT DESIGN 8
HSP COMPONENTS SUPPORTIVE OF AN ENABLING ENVIRONMENT 12
HSP COMPONENTS THAT IMPROVE HEALTH SYSTEM RESPONSE 20
HSP COMPONENTS THAT ENGAGE AND EMPOWER CIVIL SOCIETY 28
SUMMARY OF STRENGTHS AND WEAKNESSES OF HSP TO DATE 35
III. HSP AS A FOUNDATION FOR REDUCING MATERNAL AND NEONATAL MORTALITY
IN INDONESIA 37
STOCKTAKING 37
RECOMMENDATIONS FOR THE EXTENSION PERIOD 39
IV. RECOMMENDATIONS FOR NEW USAID PROGRAMMING .43
APPENDICES
APPENDIX A: SCOPE OF WORK 49
APPENDIX B. PERSONS CONTACTED 65
APPENDIX C: TOOLS AND GUIDELINES DEVELOPED WITH HSP ASSiSTANCE 71
APPENDIX D. ACCELERATING INFANT AND MATERNAL SURVIVAL (AIMS) 73
APPENDIX E: INVESTING IN 181 77
APPENDIX F: DIARY OF AN ADVOCACY PARTICIPANT 81
APPENDIX G: REFERENCES 89
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA v
FIGURES
FIGURE 1. HSP OBJECTiVES 9
FIGURE 2. THE HOUSEHOLD-TO-HOSPITAL CONTINUUM OF CARE 10
FIGURE 3. HSP GOAL AND OBJECTIVES 38
FIGURE 4: GOALS AND OBJECTIVES: RESULTS FRAMEWORK .47
FIGURE 5: INVESTING IN IBI 48
TABLES
TABLE I: EVALUATION MEETINGS WITH HSP STAKEHOLDERS 2
TABLE 2. HSP: 2007 PROGRAM OUTPUTS 6
TABLE 3. HSP: 2007 PROGRAM OUTCOMES 7
TABLE 4. FUNDS RAISED THROUGH PUBLIC-PRIVATE PARTNERSHIPS 19
TABLE A.1. CHILD MORTALITY RATES (/1000 LB) BY TIMING AND WEALTH QUINTILE 52
vi EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
EXECUTIVE SUMMARY
The purpose ofthis review is to provide a forward-focused evaluation ofthe USAID-funded Health
Services Program (HSP) in Indonesia. The evaluation has two principal objectives:
1. To achieve a thorough understanding ofthe outcomes and results ofHSP interventions and the
effectiveness ofHSP strategies in achieving results in the focus areas (advocacy, behavior change, role of
private sector midwives, and technical support to the Government ofIndonesia [GOl]). For evaluation
purposes, effectiveness is defined by the extent to which results are (1) replicable; (2) sustainable by the
GO! and local partners; (3) consistent with GO! national and subnational policies and programs; and (4)
perceived as collaborative by GO! and civil society partners.
2. To develop recommendations for future activities and implementation strategies for immediate and
midterm time frames consistent with USAID/Indonesia's commitment to Ministry ofHealth (MOH)
priorities in maternal, neonatal, and child health (MNCH) (i.e., achieving Millennium Development Goals
[MDGs] 4 and 5); building health system capacity where it can be directly linked to positive impact on
MNCH outcomes; working closely with a broad range of civil society partners; and forging productive
relationships with the private sector.
The challenge ofthe evaluation was to pivot deftly from assessment of an extensive and complex project
to recommendations for future USAID MNCH interventions in a large and diverse country undergoing a
dynamic process of decentralization. The report structure reflects the process the evaluators followed. It
began with an analysis of what HSP has accomplished, moved to thinking about how those
accomplishments contribute to the ultimate goal ofreducing maternal and neonatal mortality and
morbidity, and went on to make strategic suggestions about how to build on HSP successes to reinforce
USAID's general approach to reducing maternal and neonatal mortality in Indonesia.
The evaluation was conducted by a four-person team composed of a leader with expertise in
implementation and evaluation ofmaternal and neonatal health programs, a private provider network
expert, an expert on health systems and governance, and an expert on behavior change and neonatology.
The team spent four weeks in country, August I8-September 11, 2008, during which they reviewed
program documents, visited field sites in five districts, and interviewed private, public, and commercial
sector stakeholders.
HSP, USAID/Indonesia's flagship MNCH project, is a four-and-a-half-year cooperative agreement
awarded to lSI Research and Training Institute and partners. Starting in April 2005, it was designed to
address the major public health problems facing mothers, newborns, and children in Indonesia. HSP
provides technical assistance (TA) to government counterparts, civil society partners, nongovernmental
organizations (NGOs), and communities on implementation ofselected evidence-based interventions.
The program was originally designed to reduce maternal, neonatal, and child mortality through an
integrated package oftechnical interventions that could be made available to districts and a system for
replicating that package widely to maximize the chance of national impact as quickly as possible. The
project design emphasized rapid scale-up of pilot interventions. The original integrated package as
presented in the request for applications (RFA) was designed around five strategic approaches to
decentralized district provision of health care: (1) integrating technical components; (2) strengthening
decentralized health systems and services; (3) leveraging funds from other donors; (4) harnessing NGOs
and private voluntary organizations (PVOs); and (5) engaging the private sector. The project was to
package and make available interventions based on evidence-based approaches to maternal, neonatal,
child, and reproductive health; infectious diseases; drug and commodity management; and
decentralization and reinforcement of district health systems and services.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA vii
In large measure the project produced results that are replicable, sustainable, and consistent with GO!
policies, and it implemented its activities through collaborative relationships with GOI and civil society
partnerships. HSP met or exceeded all ofits targets. The project produced high-quality reports and
effective communications on project progress and achievements. It also responded to USAID requests
with skill and alacrity, even when they were outside the original scope of work (e.g., tsunami, national
call to action for health).
HSP's principal strategy for ensuring that its technical inputs will be replicated and sustained is its
collaboration with the MOH in updating guidelines and tools to reflect current evidence-based best
practices. Although this strategy was not contemplated in the original design, which emphasized scale-up
and replication, HSP seized upon the MOH's desire to update policies that seemed to be a barrier to scale￾up and turned it into an opportunity to enhance the environment for reducing maternal and neonatal
mortality. In addition, many ofHSP's district and village-level interventions, such as P4K, a program
dedicated to birth preparation and preparedness for complications, and district team problem-solving
(DTPS), helped to improve and facilitate implementation ofMOH strategies.
HSP worked very hard at the district level to ensure that most interventions had a sustainable home with
the GO! or an NGO or professional organization and had prospects for financial support after the project
ended. It supported NGOs, district advocacy and behavior change communication (BCC) teams, and
professional organizations to mobilize corporate support to the extent possible within the constraints of
being part ofa USAID project. HSP worked with the MOH and other national organizations (e.g., JNPK,
the National Clinical Training Network) to update national evidence-based training modules.] HSP has
collaborated with other donors in efforts to identify partners, such as JNPK, the Indonesian Midwives
Association (lBI), UNICEF, CARE, and the Australian Agency for International Development (AusAID),
which can replicate activities beyond HSP districts.
Similarly, HSP adapted successful strategies developed by USAID and NGO partner organizations and
applied them in reinforcing MNCH in HSP districts. These included the approaches developed by the
USAID Local Government Support Program (LGSP) for drafting and passing local laws and BCC events
proposed by NGO partners, such as the 1,001 mothers rally and the 2,010 couples rally on early initiation
of breastfeeding (EIBF).
The project has a good track record oflearning from first-round application ofits tools to refine
sequencing, quality, and integration ofdistrict, subdistrict, and village interventions (DTPS, training of
trainers [TOT], fundraising, BCC, and advocacy). Throughout, HSP has shared information with other
donors and USAID projects, supporting the Millennium Challenge Corporation (MCC), collaborating
with the LGSP, and facilitating a smooth transition ofthe Bidan Delima program from the Sustaining
Technical Achievements in Reproductive Health (STARH) project.
The evaluation also identified weaknesses in the project that can be attributed to challenges in design and
implementation. The project design omitted critical interventions for reducing the maternal mortality rate
(MMR) and the neonatal mortality rate (NMR), such as improvement in use and quality of comprehensive
emergency obstetric and neonatal care (CEONC) services in hospitals, referral systems and support,
supervision, and information/accountability systems focused on improving the response ofthe health
system to maternal and neonatal complications. Although lSI proposed a critical pathways model that
included interventions to address these concerns, it was discouraged from focusing too much attention on
improving hospital-based CEONC and health center-based basic EONC (BEONC) as well as the
supportive systems that link skilled community-based providers (e.g., community midwives and private
I The modules include Making Pregnancy Safer (MPS), Basic Delivery Care (APN), Basic Emergency Obstetric and
Neonatal Care (BEONC), Comprehensive Emergency Obstetric and Neonatal Care (CEONC), and Integrated
Management ofChildhood Illness (IMCI).
viii EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
midwives) to higher levels ofthe health system that are critical for addressing the major causes of
maternal and neonatal mortality.
From the beginning HSP has had to deal with the trade-off between pressures to scale up and replicate
across a large number of districts and giving attention to adapting strategies to the local context. In some
circumstances this may have inhibited more sustainable community creativity and decision-making.
There was too much emphasis on replication through a TOT approach without adequate assessment of
whether this leads to capable implementation (clinical, OTPS, and BCC). Except for its assistance to the
MOH on national guidelines, the project has used TOT as its replication strategy rather than exploring
others, such as district-to-district TA, peer-to-peer coaching, and whole-site training. There are
indications that without considerably more time for repetitive trainings and continued TA, this strategy is
not sustainable in most districts once the project ends.
Incentives and supports provided by the project may be intrinsic to the replicability and sustainability of
activities (e.g., seed money for community health committees [CHC] and advocacy, facilitation, and TA
for advocacy, BCC, OTPS activities, and support for materials). It is not clear ifreplication in new areas
is possible without a similar incentive structure.
The evaluation strongly recommends extending the project to consolidate the package ofinterventions so
that it is more integrated and solidified. An extension would also allow HSP to prepare the groundwork
for scaling up in a district where it can build on HSP initiatives, such as passage oflocal MNCH laws and
district-wide planning to formulate effective approaches to implementation and monitoring and evaluation
(M&E). The extension would enable the project to further observe and document the replication process
and compare project subdistricts with replication subdistricts.
USAID's interest in the sustainability and replicability of HSP interventions also argues for targeted
research and evaluation during the extension period to further determine how much HSP's interventions
have contributed to achieving the desired maternal and neonatal outcomes, what combination of
interventions might be considered best practices, and how packages of interventions can be tailored to
districts with different socioeconomic characteristics.
HSP has built a strong foundation for new USAID programming to reduce maternal and neonatal
mortality, but there are four challenges that should be addressed in any new programming: (1)
geographical focus and size ofthe project area; (2) emergency obstetrical and neonatal care and maternal
and perinatal audits, which were not originally a major focus of HSP; (3) increased attention to gender,
sociocultural, and economic differences in the design of programmatic approaches; and (4) greater
attention to private healthcare providers and facilities. With these considerations in mind, the evaluation
makes the following recommendations for the design ofnew MNCH programming in Indonesia:
1. Focus on reducing maternal and neonatal mortality: With resources limited, the best option is to
focus on maternal and neonatal mortality to help Indonesia most effectively reach its MOG 4 and 5
goals.
2. Narrow the geographic spread to three to seven districts that can implement integrated
approaches based on a continuum of care or a critical pathways model adapted to the local
context (see Results Framework 1 below): The National Strategic Plan for Making Pregnancy Safer
(MPS) provides the framework for approaches that implement interventions strategically throughout a
district and cover all subdistricts based on a baseline needs assessment.
3. Engage the MOH and other GOI organizations, donors, and NGOs as learning partners: A
comprehensive integrated approach will allow USAID to collaborate with the MOH and other donors
to examine the effectiveness of different models. It is not necessary for USAID to be responsible for
strengthening all dimensions ofthe health system in each district where the new program operates.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA ix
4. Select districts according to specific criteria: The districts selected for USAID programming
should be representative ofthe diversity of circumstances found in Indonesia so that proven
approaches and tools developed will be appropriate for replication in similar contexts.
5. Prioritize the strengthening ofinformation systems in communities, integrated service posts,
community health centers, and hospitals: At the community and integrated service post levels,
engage local health committees to extend registration of pregnant women to the collection and
analysis ofinformation on maternal and neonatal outcomes. At hospitals and health centers, activate
and strengthen MOH-mandated maternal and perinatal audit systems, which are currently not fully
operational or effective. The audit systems should also cover private providers and maternal and
neonatal healthcare facilities so that they too can be held accountable for outcomes. It is also
recommended that the new program develop a district-wide surveillance and response system with
oversight from safe motherhood committees at different levels ofthe district health system, with
ultimate accountability residing with the district health officer (DHO), provincial health officer
(PHO), and civil society monitoring groups.
6. Give priority to actions that increase access to and the availability of quality 24/7 BEONC and
CEONC in districts: Nationwide, 59 percent of births in Indonesia now take place at home, where
about half are assisted by skilled providers, who mayor may not be linked to higher levels of care.
This situation decreases the chance that a woman and her baby will receive timely and adequate care
if there is a serious complication.
7. Increase attention to gender-based, sociocultural, and economic constraints to accessing quality
life-saving MNCH care through a rights-based approach to reducing MMR and NMR: A rights￾based approach empowers communities to ensure that every woman and newborn has access to
skilled delivery care and to EONC when complications arise.
8. Integrate the private health sector into district models for reducing MMR and NMR: Private
providers are a major source of maternal and newborn care in Indonesia. It is recommended that the
new program pilot a variety of public-private provider partnerships to improve MNH service quality
and accessibility.
9. Build the capacity ofIBI as a professional organization: It is recommended that USAID develop a
separate but linked activity to strengthen the Bidan Delima program and lEI's capacity to implement
it. Midwives are also a major provider of MNH services, especially at the community level and in
private practice.
10. Invest in Bidan Delima in Indonesia: IBI's Bidan Delima program has potential to enhance private
provision ofmaternal and child health services, promote facility-based births, and improve the quality
of care offered by private midwives.
11. Support learning from experience in reducing MMR and NMR across Indonesia: Knowledge
management needs to be central to any future project because it will be important to widely
disseminate lessons learned and best practices that emerge from working comprehensively at the
district level.
x EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
I. INTRODUCTION
The Health Services Program (HSP) is a cooperative agreement awarded to JSI Research and Training
Institute and partners to carry out a four-and-a-half-year program starting in April 2005 to address the
major public health problems facing mothers, newborns, and children in Indonesia. HSP provides TA to
government counterparts, civil society partners, NGOs, and communities on evidence-based
interventions. USAID/lndonesia requested a forward-focused evaluation ofthe project within the context
ofthe Mission's MNCH (CSH-funded) portfolio and contracted with GH Tech to conduct the evaluation
presented here.
The evaluation responds to two principal objectives:
1. To achieve a thorough understanding ofthe outcomes and results ofHSP interventions and the
effectiveness ofHSP strategies in achieving results in the focus areas (advocacy, behavior change, role of
private sector midwives, and technical support to the Government ofIndonesia [GOIJ). For evaluation
purposes, effectiveness is defined by the extent to which results are (1) replicable; (2) sustainable by GOI
and local partners; (3) consistent with GOI national and subnational policies and programs; and (4)
perceived as collaborative by GOI and civil society partners.
2. To develop recommendations for future activities and implementation strategies for immediate and
midterm time frames, consistent with USAID/lndonesia's commitment to Ministry of Health (MOH)
priorities in maternal, neonatal, and child health (MNCH) (Le., achieving Millennium Development Goals
[MOOs] 4 and 5); building health system capacity where it can be directly linked to positive impact on
MNCH outcomes; working closely with a broad range of civil society partners; and forging productive
relationships with the private sector.
This evaluation diverges from the standard assessment of achievements against quantifiable objectives.
HSP regularly reports on both process and outcome indicators. In almost all cases, the project has met or
exceeded those types oftargets. The evaluation also does not review the situation ofMNCH in Indonesia
or provide an overview ofthe Indonesia health system. The former can be found in the scope of work
provided in Appendix A and the latter in the recent World Bank report, Investing in Indonesia's Health.2
METHODOLOGY
A four-person team conducted this evaluation, consisting of a team leader with expertise in implementing
and evaluating maternal and neonatal health programs, a private provider network expert, an expert on
health systems and governance, and an expert on behavior change and neonatology. The team spent four
weeks in Indonesia, August 18-September 11,2008. Its members reviewed an extensive body of
documents (see Appendix G) from the project, the government, NGOs, and others.
After an introduction to the project components and achievements by HSP central office staff, the
evaluators visited six districts (Kota Malang, Kabupaten Malang, Kabupaten Deli Serdang, Kota Medan,
Kabupaten Sumedang, and Kota Bandung) in three provinces (East Java, North Sumatra, and West Java)
where HSP is working. During the field visits the team met with numerous and diverse stakeholders,
including mayors, members of district parliaments, district and provincial health office staff, provincial
and branch leaders of lEI, members ofNGOs, community leaders and members, public and private
healthcare providers (midwives, nurses, and doctors), community health volunteers, and women who are
pregnant or have newborn babies. The evaluators also had an opportunity to exchange ideas with
community health committees and to observe and converse with health volunteers during integrated
service posts' monthly health days. The team had an opportunity to talk directly to HSP staffin the
2 World Bank, 2008, Investing in Indonesia's Health: Challenges and Opportunitiesfor Future Public Spending
(World Bank: Jakarta).
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
regions visited, and all HSP staff were sent a set of questions about their involvement with and
assessment ofthe project; the team compiled their responses as part ofthe evaluation. Upon return to
Jakarta, the evaluation followed up with HSP central office staff to address additional questions and
information gaps. (See Table 1 for meetings with HSP stakeholders.)
TABLE I: EVALUATION MEETINGS WITH HSP STAKEHOLDERS
ORGANIZATION TYPE STAKEHOLDERS
Directors General of Community Health and Medical Services, Center of
Ministry of Health Health Promotion; Directors of Maternal Health, Child Health, Special
Medical Care, and Basic Medical Services, and Head of Health
I
Financing and Insurance
MenkoKesra Department of Health Coordination
Bappenas Health and Nutrition
Donors WHO, World Bank, Ford Foundation, MCC, and USAID
Professional Organizations IBI, POGI, JNKP, Indonesia Pediatrician's Association (IDAI), and
Perinasia
Implementing Partners JNPK. WRI, and HSP staff
Companies Johnson and Johnson and OneComm
Village CHC members, Kader, Bidan di Desa, Bidan Delima and other private
midwives, pregnant and postnatal mothers, fathers, and babies
Provincial PHO and hospital staff
DHO, Local House of Representatives (DPRD), IBI, JNPK, Bappeda,
District Partners NGOs, media, CSOs, FBOs; subdistrict: puskesmas staff and subvillage
leaders ,
Experts Technical experts and academics
HSP National and regional staff
During the field visits the team visited a cross-section of public healthcare facilities, among them
community birthing facilities (polindes), village health posts (poskesdes), satellite health centers (pus/us),
subdistrict health centers (puskesmas), and district and provincial hospitals. Some ofthese facilities have
been supported by the HSP project; others had little contact with it. The team visited a midwifery school
and training sites used by JNPK for clinical training and interviewed private midwives in their clinics,
some of whom were part ofthe Bidan Delima program.
In Jakarta, the evaluation team met with staff of governmental agencies, including several offices ofthe
MOH and two planning ministries, MenkoKesra and Bappenas, and a broad spectrum of donors, NGOs,
professional organizations, and health and governance experts (see Appendix B for a complete list). The
team also met with HSP technical advisors and management staff and with USAID staff.
2 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
OVERVIEW AND STRUCTURE OF THE REPORT
The challenge ofthe evaluation was to pivot deftly from assessing an extensive and complex project to
making recommendations for future USAID interventions in MNCH in a large and diverse country
undergoing a dynamic process of decentralization. The report structure tries to reflect the process
followed by the evaluators: it began with an analysis of what HSP has accomplished, moved on to
thinking about how those accomplishments contribute to the ultimate goal ofreducing MMR and NMR,
and made strategic suggestions about how to build on HSP's successes to reinforce USAID's general
approach to reducing maternal and neonatal mortality in Indonesia.
Section II ofthe report addresses the first objective, analyzing how effectively HSP interventions
demonstrated consistency with GO! policies, the degree to which they were undertaken in a collaborative
fashion, and whether they are replicable and sustainable. The team made a detailed assessment of each
component ofthe project. This section analyzes the strengths and weaknesses of each, raises issues for
consideration by HSP and USAID, and proposes component-specific recommendations for the rest ofthe
project. Section II ends with a general assessment ofthe strengths and weaknesses ofthe project and
general recommendations that coalesce around the component-specific recommendations.
Section III focuses on the transition from HSP to USAID follow-on activities. To promote understanding
ofthe extent to which HSP activities provide a foundation for future USAID MNCH programming,
particularly mortality reduction, this section addresses two additional questions:
1. To what extent were HSP activities effective in changing the practices of healthcare providers, policy
makers, women, and their families so as to contribute to greater maternal and neonatal survival?
2. Are HSP's activities, in the aggregate, the right combination and types of interventions necessary to
reduce maternal and neonatal mortality and morbidity in Indonesia? Ifnot, why not, and what else is
necessary?
To address these two questions, the evaluation team found it useful to examine HSP design and activities
in terms of a results framework that postulates critical interventions for reducing maternal and neonatal
mortality based on current international consensus on what is necessary, effective, and evidence-based,
summarized as:
1. Stronger policies and governance structures necessary to ensure universal access to skilled antenatal,
delivery, postpartum, and essential newborn care (supportive enabling environment) and to basic and
comprehensive EONC in case of complications
2. Improved quality, availability, acceptability, affordability, and timeliness ofMNCH services,
including normal delivery (preferably facility-based) and basic and comprehensive EONC in public
and private sectors, supported by effective health management systems and evidence-based protocols
(responsive health system)
3. Increased involvement of civil society organizations (CSOs) in planning, management, and oversight
of public and private healthcare, advocating for the rights of pregnant women and children, and
monitoring maternal and neonatal outcomes (empowered and engaged civil society).
Section IV proposes recommendations for future USAID MNCH programming and suggests general
principles to guide the design of new programs and project design.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 3
4 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
II. ASSESSMENT OF HSP
OVERVIEW OF HSP OBJECTIVES AND ACCOMPLISHMENTS
HSP is USAID/Indonesia's flagship MNCH project. It was originally designed to reduce maternal,
neonatal, and child mortality through an integrated assistance package of evidence-based technical
interventions that could be made available to districts and a system for replicating the package widely to
maximize the chance ofimmediate national impact. The project design emphasized rapid scale-up of
interventions. The original integrated package as presented in the RFA was designed around five strategic
approaches focused on decentralized district provision of healthcare: (1) integrating technical
components; (2) strengthening decentralized health systems and services; (3) leveraging funds from other
donors; (4) harnessing NGOs and PVOs; and (5) engaging the private sector. The project was to package
and make available such interventions as evidence-based approaches to MNCH and reproductive health,
infectious diseases, drug and commodity management, and decentralization and strengthening of district
health systems and services. 3
Given the breadth ofits original scope, the focus and objectives ofHSP have not always been clear. The
tsunami in Aceh, which occurred three months before the project agreement was signed, initially diverted
much attention away from its original scope of work. That same year the USAID Mission also asked the
project to lead a national health summit on reducing maternal mortality. Yet despite such added
responsibilities, HSP has been very productive in developing district and national-level planning,
budgeting, advocacy, and behavior change communication (BCC) tools, training modules, and clinical
guidelines in close collaboration with the MOH, provincial and district health authorities, and other
stakeholders. HSP has also engaged a broad spectrum of civil society groups and government officials in
planning and advocating for increased district-level MNCH resources.
While most ofthe tools and guidelines have been adopted by the MOH and applied in HSP focus districts,
few have been systematically evaluated for their effectiveness in changing healthcare provider practices
or removing barriers to women's and newborns' access to life-saving interventions.4 HSP was more
concerned with replicating than validating approaches. The evidence on effectiveness is well established
for some interventions the project addressed, such as active management ofthird-stage labor (AMTSL),
immediate breastfeeding, birth preparedness and complication readiness, and essential newborn care.
However, measuring the impact on maternal and neonatal mortality of evidence-based practices as
implemented in the districts was not part ofthe original project design.
HSP has demonstrated impressive results in developing and replicating activities across many districts.
Table 2 illustrates that 2007 program outputs have often exceeded targets.
Accomplishments include increases in district budgets for MNCH; drafting and passage ofMNCH laws;
upgrading training organizations to provide in-service training of public and private providers in MNCH
clinical care and quality assurance; formation and funding of community health committees (CHCs) to
establish birth preparedness and emergency response systems and promote hand-washing and
breastfeeding; and building district and community capacity in MNCH planning and budgeting, advocacy,
and BCC.
3 The description in this paragraph is taken from the RFA program description.
4 See Appendix C for complete list oftools and guidelines developed with HSP assistance.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 5
TABLE 2 HSP. 2007 PROGRAM OUTPUTS
PROGRAM AREA AcnVlTY FY07 FY07
TARGETS RESULTS
Advocacy and Number of national, provincial, or district-led 18 initiatives 49 initiatives
Decentralized advocacy initiatives in support of basic human
Planning services
Number of districts reporting an increased 3 districts 22 districts
share of the district budget for MNCH services
Number of districts with increased financial 3 districts 22 districts
resources accessed from government or other
sources to deliver basic human services
Number of people trained in advocacy 360 people 350 people
techniques
Number of districts with plans and budgets to 23 districts 14 districts
improve MNCH service delivery
Provider Training Number of health personnel receiving clinical 910 providers 1,266
training in basic delivery care providers
Number of health personnel trained in basic or 276 providers 500 providers
comprehensive obstetric and neonatal care
Percentage of trained providers who perform 95% of 99% of 384
to estab~ished standards providers providers
visited visited
Midwife membership in the Bidan Delima 6,400 6,518
Program
Number of midwives trained in supportive 48 supervisors 261
supervision supervisors
PPP Number of new public-private partnerships 1 partnership 12
(PPPs) partnerships
Community Number of people trained in BCC techniques 150 people 108 people
Mobilization and Number of people trained in community 800 people 1,067 people Behavior Change mobilization
Number of Community Health Committees 350 363
(CHCs) operational committees committees
Number of CHCs established through 385
replication by GOI or other donors committees
From HSP. 2007 Annual Repott, p.3
The results based on outcome indicators are somewhat mixed (see Table 3). In 2007 a rapid survey found
that the percentage of births attended by skilled providers varied across HSP districts, with an average
decrease (69.5% to 66.5%) as a result of a significant decline in two districts in Banten (which went from
80% to 47%) but an overall slight increase in all other districts (70.9% to 74.5%) compared with the 2005
baseline. However, the program's 2008 rapid survey saw an average increase in skilled birth attendance to
76 percent, which is closer to the 73 percent national average recorded by the preliminary results from the
6 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
Indonesian Demographic and Health Survey (IDHS), as compared to 66 percent in 2002--03. This puts
HSP districts, exclusive of Banten, squarely in line with the national average. 5
Similarly to the IDHS results, contraceptive prevalence rates seem to have stagnated or decreased slightly
in HSP districts in 2007, although a slight increase is documented in the 2008 rapid survey. (Note:
Because HSP has not been promoting family planning services in any of its districts, it is not possible to
draw any direct conclusions about these outcomes).
Rates of childhood diarrhea have decreased steadily over the past two years in HSP target areas. At
baseline, 28 percent of children less than 36 months of age had had diarrhea in the previous two weeks; in
2007 the rate was 25.8 percent and it dropped again in 2008 to 21.5 percent.
HSP has also recorded significant increases in the practice of initiation of breastfeeding within the first
hour of life. At baseline, only 9.3 percent of mothers reported having immediately breastfed their
newborns. In 2007, the rate had risen to 20.7 percent and in 2008 to 27.2 percent.
TABLE 3. HSP 2007 PROGRAM OUTCOMES
BASELINE ACHIEVED ACHIEVED
OUTCOME INDICATOR (Rapid Survey (Rapid Survey (2006 Survey) 2007) 2008)6
% of children less than 36 months 28% 25.8% 21.5%
of age with diarrhea in last 2 weeks
% of deliveries attended by skilled
I
69.5% 66.5% 76.0%
health personnel
Modern contraceptive prevalence I
75.8% 74.5% 79.5%
rate
% of caretakers washing hands 6.6% 11.9% 7.4%
with soap at 3 of 5 critical times
% of women initiating breastfeeding 9.3% 20.7% 27.2%
HSP 2007 Annual Report p.3, draft HSP 2008 Annual report p. 3
The rapid survey and IDHS results raise questions about whether HSP can attribute changes in outcome
indicators to its interventions. A recent World Bank. report on Indonesia's health system raises similar
doubts about the impact of increases in district budgets alone on better MNCH outcomes. The findings
from a regression analysis found little statistical correlation between district healthcare spending and
coverage of child immunizations and skilled birth attendance (World Bank, 2008, p. 66).
Assessing attribution is further complicated by the fact that USAID asked HSP to work in 31 districts but
only a few efforts took place at the district level, including planning and budgeting, advocacy, and BCC.
HSP had little influence on other activities within the district, such as training of providers or upgrading
facilities. Its other activities, such as community-level CHCs and preparedness programs (P4K) were
implemented in a concentrated way only in about three villages in each of four subdistricts.
5 While the rapid survey demonstrates large changes in the percentage of newborns and women receiving a visit
from a midwife or nurse within one week postpartum, the results are not quite comparable because the questions
used in the 2005 survey and the rapid survey in 2007 were not the same.
6 These results were not reviewed by the HSP Evaluation Team for statistical significance, as they were not available
before the team left Indonesia.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 7
THE CHALLENGES OF THE PROJECT DESIGN
One ofthe most important lessons learned over the last 20 years is that to reduce maternal and neonatal
mortality, women must have timely access to quality EONC, because every pregnancy entails risks that
can develop into life-threatening complications for mother or baby.
• Maternal mortality: In virtually every country where maternal and neonatal mortality and morbidity
are high, the principal causes ofmaternal death are hemorrhage, eclampsia, infection, obstructed
labor, and unsafe abortion. Effective response to these life-threatening complications requires a
skilled provider who can immediately detect complications, stabilize the woman for transport to a
BEONC-level facility, and have prompt access to a CEONC level of care if a c-section and blood
transfusion are necessary.
• Neonatal mortality: Newborns die principally of asphyxia, preterm births, and infection. For
newborns, interventions can be initiated by a skilled provider trained in newborn resuscitation who
recognizes the importance ofskin-to-skin contact before and during transport to a higher level of care.
Because many life-threatening complications are neither predictable nor preventable, it is critical that all
pregnant women have access to skilled birth attendants, who can recognize complications and make
informed decisions to refer women or newborns with complications to EONC services.
A second lesson learned is that skilled care is only effective if it is part of a functioning healthcare system
that links women and newborns to higher levels of care. This means that the healthcare services adhere to
national clinical guidelines that meet international standardsfor EONC and skilled birth attendance. A
functioning system also depends on policies that support training and rational deployment ofhealthcare
professionals, especially midwives.
The third lesson learned is that it is essential to have reliable information about the causes and
circumstances surrounding maternal and neonatal deaths in order to understand how the health system
needs to be improved to ensure that women and newborns have access to life-saving care when
complications arise.
Elements Missing from Project Design and Implementation
Although the original goal ofthe project was to "reduce maternal, neonatal and child mortality and
morbidity with a special focus on the poor and vulnerable through an integrated decentralized district
approach," the objectives were largely related to process rather than impact. As reflected in Figure 1,
project objectives did not prioritize implementation of an integrated strategy of interventions critical to
reducing maternal and neonatal mortality.
8 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
Figure 1. HSP Objectives
Communities
and
Households
for the benefit of
.....!.-J- influenced by
Integrated assistance package
Integrate Strengthen
technical decentralized
interventions health systems
Leverage
other
donors
Harness NGOs
and PVOs
Engage the
commercial
sector
.£J-ProVided to
Districts
The RFA stipulated that the program should support decentralization ofthe Indonesia health sector
through a replicable integrated assistance package. The emphasis on scale-up and replication was
premised on the assumption that there were tools and policies to scale up in many districts.
Early in the project it became evident that many ofthe national guidelines and tools were out of date and
not based on current evidence-based practices. HSP therefore spent much ofthe first year helping the
MOH to update guidelines, tools, and training modules while emphasizing a community mobilization and
BCC strategy in selected villages that was focused on birth preparedness, early initiation of breastfeeding
(EIBF), and hand washing (Annual Report 2006). The project correctly attempted to rectify the omission
of attention to EONC and routine auditing to understand, document, and address the causes of maternal
and neonatal deaths at different levels ofthe health system. HSP undertook to train healthcare providers
in essential newborn care in key national and provincial hospitals to strengthen their capacity to deliver
and train providers in CEONC.
In its critical first year, USAID asked the project to curtail the essential building block of EONC training
in hospitals and focus on district-level and community-based interventions. The result was to severely
limit HSP's capacity to improve the quality oflife-saving service delivery. Instead it worked with the
MOH and mPK on updating the training curriculum and supporting the training and certification of
trainers on basic delivery care, BEONC, and CEONC. The restriction against working with CEONC
health facilities to strengthen service delivery meant it was difficult for the project to implement an
integrated strategy based on a continuum of care model (see Figure 2).
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 9
Figure 2. The Household-to-Hospital Continuum of Care
Peripheral Facility
Health Post
Center/Clinic StaN
with BEONC
skills
ENABUNG ENVIRONMENT
Aur'lllOistrlct
Hospital StaN
wlthCEONC
skils
4 HHCC OF MATERNAL AND NEWBORN CARE
The project design omitted critical interventions for reducing MMR and NMR, such as improvement in
use and quality ofCEONC services in hospitals and referral, support, supervision, and information!
accountability systems in order to improve the response ofthe health system to maternal and neonatal
complications. A study of 12 Indonesian hospitals showed that 92 percent of maternal deaths result from
delays in referral and case management, and 40 percent ofthem occur on the way to the hospital. Delays
result both from belated decisions to seek care and delays at referral facilities in getting women and
newborns with life-threatening complications to the next level of care. The decision to seek care is greatly
influenced by the perceptions of women and their families that quality care is lacking at primary health
centers and hospitals, as well as by concerns about costs. Once women reach the health facility, they
experience additional delays caused by the failure of providers to perceive the urgency of complications,
inappropriate care, and lack oftrained providers and supplies. Although lSI, the prime contractor,
proposed a critical pathways model that addressed these concerns, it was discouraged from giving too
much attention to improving hospital-based CEONC, health center-based BEONC, and the supportive
systems that link skilled community-based providers (e.g., community and private midwives) to higher
levels ofthe health system that are critical for addressing the major causes ofmaternal and neonatal
mortality.
HSP primarily focused on interventions like clinical training and quality assurance efforts-AMTSL,
EIBF, and immediate postpartum neonatal care in basic delivery care (APN), BEONC, CEONC, and
supportive supervisiorr-improving policies and guidelines, developing community-level birth
preparedness plans, and promoting hand washing and EIBF. All ofthese, though important, are not
adequate to improve maternal and neonatal outcomes ifthey are not part of an integrated strategy that
incorporates CEONC and reinforcing essential health systems. Once HSP stopped working in hospitals, it
was unable to ensure the continuum of care and give the needed support for referrals from community￾based providers. It did provide support for pilot testing the introduction of kangaroo mother care (KMC)
at the hospital level in 2008 in response to a recommendation made at a regional USAID conference in
10 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
Bangkok in 2007.7 The project has been successful in promoting integration of AMTSL and EIBF among
midwives.
HSP's primary contributions to reducing MMR and NMR were to help the MOH to identify evidence￾based practices, disseminate them through updated guidelines, and integrate them into national clinical
training modules. Critical elements that remain to be completed are to (1) implement guidelines at
national scale and adapt them to different local contexts through an integrated strategy within a district,
and (2) ensure that people who are trained in APN, BEONC, and CEONC are supported by strengthened
supervision, information, and referral systems.
Multiple and Complex Components Too Widely Spread
The HSP project is spread thin over too many districts, which makes it extremely difficult to apply the
whole package intensively enough to achieve the desired improvements in maternal and neonatal
outcomes. The mandate to scale up too quickly pushed the project into 31 districts in six provinces (North
Sumatra, Banten, West Java, Special Metropolitan ofJakarta, East Java, and Aceh).8 It would be difficult
for USAID to support a district-wide integrated systemic approach to reducing maternal and neonatal
mortality in such a large number of districts for the amount offunding provided to HSP.
The focus on scaling up in a large number of districts rather than on impact resulted in HSP working at
the district capital on advocacy, BCC, and DTPS planning but in only three villages in each offour
subdistricts on other project activities. For example, in the Malang district, HSP provided direct support
to CHCs in only 12 ofthe district's 390 villages, and gave supportive supervision in only four ofthe
district's 39 community health centers. While health center and community activities were implemented
in a way that built the capacity ofDHOs to use HSP tools in other geographic areas, the project did not
track how often this happened and on what scale. This makes it difficult to gauge its impact on the two
health outcome indicators at the district level: incidence of diarrheal disease and skilled attendance at
birth.
The breadth ofthe project also makes it difficult to assess the sustainability ofindividual components, if
sustainability is defined as activities continuing to be operational at the same level without project
support. Where there is a public sector organization, donor, or NGO that has assumed ownership of
activities, there is more likelihood that those activities will be both replicable and sustainable within and
beyond districts.
Inadequate Attention to Formative and Operations Research
Lack ofresearch and evaluation components makes it hard to test methodologies, customize them to the
local context, and attribute outcomes to a given activity. HSP was not designed as an operations research
project, and from the beginning USAID made it clear that research and evaluation were not to be a focus
ofthe project. Nevertheless, for HSP and USAID to convincingly link health outcomes to project
interventions, it is necessary to demonstrate that similar changes did not occur in other districts without a
donor presence.
7 In September 2007, representatives ofUSAID, the MOH, and HSP attended a regional conference on Scaling Up
Best Practices in MNCH. The Indonesia country team prioritized KMC care for low-birth-weight newborns.
USAID, through its Participant Learning Program, was able to make available support for a team of practitioners
from three Indonesian teaching hospitals to go on a KMC study tour to Cape Town, South Africa, in May 2008. HSP
has since provided a grant to the Indonesia Association ofPerinatologists, Perinasia, to provide follow-on technical
support to ensure KMC is well institutionalized in these facilities as well as being established by policies ofthe
MOH and professional associations.
g Currently HSP is only in five provinces and 25 districts now that the post-tsunami work in Aceh has ended.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 11
A Solid Foundation to Build On
Despite the significant design challenges, HSP has been very successful in laying a solid foundation to
address the major causes ofmaternal and neonatal mortality in Indonesia. Among its accomplishments:
1. An integrated package of evidence-based national guidelines for reducing maternal and neonatal
mortality
2. A district-level advocacy process for increasing political and financial commitment to MNCH in
support of Indonesia achieving MDGs 4 and 5, including a process for passing local laws and decrees
3. An improved process for district-level MNCH planning and budgeting based on data for decision￾making (DTPS)
4. An evidence-based integrated maternal-neonatal curriculum for normal delivery care, BEONC and
CEONC, and supportive supervision for village midwives
5. Effective district-level BCC strategies focused on birth preparedness, EIBF and hand-washing, using
public-private partnerships (PPPs)
6. A replicable strategy to mobilize communities to draft and implement village and household-level
birth-preparedness plans
7. Expansion ofthe Bidan Delima program to improve the skills of private midwives through support to
the Indonesia Midwives Association (lBI)
To address the first objective ofthe evaluation, the project interventions below are assessed according to
whether they were consistent with MOH policies, the product of collaborative processes with different
branches ofthe GO! and with civil society, replicable, and sustainable. The components are also grouped
by their contribution to (l) an enabling environment that strengthens governance through better policies
and guidelines, enhanced data collection and use, and improved planning and budgeting; (2) a health
system that is responsive to the population's needs and increases access to and improves the quality of
MNCH care; and (3) a civil society that is engaged and empowered to work actively to ensure access,
uphold human rights, and monitor the quality ofMNH care at all levels ofthe health system.
HSP COMPONENTS SUPPORTIVE OF AN ENABLING ENVIRONMENT
Improved Policies and Guidelines: Advocacy
The purpose ofHSP assistance in advocacy is to establish a network of district-level advocates who,
through their combined capacity and shared vision, are able to successfully advocate for better policies
and a budget for expanded MNCH services. This advocacy work is closely related to providing assistance
in decentralized planning and budgeting using the DTPS planning tool. This tool, created by MOH, was
expanded by HSP to give more attention to MNCH and to cover drug commodity and supply
management.9
The HSP advocacy component consists of building capacity in order to improve MNCH policies and
increase and better target budgets. HSP provided technical training and TA to advocacy groups composed
of diverse public and private stakeholders. The approach builds on Indonesia's tradition of local
participatory planning to codify the planning process in legal (local MNCH laws) and administrative
(DTPS and bottom-up planning process) instruments. Over the past two years HSP led and supported
advocacy processes in 26 districts (2007 and 2008).
9 See the next section for more detail on DTPS.
12 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
The advocacy training and support are supervised in each ofthe five regional HSP offices by a Program
Coordinator (PC) for Advocacy. In 2007, the PCs each supported two districts. Before the first training
session the PC identifies and contacts stakeholder groups, such as the DHO, parliamentarians, and NGOs,
and invites them to participate in a three-day advocacy training. According to HSP, a typical group
consists ofthree DHO staff, two from the district executive government, two from the district parliament,
three members of professional organizations, 10 from different civil society organizations (CSOs), and
representatives ofthe local media.
HSP subcontracted with the Women's Research Institute (WRI) to design and conduct the trainings. The
first day is an orientation session on advocacy and understanding local MNCH issues and challenges; the
second day orients the participants to different advocacy techniques; and the third day is a hands-on
lobbying effort aimed at obtaining commitments from the parliament on MNCH funding. During the
workshop the new advocacy team drafts a work plan for which HSP provides seed funding of up to
Rp 45,000,000 ($5,000). The advocacy teams have used HSP support as matching funds for raising
additional money to support the production offilms, meetings with regional planning boards and
parliament, and media coverage.
While the primary aim ofthe advocacy team was to lobby the Local House ofRepresentatives (DPRD)
for an explicit MNCH budget, after the workshop several advocacy teams initiated efforts to get district
policies passed on MNCH, with a specific directive guaranteeing increased funding to improve the health
ofmothers and children. HSP hosted a series of workshops for legislators from the districts where
advocacy teams were established to help them better understand their responsibilities and strengthen
working relationships with authorities in drafting and passing legislation, as well as budgeting and
monitoring. Consultants referred by LGSP helped to draft the district law.
In Sumedang, Indonesia's first MNCH-specific bill was enacted as law on June 2, 2008. In Malang
District the DPRD passed the second law on September 26. Currently, 12 other MNCH advocacy teams
in HSP partner districts are shepherding MNCH laws through various stages of passage: Aceh Besar,
Aceh Barat (NAD), Pasuruan, Madiun, Kediri, Kab. Malang (East Java), Purwakarta, Cianjur, Sumedang,
Kab. Bogor or Kab. Bandung (West Java), Medan, Deli Serdang, Siantar or Sibolga (North Sumatra), and
Serang (Banten). In Sumedang and Malang the initiative for passing the law came from the DPRD while
in Deli Serdang it was initiated by the district elected executive officer.
Strengths of the Advocacy Component
1. Sustainability: Districts that have initiated the process to pass an MNCH law are likely to sustain
political and financial commitment to MNCH services even after new elections. The advocacy
process built consensus and common purpose among a diverse group ofstakeholders. As they move
forward to enact and implement the law, however, members ofthe advocacy team may find their
perspectives may not be as unified as their roles change to being funders, implementers, and
monitors. Nevertheless, the experience of working together has given the teams an effective process
for negotiating differences to reach consensus.
2. Replicability: Advocacy training and the process of drafting laws and lobbying for their passage
have provided both governmental and nongovernmental organizations with new skills they can apply
more generally. The HPS advocacy guide offers solid support to those who have been through the
training and increases the likelihood that they can transfer some oftheir skills to new participants.
The replicability ofthe guide has also been demonstrated. WRI facilitated the training in 15 districts
in 2007. At the request ofthe MOH, national trainers were also oriented to the advocacy module.
Participants were mainly stafffrom the MOH health promotion unit, although some were from the
Directorates of Maternal and Child Health. Representatives of PHOs, DHOs, and local NGOs were
also trained as trainers with HSP support and facilitated II district advocacy trainings supported by
HSP in 2008.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 13
3. Members ofthe advocacy team became champions for MNCB within their own organizations. This
is particularly valuable in organizations like DPRDs, where MNCH had not previously been very
visible. NGO members were also empowered to be more vocal within government institutions.
4. Consistency with MOB policies: The process gave participants knowledge of how to translate
national guidelines into local action that is consistent with MOH policies. The advocacy manual has
been printed as part ofthe MOH's own DTPS-MNCH efforts.
Weakness of the Advocacy Component
The teams required more support than was originally anticipated. Originally WRI was contracted just for
the training, but after its first contract ended, HSP asked it to provide technical support to the advocacy
teams. Similarly, LGSP was enlisted to help with drafting laws, which requires specialized skills that not
easily transferable through short-term training. Training without follow-up support was not adequate for
teams to function effectively. This is a lesson for future advocacy activities, such as drafting an
implementation plan for laws once passed and monitoring its application. It is likely that different skills
will be necessary for these steps. Whether the activities can be sustained without the assistance ofHSP
district PCs is not clear.
Issues
Having a district law for MNCH will guarantee the consistency oflocal government support to MNCH if
and when the district official or DPRD changes after an election, although it is more likely that a newly
elected official will drop a previous decree. However, in both cases, the real key to any impact and
sustainability of passage ofthe law is monitoring its observance.
One ofthe lessons learned is that laws initiated by parliamentary committees that oversee social services
appear to be more politically advantageous than laws initiated in the district official's office. Because
consensus is built among various factions in parliament, including the official's party, laws initiated there
pass more quickly with broader-based support and, once passed, the official's approval is virtually
guaranteed. However, ifthe official initiates the process, there is the danger that opposition parties in
parliament may oppose it, especially around election time, in order to deny the incumbent political
advantage, particularly ifthe measure has popular support. This was illustrated by concerns among the
Deli Serdang Advocacy Team, who reported that passage ofthe law might be delayed because some
opposition factions in the DPRD did not want the incumbent official to claim credit for it before
upcoming elections.
There has been considerable discussion within HSP districts and by several experts interviewed by the
evaluators about the relative value of passing a specific MNCH law or incorporating MNCH articles into
a more general health law. According to the HSP Advocacy Advisor, some districts had begun working
on a general district health system law before HSP introduced the idea of a more focused MNCH law.
These districts intend to incorporate specific MNCH articles into the general law. USAID LGSP staff
believed it would be better to adopt the more general approach of a health law with MNCH components
that can be followed up with rewulations. It would be worthwhile to collect information on both processes
to see which is more effective. 1
10 Others, including Professor Laksono, an expert on decentralization and health, and Dr. Arum Atmawikarta from
Bappenas also support passage of a general health systems law with MNCH articles, like the one in Serang. These
more general laws can be supported with mayor's regulations or decrees. HSP recently contracted with Mahlil Ruby
to create a tool that will standardize data collection and analysis ofinformation about district budgets for MNCH
activities. Dr. Ruby is now training provincial and district partners to use the tool to monitor funding in 23 districts
that used the DTPS process and advocacy to draw up and pass MNCH budgets. Besides tracking budgets submitted,
the teams will also try to ascertain whether funds allocated matched those budgeted.
14 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
There are a number of questions worth exploring about the sustainability offuture applications ofthe
advocacy tools in new districts:
• Is there a potential institutional home or host for this tool at the district or provincial level? The
current institutional home is the central MOH Director General ofCommunity Health, which is too
far removed from implementation.
• Who can assess strategic stakeholders before the advocacy workshop and facilitate the advocacy
process, as the HSP PC now does?
• Is HSP seed money a necessary ingredient to motivate advocacy teams? Who could provide this in
the future? Will districts see value in supporting TA directly from their own resources?
• How well can advocacy coalitions be sustained without an external facilitator?
One initiative some MNCH advocacy teams are taking to address this challenge is to have the team
mandated through a district decree. While that will ensure support from the district for team operations
previously supported by HSP seed money, it may also compromise their political independence from the
district government. However, with an increasing number ofMOH staff involved in district-level
advocacy initiatives, enthusiasm for this approach is growing.
Recommendations
1. It is recommended that HSP continue to provide technical support to districts that have either passed
or are close to passing an MNCH law to help the DHOs draft viable implementation plans and
support advocacy teams as they draw up and implement a monitoring plan.
2. HSP should further analyze the effectiveness ofits TOT replication process to ascertain how much
training is needed to develop capable facilitators and evaluate the level and kind of TA the advocacy
teams need to draft and advocate for local laws; draft implementation and monitoring plans; and meet
the requirements ofthe law and monitor its implementation.
3. The process of advocating for MNCH laws is one ofthe most innovative HSP activities. It is
recommended that the wealth oflessons HSP has learned from the process be written up in five or six
case studies from different districts. There has been widespread interest from non-HSP districts and
other donors (see Appendix F, the NGO diary) in learning from and replicating this activity.
4. HSP and the Center for Health Promotion should include professional organizations (such as the
Indonesian Health Promotion Association or the Indonesian Public Health Association) and higher
institutions of public health (such as the Faculty ofPublic Health or the Association oflndonesian
Schools of Public Health) in TOT on advocacy, to ensure that skills in advocacy are transferred
throughout the educational system. This will contribute to both sustainability and replicability after
the project ends.
Improved Decentralized Planning and Budgeting: DTPS
HSP revised and trained DHO staff on an MOH planning tool referred to as the District Team Problem
Solving (DTPS) tool. The tool guides users through a planning and budgeting process that begins with
collecting data on population and health in the district. The use ofDTPS helped DHO staffto draw up
budgets and plans that reflected district needs. HSP has helped the MOH to revise the tool to address both
maternal and child health!! and to incorporate drug and commodity management into planning. HSP
regional office staff work with district planners in partner districts, helping them to collect and analyze
MNCH data, draft plans and budgets that respond to district problems, and support DHOs in negotiations
with the regional planning board and DPRD to ensure that their budgets are maintained. In 2006, when
11 The previous version covered only maternal health.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 15
central-level deconcentration funds were plentiful, the project also helped the MOH to draft guidelines for
them and trained district officials in procedures to obtain and use them.
HSP supported the MOH revision ofthe DTPS Making Pregnancy Safer (MPS) planning methodology,
and at the request ofthe MOH drafted a DTPS MNCH module that included both a reference manual and
a participatory training module. The new DTPS incorporated drug and commodity management as part of
MNCH planning and used the national standard annual budget planning template, which allowed the
results ofthe DTPS to be dropped directly into the DHO budget proposal to the regional planning board. 12
The revised DTPS changed the budgeting process from one in which the same budget allocation was
repeated year after year regardless ofthe situation in the district to one based on evidence gathered by the
DTPS team on the needs and health ofthe population and the operational costs required for proposed
activities. An HSP District Facilitator worked with DTPS teams, composed mainly ofDHO staff and a
few representatives from NGOs, professional organizations, and the DPRD, to gather and analyze health
information. HSP TA also provided training on how to apply the tool to match planning and budgeting to
actual need.
Strengths of the DTPS
1. Collaboration: The DTPS promoted a team approach to MNCH planning by involving a variety of
stakeholders who worked collaboratively with the DHO.
2. Sustainability: DTPS was influential in stimulating an appreciation by the DHO and other
stakeholders for data collection and analysis as the foundation for planning and budgeting. It provided
the DHO with evidence with which to argue for increased district budgetary allocations, and enabled
the DHO to articulate a more compelling argument for giving MNCH priority for district funding.
HSP assistance to the DHO on application ofDTPS increased MNCH budgets in districts where the
project is active.
3. Consistency with MOB Policies: Participants from the DHO believe that adhering to the MNCH
Minimum Service Standard as part ofthe DTPS helped improve health service coverage. For
example, in Malang district the DHO reported an increase in each woman getting four antenatal visits
for high-risk neonates.
4. Replicability: The DTPS process provided a realistic framework for subdistrict planning as part of
the DHO planning process. HSP also pilot-tested in three districts support for the bottom-up planning
process (musrenbang, discussed more fully below). The pilot test was successful in focusing
discussions between health center staff and village musrenbang participants on common criteria for
selecting and planning health activities and investments.
Weaknesses of the DTPS
1. In the first districts where HSP helped with application ofthe DTPS, the process was not
synchronized with the district-wide bottom-up planning process. Later the timing ofthe two processes
was better synchronized, and in Sumedang, the district planning board created a way to combine the
two planning procedures into a combined top-down and bottom-up approach.
2. Poor internal coordination and communication in HSP often confused the DHO partner in the field
because tools and processes were being developed and rolled out at the same time (e.g., the delay by
12 The earlier DTPS MPS produced a technical proposal that required additional work to adjust the results to the
budget template used by the local planning body). The current DTPS is line with the latest government regulation
number 13 on the standard government budget planning processes.
16 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
HSP in choosing between two different planning tools, DTPS and Prospect, both approved by the
MOH). Some districts started with one and then had to switch to another.
3. Although the DTPS has been applied in 31 districts, very few trainers are independently capable of
replicating the methodology in new districts. HSP has trained 119 trainers, but only 20 are considered
fully qualified.
4. Health data collected for the DTPS are inconsistent. A 2008 HSP assessment of health information in
Deli Serdang and Sumedang reported that information changes as it is passed up from lower levels to
the DHO, and there are no standards for validating data.
5. Even though the DTPS has stimulated greater interest in the use of data for district planning, they are
not used routinely to improve service delivery (Le., to correct errors or increase coverage).
Issues
1. The main challenge is to determine how to build on advances in evidence-based planning and
budgeting to improve services. There are many barriers, such as human resource allocation,
deployment, and competency ofhealth workers or inadequate referral, information, and supervision
systems, that are not under the direct or exclusive control ofthe DHO. This is likely to constrain even
the best of plans.
2. What is not clear from discussions and DTPS documentation is the extent to which services provided
by private providers and health facilities are factored into planning and budgeting. For example, if
plans are based on the needs ofthe district population as a whole but do not recognize that private
providers may be meeting some ofthese needs, there may be a tendency to overdevelop the public
supply side.
3. The lack of any system for tracking maternal and neonatal outcomes is a major constraint to
elaborating reality-based plans and budgets that really address the problems in the health system that
contribute to high rates ofmaternal and neonatal mortality. While there are guidelines for MPS and
conducting maternal and neonatal audits of deaths and near misses, they have not yet been
implemented at the district level; nor are they adequately budgeted for in the DTPS process.
4. The role of PHOs in the process is not clear, although they have facilitated the DTPS in some
districts. 13 Ifthey are to be effective in disseminating information, implementing guidelines,
replicating evidence-based practices, and monitoring outcomes, they need to have a more prominent
role in district-level planning and oversight.
5. HSP staff concurred with the opinion of national MOH staffthat the DTPS process should be better
integrated with other components ofthe project. Specific ways that MOH and HSP have agreed to
integration in the future are to ensure that integrated management of childhood illness (IMCI) and
supportive supervision efforts contribute to subdistrict health center planning and that BCC and
provider training teams participate more fully in district DTPS planning
6. Given the breadth and intensity ofHSP activities in some districts, regional staff were ofthe opinion
that a single district facilitator, whose primary responsibility is community mobilization and who only
secondarily provided support to planning, was not enough. They recommended that there be three
staffmembers per district: a coordinator, a facilitator of district-wide processes like the DTPS, BCC,
and advocacy, and a third person to facilitate social mobilization.
13 Unfortunately, the evaluation team did not have a chance to speak with the provincial facilitators ofthe DTPS
from PHO; field visits were focused at the district level.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 17
7. The DTPS does not seem to be applied in a manner that results in rational planning for the
distribution ofservices and personnel across the district. Districts could use help in determining
where to upgrade primary health center services to include labor and delivery based on a district
needs assessment. For example, at one ofthe districts visited, the BEONe health center was
established because the facility already had beds so it could be easily converted. However, the facility
has no patients despite the upgraded facility and staff, which suggests there may not be the need or
demand for this service in its coverage area. Further, the facility's head indicated he had no input into
the decision to upgrade. Districts can be supported to strategically plan for their service delivery
needs based on an evaluation oflocal community needs; they need help in adapting MOH's "one size
fits all" guidelines to their local context. This could be more readily accomplished in a project that
takes a comprehensive approach to improving district planning, financing, and implementation.
Recommendations
1. There should be greater devolution of planning and use ofinformation for decision-making to lower
levels ofthe health system, such as the community health centers and their satellite facilities. HSP
recently initiated efforts to strengthen health center planning and link it to the musrenbang, but there
is still a need to reconcile the bottom-up process with the more top-down DTPS process. The
supervisory and information systems that are vital to effective planning and implementation also need
improvements. There is potential to empower communities to playa larger role in planning,
budgeting, and monitoring by strengthening community health committees and community volunteers
to effectively participate in the musrenbang and collect information about maternal and perinatal
outcomes of pregnant women who are identified through P4K. 14
2. HSP should advocate for adapting the Sumedang integrated planning approach in other HSP districts.
Providing real budget ceilings during the musrenbang process greatly improved the quality ofthe
proposals it generated.
Increased Leverage of the Commercial Sector: Public-Private Partnerships
HSP has sought private contributions to support program activities. The project was able to secure
support from corporate resources, particularly for its humanitarian and relief efforts in Aceh and for the
West Jakarta Flood Relief, among others. It has also trained district advocacy teams and IBI leadership on
how to approach the corporate sector for financial support, and districts were able to secure some support
for community events on breastfeeding. HSP also drew up simple proposal templates for approaching
potential corporate sponsors.
Strengths
1. The program was able to raise considerable amounts ofmoney in support of a variety of activities
(see Table 4).
14 There are several models for this type of effort in conjunction with community-based maternal and neonatal
audits. UNICEF has recently done this successfully in several states in India (see UNICEF, 2008), and the MOH in
Bolivia implemented a similar effort in rural areas ofthe Department ofPotosi between 1999 and 2003 with the
support ofPAHO (see de la Galvez, 2004)
18 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
TABLE 4 FUNDS RAISED THROUGH PUBLIC-PRIVATE PARTNERSHIPS I',
COMPONENT RUPIAH US Dollars
Advocacy Rp 2,104,000,000 $233,778
Breastfeeding advocacy events Rp 534,713,200 $59,413
BCC hand-washing promotion Rp 90,250,000 I $10,028
Bidan Delima Rp 50,000,000 I $5,556
Community health committees Rp 4,800,000 I $533,
2. HSP has also been assisting Johnson & Johnson (1&J) to program its 2008-13 support for the Bidan
Delima program. Since 2005, when JHPIEGO secured support from J&J for Bidan Delima, the
company has progressively expanded its support, committing more than $470,000 so far. J&J's
corporate headquarters has recently made Bidan Delima one ofthe company's showcase programs
globally, therefore securing a significant additional .Ievel of corporate social responsibi:Iity funding for
Bidan Delima over the next five years. In 2008, J&J is supporting public service announcements on
four national TV stations, training for another 500 Bidan Delima as facilitators, and underwriting
printing valued at $170,000. J&J's five-year objective for Bidan Delima is to accelerate its expansion,
starting by doubling membership in the next three years. As USAID's implementing partner, HSP has
facilitated collaboration between the two donor agencies. HSP, as IBI's primary technical partner in
managing Bidan Delima, has helped LBI to articulate its funding needs to J&J, and also helped it
understand the opportunities and constraints of working with Bidan Delima. HSP and J&J are now
asking IBI to formally establish a Bidan Delima stakeholder group so that donors can get regular
updates on the program, encouraging transparency and accountability, and also helping IBI access
additional technical support.
Weaknesses
1. While categorized broadly as public-private partnerships, these efforts have been more about
fundraising and garnering outside financial support for activities than actual partnership.
2. The project has not been involved in designing or piloting PPPs that are specifically designed to
address an MNCH issue and involve both public and private stakeholders in design ofthe
intervention.
Issues
1. Indonesia's strong corporate social responsibility laws require corporations doing business in
Indonesia to allocate funds for social causes. This creates an environment conducive to raising funds
from corporate support for MNCH activities. The ability of a project to generate sustainable corporate
support, however, is compromised by legal constraints preventing some US government-supported
projects (which are not separate legal entities in Indonesia) for accepting other money for project
activities. Corporate sponsors want to contribute to efforts and organizations that have a permanent
presence. Conversations with USAID mission staffsuggest that this has been a challenge for many
USAID partners.
2. The term public-private partnership is very broad and can range anywhere from corporations offering
financial or in-kind support to private sector health providers working with government. The PPPs
15 This table does not include over $260,000 of cash and in-kind donations leveraged by HSP for Aceh and Jakarta
flood relief efforts.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 19
most likely to have a significant impact on reducing MMR and IMR are those between private and
public healthcare service providers. The HSP project did not address these partnerships except for the
Bidan Delima program.
Recommendations
1. Before it ends HSP might explore a more strategic PPP public private partnership in at least one
district, such as involving the corporate sector in advocacy efforts. In future districts can explore other
PPPs, such as a voucher program, an insurance scheme, or contracting with private organizations for
services that fall within the purview ofDHOs, such as health care delivery or monitoring.
HSP COMPONENTS THAT IMPROVE HEALTH SYSTEM RESPONSE
Reducing maternal and neonatal mortality requires that quality services be accessible at the community
level for normal births with effective referral linkages to higher levels of care that meet quality standards
in case obstetric or neonatal complications arise during pregnancy, labor, delivery, or postpartum.
Specific TA HSP provides to the MOH includes (a) updating standards in clinical guidelines, tools, and
training modules; (b) strengthening district capacity in MNCH program management and quality
improvement (supportive supervision, quality assurance); and (c) improving the quality of care (provider
training).
Guidelines revised with HSP assistance include:
• DTPS
• Guidelines for the management of MNCH deconcentration funds
• Making Pregnancy Safer strategic implementing guidelines
• Minimum service standards
• Integrated technical manual maternal-perinatal audit at the district level
• IMCI.
The MOH has asked HSP to package these guidelines and those drafted by UNICEF on HMIS, the HSP
advocacy manual/training module, the BCC training module, and the lNKP training modules (see below)
into an integrated district MNCH health implementation toolkit.
HSP supported improvements in the quality of care at community health centers and satellite sites by
emphasizing upgrading the skills of providers in normal delivery and newborn care and strengthening
supervision to monitor and improve on the quality of care and MNCH management. During the first year
ofthe project, HSP also helped improve provider capacity at the district hospital level in a few hospitals.
However, its principal strategy has been to update training curricula and support the ability ofthe national
training program through JNPK to incorporate these training packages into their activities. 16
Improved Provider Capacity in Obstetric/Neonatal Care: Guidelines and Clinical Training
HSP worked collaboratively with the MOH, the University ofIndonesia, professional organizations, and
JNPK, the national clinical training network, to ensure that the guidelines and training modules reflected
current evidence-based practices, including AMSTL, a tighter focus on neonatal care, IMCI, and EIBF.
The clinical tools revised with HSP assistance include those for APN, BEONC, CEONC, and IMCI.
16 For example, for normal delivery care (APN) the training curriculum was updated to include evidence-based
practices in maternal and newborn care, such as AMSTL, management of birth asphyxia, and early initiation of
breastfeeding.
20 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
HSP worked with JNPK master trainers to train JNPK provincial and district level trainers on APN using
the updated guidelines and curriculum. In its districts, HSP also works with JNPK to certify provincial
and district APN trainers by administering a competency assessment when the trainers replicate training
for health center providers. After providers are trained, JNPK trainers visit each ofthem in their
workplace to qualify the provider using a checklist (the same checklist is used for supportive supervision)
and also accredit the health facility. HSP pays the cost of certification and accreditation because districts
were not accustomed to doing this in the past. When a private midwife enrolls in APN training she pays
the cost of her training, which also covers follow-up by the JNPK trainer who qualifies her and accredits
her facility. 17
HSP has followed a similar approach to upgrading provider skills in handling maternal and neonatal
complications. The project worked with MOH and JNPK to update the training curriculum for health￾center-level BEONC and with IDAI and JNPK to improve neonatal care as part of CEONC at provincial
and district hospitals. In addition to following a TOT methodology, HSP support for CEONC also
included on-the-job training (OJT) supervision of263 neonatal unit practitioners in 18 provincial and
district hospitals. This pilot training was incorporated into the standards and methods ofthe JNPK
CEONC training program.
The project does not directly train providers or help districts determine their training needs and resources,
although HSP supported JNPK when it conducted a training needs assessment in its districts early in the
project. Each district through its annual planning process determines who is to be trained. It is not clear
whether districts refer to the JNPK training needs assessment or do their own competency evaluation to
determine which providers need training. HSP staffreport that some districts prioritize who should be
trained based on MNCH indicators within the district; others may use input from the supportive
supervision process to identify trainees.
Strengths
1. Consistency with MOH Policies: HSP worked with the MOH to update the MNCH policies and
guidelines that formed the basis for revising training curricula to ensure that they were standardized.
2. Replicability and Sustainability: The MOH's adoption ofthe guidelines, tools, and training modules
revised by HSP supports their use in districts and their roll-out through the national training system
(led by JNPK for APN, BEONC, and CEONC and the MOH for IMCI). Other donors using tools
developed with HSP support include UNICEF, UNFPA, AusAID, Care International, CRS,
International Organization for Migration, Save the Children, ADB and GTZ. For the CEONC
package, MOH provided additional funds for JNPK to introduce the training in four other provinces.
3. Collaboration with Pediatricians: HSP's guidance on incorporating neonatal care into the APN,
BEONC, and CEONC curricula and its intensive work to revise the IMCI package has had the
additional benefit ofinvolving pediatricians in the development oftraining curricula and in becoming
trainers. Because ofits history as a reproductive health training organization, JNPK has been
dominated by OB/GYNs and midwives. The collaborative process to update the curricula facilitated
by HSP has engaged the Indonesian Pediatric Association and the Association ofOB/GYNs in
working together and sharing ownership ofthe training network. This may also facilitate increased
collaboration among perinatologists/neonatologists and OB/GYNs in clinical practice.
17 This process is very similar to the process used by the Bidan Delima program and uses the same tools, except that
the Bidan Delima self-assessment and validation tool also includes management and marketing components.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 21
Weaknesses
1. While HSP support has improved training programs, it has not worked to reinforce systems to help
districts optimize their investments in training. For example, records are not routinely kept or
analyzed on the coverage oftrained providers within health centers and satellites. Further, while the
standard is to train 100 percent of providers, districts often do not meet the standard or strategically
prioritize who is trained within a facility or acrbSS facilities. The lack ofstrategic prioritization
compromises the investment.
2. Districts have limited or no provision for funding training follow-up and certification activities, and
lNPK stated that it did not have adequate resources to certify all trainees. Follow-up support and
training certification are essential to ensure that the training gets translated into effective practice at
the worksite.
3. Some ofthe training sites visited that lNPK uses were underutilized. The clinics did not provide a
sufficient clinical practicum experience for trainees.
Issues
1. One ofthe challenges HSP faces is determining the effectiveness ofscaling up in-service training
programs. The data suggest that APN training does improve provider competency. JNPK reports that
ofthe 384 providers visited post-training in 2007,99 percent were qualified as meeting basic APN
competencies (HSP Annual Report, 2007). However, there is more that needs to be learned about how
well APN training improves maternal and newborn services at the worksite. For example, since many
work in health centers that do not have routine delivery services or in villages without a birthing
facility, there is little opportunity for midwives, who mostly do home deliveries, to apply their new
skills. So far there has been no assessment ofthe impact of APN training on the quality of care for
home births or births at private midwife clinics.
2. Even among health centers with delivery services, it can be challenging to monitor the quality of
services. For example, some that provide normal obstetric care or have received BEONC training do
not have sufficient numbers of deliveries for trainers to assess competency.
3. The lack of clear criteria for deciding who receives training makes it difficult to assess how prepared
districts are to provide skilled labor and delivery care. It is not clear how midwives with the required
APN competencies are distributed throughout the district. Nor is it known how many midwives have
been trained in APN or whether enough have been reached to have an impact on the quality of
MNCH service delivery at the health center and satellite level in the HSP districts.
4. There is also the question of whether off-site training is the best strategy for improving quality of care
at the facility level. It is worth considering whole facility training that would be geared to improving
supportive systems as well as clinical skills.
5. One major question not addressed by the MOH, lNPK, or HSP is whether there is value in having a
module on normal home-based delivery. Although the lNPK APN training package is designed for a
normal delivery at a midwifery facility, the reality is that most births still occur at home, whether
assisted by midwives or not. 18 To change the current situation requires intensive improvements in
facility-based delivery care and aggressive BCC and advocacy to convince Indonesian women to
deliver in facilities. Meanwhile, it may be worthwhile to improve the quality of care in home births
18 For instance, a baseline study by the MOH project Save Newborn Lives 2 (SNL 2), supported by Save the
Children in the Garut district in West Java found that 56 percent ofthe mothers already said they intended to deliver
their babies with traditional birth attendants when they were pregnant; those who intended to deliver with midwives
were only 37 percent.
22 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
while connecting to a referral strategy that gets home-delivery women and newborns with
complications rapidly to higher levels of care.
Recommendations
1. There is a need to study how much APN and BEONC training contribute to improving the quality of
MNCH. Additional formative research is required to understand if and how midwives are applying
the skills they have leamed in APN to the home birth setting. This research could consist of
accompanying midwives to home births to observe maternal and newborn care practices. A
maternal/perinatal audit process could also make it easier to understand the special needs that might
attend home births.
2. Ways to leverage opportunities for trainees to update their colleagues on what they leamed in training
should be explored. HSP created a good model for this in its DVD on steps for integrating AMTSL
with early initiation of breastfeeding for midwives who deliver unassisted. Providers who attended
the workshop and received the one-day training were able to go back to their worksites and share the
DVD and information with their colleagues. During the site visit, we encountered several midwives
who reported practicing the immediate breastfeeding protocol because they had seen the video, even
though they had not attended training.
3. HSP can also work with JNPK and others to find ways to shorten training or deliver it in different
formats while preserving quality, so that the accessibility ofthe training programs is increased and
costs are lowered. TheJNPK pilot, which includes a self-study module and a five-day clinical
practice program, is an example that has the added advantage of perhaps being more attractive to
private providers, who are less likely to have time available for a long program.
4. HSP can also work with districts and JNPK to ensure adequate posHraining support and certification.
JNPK will either have to raise its charges for training to cover the costs offacility certification and
qualification of providers, or the districts will have to bear the certification costs.
5. For the longer term, improvements in human resource management systems at the district level to
rationalize selection for training and distribution oftrained personnel would increase the impact of
investments in APN, BEONC, and CEONC training. A more systematic approach for assessing
provider competency would also help identify those who need reinforcement through training.
6. Because provider competency in maternal and newborn care is inextricably linked to the quality of
pre-service education, so any later project should stay abreast of developments in improving the
quality of pre-service education and what this might portend for in-service training needs.
Improved Quality of MNCH Services: Supportive Supervision
The skills and performance ofthe 56,000 village midwives deployed by the government since the 1990s
vary greatly. HSP supported improving supervision ofvillage midwives by training health-center-based
midwife coordinators in supportive supervision. The MOH, with help from HSP and JNPK, revised the
supportive supervision tool for MNCH services. The package consists of guidelines for midwife
coordinators, a training package, and supervision checklists. With support from HSP, 406 stafffrom 115
facilities have been trained and are implementing supportive supervision, the phases of which include
checklist orientation, self-assessment, verification and recapitulation, development of a self-improvement
plan, and monthly meetings to monitor corrective actions. The guidelines have two checklists, one for
MNCH services to be used at health centers and satellites generally and the second for centers that offer
delivery services, including BEONC. The four components in each checklist-logistics (drugs and
supplies); nonclinical (facilities and equipment); management (recordkeeping); and clinical procedures￾deal with factors that affect service performance.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 23
HSP created a training program on supportive supervision for midwife coordinators and conducted a
training oftrainers to build a group of25 national trainers and 120 provincial and district trainers,
including a provincial and district JNPK trainer, DHO representatives (district midwife coordinator and
MNCH staff), and one PHO MNCH officer. The 145 trainers train the supervisory teams at community
health centers.
HSP has conducted training in 23 districts at 92 health centers, where the head, the midwife coordinator,
and the nurse or midwife in charge ofthe MCH program are trained in the guidelines, use ofthe checklist,
and supportive supervision skills. The approach emphasizes improvement rather than more traditional
fault-finding. Unlike with APN or BEONC training, HSP pays for all the costs oftraining staff in
supportive supervision. HSP also created a software program to capture and analyze scores from the
supportive supervision checklists.
The supportive supervision process uses the monthly meetings with midwives at the health centers to
address quality improvement. The midwife coordinator is also supposed to visit each village midwife
every quarter. Districts and facilities using the supportive supervision process are able to monitor quality
indicators. Facilities where the program has been implemented report higher compliance with quality
indicators over time, although the data on the performance offacilities participating in the program has
not been aggregated and analyzed.
Strengths
1. Consistency with MOB Policies, Replicability, and Sustainability: As the supportive supervision
guidelines come from the MOH, this aspect ofthe program facilitates sustainability and replicability
at the provincial and district levels. MOH has trained PHO staff in the guidelines not only in the six
HSP provinces but also in 23 others. Other donors, such as UNICEF, are using the trainers to
replicate the approach in other non-HSP districts. Replication is thus happening before the program
has been evaluated. HSP is undertaking a process review ofthe supportive supervision program in
five provinces in September 2008.
2. Sustainability: Based on limited observations and interviews, the supportive supervision approach
seems to have made it easier for midwife coordinators to carry out their supervisory responsibilities
and energized a process that had only existed on paper. Staff now have the skills and tools to assess
quality and take action to improve it.
Weaknesses
1. Because the process focuses on inputs, there is no link to the volume ofservices being provided at a
clinic (which is also a dimension of quality). For example, a clinic could score well on aU quality
indicators but have no patients. At present the supervisory process does not hold providers
accountable for increasing demand for services, yet the health center and satellite structure is
designed to provide community outreach to increase service use.
2. The supervisory process does little to monitor or improve the quality of home births for mother or
newborns that are assisted by village midwives or midwives in health centers without delivery
services, who may attend births in facilities or homes through their private practices.
Key Issues
1. To further ensure sustainability, it is necessary for districts to budget for supportive supervision
training in the future. While HSP bore these costs during the pilot phase, it is expected that the
districts will pick them up as part oftheir annual budgets. HSP staffreport that several districts were
intending to use deconcentration funds to support the activity, but since these funds are not likely to
24 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
be available, it might jeopardize supportive supervision. (This reinforces the link of budgeting
processes and advocacy discussed elsewhere).
2. Providers are being trained on APN, but unless they work in a health center with delivery services,
their skills may neither be applied nor assessed.
3. The supervision process does not extend to private facilities in the community, although the DHO is
responsible for licensing private health facilities in the district once every five years. In general,
private providers are not supervised by the midwife coordinators in each district. (Within HSP
districts there is an exception to this rule at Medan and Surabaya, where the midwife coordinator
invites the private practice midwives to the monthly meeting). The Bidan Delima program described
later is a vehicle for providing supportive supervision and quality improvement for private midwives,
although this HSP assessment did not examine the efficacy ofthe model.
Recommendations
1. The effectiveness ofsupportive supervision in improving quality ofservices and continuous
improvement needs assessment based on evaluation and field realities. Service utilization data could
be introduced into the supervision process to reinforce the idea that health center providers are
responsible for helping increase the number of clients served.
2. Also recommended is a search for approaches to monitor the quality of delivery and newborn services
that take place in the home or a midwife's private clinic. For example, one approach could entail
calling a midwife coordinator when a woman goes into labor so that she could assist, observe the
community midwife and provide OJT support. This same approach might be used for facility births in
private clinics, perhaps in coordination with IBI through the Bidan Delima program. One ofthe
requirements for qualification could be that at least one birth be observed.
Improved Quality of MNCH Services: Bidan Delima
Private midwives are providing a large and growing proportion of maternal and newborn services in
Indonesia. Ensuring the quality ofthose services is important to reducing MMR and IMR. HSP's
principal vehicle for improving the quality of private provider services is through its support to the Bidan
Delima program ofIBI, the Indonesia Midwives Association.
IBI began the Bidan Delima program in 2003 under the STARH program to increase the quality of care
private midwives provide. Since 2004 the program has expanded from 50 to 203 districts in 15 provinces
with 7,462 members and 1,120 volunteer facilitator/supervisors. In some districts as many as one-third of
the midwives have been validated as Bidan Delima. The program is managed through IBrs national
office and provincial and district chapters.
The Bidan Delima program requires midwives to meet certain standards. To qualify, all midwives are
expected to have completed the APN and Contraceptive Technology Update training. They must also
complete a self-assessment evaluation and work with volunteer facilitators to improve their practices so
that they can comply with all standards. The facilitator then validates that the midwife meets all standards
and, upon payment ofthe initiation fee, the midwife receives her certificate and a kit including signage
and permission to use the Bidan Delima logo to promote her services. Once a midwife is certified, the
facilitator is expected to make supportive supervision visits to the midwife every three to six months.
Annual dues for Bidan Delima midwives are Rp 250,000.
HSP support has been aimed at reinforcing the systems and staffing needed to expand the program. HSP
supported revision ofthe program and implementation guidelines for central, provincial, and district
branches and paid for the program launch in three districts in Aceh. It is working with UNICEF to launch
the program in another two districts in Banten and paid for facilitator training and support for IBI
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 25
leadership and oversight. HSP also created a web-based tool for tracking membership and dues payments.
It supports two program coordinators and two administrative staff at IBI offices and a program manager
in the HSP office. HSP also supported an evaluation ofthe program and helped identify and approach
potential corporate sponsors.
Through the STARH program, IBI received financial support for all training and materials and a mass
media marketing campaign. For the past three years it has also received support valued at $470,000 from
Johnson & Johnson, which is likely to continue for another five years. In 2008, J&J supported facilitator
training, printing, and the costs of marketing the program using television spots developed during the
STARH program. Through HSP's contacts, IBI also received some support from Exxon to launch the
program in Aceh.
Strengths
1. Replicability: The rapid scale-up ofBidan Delima and the large number of midwives who want to be
certified demonstrate that the program is replicable. IBI leaders have stated that the goal is to certify
as many midwives as possible. While the program is sometimes referred to as a franchise model, it is
more accurately described as a quality recognition program. 19
2. The program seems to have stimulated peer exchange and support among midwives, which is
particularly positive for midwives who work alone. However, there is little evidence that these
gatherings are used to improve quality of care through review and analysis of cases.
3. The program has positioned the idea of midwives as entrepreneurs who have pride in their services
and live up to a particular standard of care. The drawback is that there is still no effective way to
guarantee the standards and quality of care because certification is a one-time, five-year qualification
(see below for ways to set and maintain higher standards).
Weaknesses
1. The costs of operating the program, even with heavy reliance on volunteer facilitators, are more than
IBI can support. Income generated from member fees is insufficient to cover expenses. A financial
analysis ofthe program, assuming that all annual fees were collected and that adequate staff were in
place to manage the program at all levels, showed that the program would require a subsidy ofRp 5
billion (about $555,000) to meet its annual operating expenses. This does not include provision for
marketing the Bidan Delima brand.
2. The management capacity ofIBI as an association is very limited. While the organization boasts
70,000 members, it has few staff and no executive secretary to manage it. The elected leaders at
central level run its day-to-day affairs ofthe association, and these can change every five years with
new elections. This limits the sustainability ofleadership development and capacity building. IBI
leaders commented that in the past the Mothercare MNH program supported a full-time executive
secretariat which "became the motor ofthe board" and enabled the association to be more effective.
3. Further, the management and financial systems ofthe association are limited and lack transparency.
Corporate or other donors are reluctant to contribute to an organization or program that lacks sound
financial management. Interviews with potential funders and HSP staff engaged in looking for
corporate support suggest that many companies would like to contribute to NGOs but only a few
NGOs have credible financial management. Therefore, private companies have more confidence in
19 Franchises require standardization offacilities, services, and management practices in return for promoting the
brand and increasing market share for franchisees. To be successful, this requires exclusive coverage areas and
substantial investments in brand development. IBI's desire for universal coverage ofBidan Delima rather than
branding a select group of clinics with distinct market areas is antithetical to a franchise approach.
26 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
giving their funds to big agencies like UNICEF or other reliable international NGOs. In general,
recognized professional organizations have more credibility in the eyes ofthe private companies, so a
strengthened IBI could be well positioned to tap into corporate social responsibility and other support.
4. The success ofthe program depends heavily on local leaders and their interest in promoting the
program in their area. Several individuals outside IBI stated that ifthe local chair is not committed to
the program or does not have the leadership and management capacity to organize and mobilize the
district, it is difficult to implement the program successfully.
5. The Bidan Delima program is highly dependent on volunteer support, which becomes more difficult
to sustain as the program expands. The program relies on volunteer facilitators to recruit, validate,
and provide continuing supportive supervision to certified midwives. Even with the goal of one
facilitator per 10 midwives, this can be a significant commitment for the facilitator who must attend
training to be certified as a facilitator and continually visit midwife clinics, especially during the
recruitment and validation process. There are few incentives to become a facilitator. Reliance on
volunteers to operate the program slows it down. Ifthe program is to expand, a new system will be
needed in which paid staff augment facilitators in performing validation and supervisory visits.
6. Midwives perceive limited continuing value added once they are validated as Bidan Delima. Many
midwives perceive value in being Bidan Delima because it encourages them to upgrade their skills
and facilities. They also notice that participation in the program has led to an increase in clients, not
so much because the brand is recognized but because their practices have improved. Nevertheless,
they do not necessarily perceive sufficient value to pay the annual fee, so payment rates are only 18
percent. (Facilitators are exempted from paying the annual fee.)
Issues
1. To be financially sustainable the program will need to derive support from multiple sources, including
income-generating activities, such as fees and payments for services, donors, and corporate and
government support. The program has achieved some success in this regard with support from J&J,
and some district governments have also supported APN or facilitator training for midwives.
The ability to secure more diversified funding requires that the program have the organizational
capacity to obtain and manage such resources and the ability to demonstrate and document the
effectiveness ofthe program as a worthwhile investment for donors, corporations, or government (see
Appendix D for suggestions on how IBI might position the program to appeal to funders).
2. How effective the program is in achieving improvements in maternal and newborn care has not been
quantified. An evaluation ofthe Bidan Delima program looked at just two districts; it is inappropriate
to generalize from such a small sample to the program overall. In that study the program showed
promise in several indicators, such as better infection prevention practices (as measured by
availability of equipment) and improved knowledge and self-reported practice in delivery, neonatal,
and postpartum care. Further, improvements were seen among both Bidan Delima and non-Bidan
Delima midwives practicing in the same area, which may be attributable to peer education and
support. The evaluation also identified possible deficiencies in the validation process that reinforce
the need for an effective quality assurance mechanism for implementation ofthe program at the
district level.
3. To secure the support of governments and corporations, the program will need to prove the model in a
compelling and quantifiable manner. This will require greater investment ofresources in evaluation,
targeted market research, and routine collecting and analyzing ofservice use, outcome, and quality
data from Bidan Delima midwives to show network reach, number of clients served, and the potential
for positive health impacts. The project could look into innovative uses oftechnology to collect and
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 27
analyze data, such as using mobile phone technology and working with vendors of automated data
reporting and recording systems.
4. Ultimately this program could demonstrate how private provider associations can increase the number
of clients served, meet the MNH needs of communities, improve health care delivery, and ensure the
quality of care among their private practice members, so that government might be willing to
outsource service provision to them or delegate related regulatory functions to the association.
5. In addition to its financial, organizational, and managerial challenges, the program will need to evolve
to ensure its continued relevance and value as government systems become stronger. Arguably, if
government oversight functioned effectively, the recognition granted by the Bidan Delima program is
no more than what the government would bestow in its regulatory capacity. Bidan Delima does not
reflect higher standards than those required of all midwives. As the quality of care in facilities
improves, Bidan Delima standards might be revisited to reflect achievement ofmore than the
minimum standards of care. A gradient recognition system could be considered to acknowledge high
performers.
6. Among the many options for increasing the value ofthe program are special educational opportunities
and distance learning programs, marketing, technical updates through newsletters and the website,
access to loan programs, and technology access and training.
Recommendations
I. HSP should continue to support the Bidan Delima program as it has been doing and also move to
build management support. The program would benefit from a dedicated committee comprised of
program staff, board representatives, and donors to guide management and expansion ofthe program.
It might also be advisable to form a technical advisory group with more external stakeholders to build
a constituency for the program.
2. More effort could also be directed to collecting service statistics, outcome data, and quality indicators
from Bidan Delima members that can be used in advocacy and fundraising. It is not enough to know
how many members there are but also how many clients they reach and the outcomes oftheir work.
The web-enabled system that HSP already developed could be expanded to collect and publicize this
information.
3. It is recommended that HSP support a study ofthe actual outcomes ofthe Bidan Delimas; changes in
their caseloads since certification; documenting fees and services provided; and establishing what
market share they have in HSP districts. It would also be useful to understand how many Bidan
Delimas are also public sector midwives and to what extent their additional preparation spills over to
that work.
HSP COMPONENTS THAT ENGAGE AND EMPOWER CIVIL SOCIETY
Increased Stakeholder Involvement in MNCH Services: Musrenbang
In 2008 HSP initiated additional activities in support of district-level planning through the musrenbanlo
process. HSP has been testing in Kediri, Sumedang, and Deli Serdang whether additional inputs to the
20 The musrenbang is a deliberative multi-stakeholder forum that identifies and prioritizes community development
policies. It aims to be a process for negotiating, reconciling, and harmonizing differences between government and
nongovernmental stakeholders and reaching consensus on development priorities and budgets. Synchronized forums
take place at the village, subdistrict, and district levels through a planning process that is both bottom-up and top￾down (LGSP, Musrenbang as a Key Driver In Effective Participatory Budgeting Musrenbang Policy BriefMarch 28
draft).
28 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
process can result in more and more sustained attention to MNCH. HSP attempted to engage both
community health committees (CHC/P4K) and health center staff more effectively in the process.
I Puskesmas
District
Musrenbang
--- ,-------'---, ---------
Sumedang has a special regulation on planning and budgeting,
Perda 1/2007. As the only district in Indonesia to have this type
of law, the Sumedang District government was able to decide
on funding allocations for each subdistrict before the meeting
of musrenbang in the subdistrict. Knowing what funding was
allocated to each subdistrict allowed participants to make
decisions based on actual resource availability. As a result, Rp
1,309,795,650 were mobilized for MNCH activities in the
subdistrict budget as well as in the health center budget from
DHO for the subdistrict. The total was more than double that of
the year before.
With technical assistance from LGSP, HSP trained musrenbang facilitators from the community health
centers and CHC in a one-day workshop. The inputs included (1) support for health center planning in
several subdistricts, with participation of village CHC members in a planning workshop; (2)
encouragement for CHC members and community midwives to be involved in drafting proposals in the
subvillage for submission to their village musrenbang; and (3) health center involvement to actively
advocate and negotiate during musrenbang for inclusion of MNCH support in the subdistrict budget. The
workshops sllpported the idea of passing village level regulations to set MNCH as a priority and to
provide a legal foundation for the CHC.
Strengths
1. Sustainability: passage ofthe budgeting Perda 112007 and the MNCH law in Sumedang had a
significant impact on gaining priority for MNCH in the musrenbang.
2. Replicability: The workshops increased participation by CHC members in the village musrenbang.
They were also successful in producing more non-infrastructure health proposals than in subdistricts
and villages that did not participate.
Weaknesses
1. In Deli Serdang and Kediri, the lack of clear budgetary guidelines at the subdistrict and village level
made it hard to draft realistic plans, requests, and proposals for funding through the musrenbang.
2. The one-day HSP workshops were not successful in sustaining collaboration between health center
staff and the CHCs.
3. Except in Sumedang, bottom-up, non-infrastructure health proposals generated by the musrenbang
did not increase at the district level. It appears that workshop participants were not sufficiently
convinced or empowered to lobby for their proposals going forward.
Issues
Village musrenbang planning processes offer opportunity for health centers and their networks to
mobilize additional funding resource to support MNCH activities at the village level, such as integrated
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 29
service posts and CHC/P4K. The MOH should recommend each district to do the health center planning
before the village musrenbang.
The Sumedang regional planning board and the advocacy team noted that the MOH is in the process of
releasing a regulation about the planning and budgeting process using the Sumedang process as model.
Once it is signed, all districts are obligated to follow it. This is an opportunity for MOH to disseminate
guidance on how DHOs and community health centers should be involved in musrenbang planning.
There is room to increase women's participation in the planning process. In its musrenbang support
activities, HSP missed the opportunity to build on its success with involving community volunteers,
members ofthe PKK national women's group and other women's groups. With few exceptions, women's
voices were lost by the second stage ofthe subdistrict process. PNPM, the national community
development program, has crafted a process whereby women and men first meet separately to draft
proposals and then come together at the village level to negotiate which proposals are adopted. This has
given women a greater voice in community decision-making.
Recommendations
1. This component ofthe project needs more work before it is either replicable or sustainable. It
deserves more attention; HSP might look to other examples of using the musrenbang for sectoral
planning, such as the process employed by the PNPM, which uses conditional cash transfers as
incentives to villages that come up with creative ideas for addressing priority community
development problems. The musrenbang pilots show promise for using this process to leverage
additional funds for MNCH, but there is still so much to be learned that further study and
documentation would be justified. There could be closer coordination with PNPM, which uses
bottom-up planning similar to the musrenbang and has a pilot program to support achievement ofthe
MCHMDGs.
Improved Awareness and Promotion of Positive MNCH Behaviors: BCC and CHCs
BCC
HSP's BCC activities focused on building skills among district stakeholders to undertake BCC activities
directed to individuals, households, providers, and communities. HSP put together 15 BCC district teams
that concentrated principally on media campaigns and events to promote immediate breastfeeding, hand￾washing, and birth preparedness. It trained the teams to undertake formative research to understand local
practices and use the research findings to craft messages for mass media campaigns and materials.
HSP worked on BCC in close association with the MOH Health Promotion Unit, PromKes, in drafting the
training and the TOT curricula. PromKes staff participated as trainers and trained other staffto replicate
the training outside the HSP districts. There are now 34 provincial BCC trainers who are competent to
replicate the training in other districts and provinces. PromKes has proposed a budget for 2009 to
replicate the process in six more districts.
HSP also worked in partnership with other USAID programs (ESP and DAP partners) to promote hand￾washing with soap, with the MCC on immunization and breastfeeding promotion, and with Mercy Corps
and CARE on breastfeeding promotion. The program also participates in the World Bank-sponsored core
group on hand-washing, which has developed protocols for seeking corporate support to promote hand￾washing.
For the hand-washing with soap activity, HSP replicated materials designed by Studio Drya Media (a
nonprofit NGO in Bandung that specializes in community empowerment, adult learning, and participatory
process) for Save the Children's food security and nutrition program, also funded by USAID. The rapid
30 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
survey demonstrated that in 2007 hand-washing with soap at three offive critical times increased from
6.6 percent to 12 percent among caretakers but dropped back to the baseline rate (7.4%) in 2008.
The breastfeeding work is targeted to a variety of audiences and stakeholders. Because the definition of
early initiation of breastfeeding (EIBF) was recently updated and highlights the importance ofimmediate
skin-to-skin contact, all the interventions aim to provide correct information to a specific audience, such
as health providers, policy makers, journalists, or community members.
JNPK gives health providers in-service training updates on EIBF in a one-day training that also covers
neonatal care, oxytocin injection within one minute of delivery, delayed cord clamping, and controlled
cord traction for placenta delivery. The training is reinforced with a clinical training DVD that has been
widely distributed. HSP has also sponsored workshops on EIBF and the international code on marketing
of baby formula to advise on the dangers offormula and the rapacious tactics ofsome formula companies.
In a survey of knowledge and practices carried out in May 2008, three-quarters ofthe midwives surveyed
who attended the workshop could correctly define the EIBF process, compared to only half ofthose who
had not attended. The survey also asked about reported practices during the month preceding the survey,
and 93 percent ofmidwives who had attended the workshop reported helping their patients to initiate
breastfeeding early, compared to 68 percent ofthose who had not attended.
EIBF interventions include community modules on EIBF and exclusive breastfeeding that include games
and other participatory methods. In the most recent rapid survey, August 2008, EIBF rates reported by
households for selected districts increased from the 9.2 percent to 27 percent.
Community Mobilization (CHC/P4K)
HSP is updating the P4K (formerly Desa SiAGa) operational guidelines for birth preparedness and
complication readiness with the MOH Directorate ofMaternal Health. The guidance sets out a process for
engaging communities in drafting birth preparedness plans. HSP district facilitators train village leaders
as community facilitators, who then lead a participatory needs assessment that establishes a CHC with
subcommittees that address village needs. Once a village has formed a CHC/P4K, HSP provides support
to implement modules on birth preparedness and complication readiness, hand-washing with soap, and
early and exclusive breastfeeding.
HSP's support to P4K committees enables them to work with pregnant women on transportation plans,
start emergency funds, and identify blood donors. The CHCs were charged with registering all pregnant
women and helping each woman and her family to develop a birth plan that was summarized on a sticker
on the outside wall of her house. The information includes her name, the place she intends to deliver, the
name of her provider, due date, and blood type. HSP provided seed money to initiate the emergency
funds, but almost all CHCs developed fundraising strategies to increase the amount.
To support effective community mobilization, HSP works primarily within the health system, building the
capacity ofdistrict and health-center-Ievel partners to facilitate community responses to health concerns.
HSP's district facilitators work with their counterparts to identify community leaders, who are then given
training and support. District staff are supervised by the same regional office staffwho manage the BCC
portfolio. In the early stages of community mobilization, tasks and skills addressed with HSP assistance
include community involvement, participatory community health assessment, and planning.
According to project reports, by the end of2007 HSP had supported 364 CHCs that had P4K plans. Of
these, 156 have also implemented hand-washing with soap activities, and 182 will have implemented
EIBF activities by the end ofFY 2008.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 31
Strengths
BCC
1. Replicability and Sustainability: By working closely with the MOHhealth promotion unit and
training its staff, HSP guaranteed that BCC trainers would be available at the unit to replicate the
process in other districts. Similarly, others that were trained were strategically located in partner
organizations that are in a position to replicate the training (e.g., the Bapelkes training institute ofthe
MOH, the OneCom advertising agency, PHO staff, and representatives of professional organizations,
educational institutions, and NGOs). HSP BCC activities had the full support of PromKes and
provincial and district staff, who played key roles at various points so that HSP could focus on
providing TA and resource persons.
2. Consistency with MOH Policies: The component supported and strengthened the policies ofthe
health promotion unit. Although district teams were free to adjust materials and promotional events to
the local context, the unit was comfortable that HSP-supported BCC messages were consistent with
national policy and standard BCC messages. HSP activities in promoting the MOH's national P4K
initiative, also ensured consistency with MOH policies.
3. Collaboration: The various stakeholders involved in the district BCC teams worked well together,
and there is respect for the different roles of private and public sector members. A number oflocal
NGOs participate in district MNCH BCC teams and represent a broad range of civil society: health
providers, women's organizations, religious organizations, and community-based organizations.
Private and public sector members stated that HSP had created favorable working conditions and
helped to build trust among team members and delineate clear responsibilities.
4. Training and Media Approaches: BCC team participants found the training interesting,
entertaining, effective, and efficient, and believe that the content prepared them to run an effective
campaign. Additionally, by involving the private sector (an advertising agency) the teams were able
to make both the message and the delivery attractive. The use oflocal media was also a plus because
they reached the local population more effectively than national campaigns.
5. The live events created healthy competition among district BCC teams. For example, when West
Jakarta organized an event to support immediate breastfeeding by bringing together 1,001 pregnant
woman, Deli Serdang responded by organizing 2,010 pregnant women, and then Surabaya responded
with a rally of2,01
°
couples (pregnant woman and their husbands). Further, the BCC teams were
successful at raising money from private sources for these events.
CHC/P4K
1. The use of games and other participatory techniques helped engage communities in organizing and
reinforcing CHCIP4K committees.
2. The seed funds and games helped to renew community volunteer interest and revitalized the
integrated health posts in some communities. The most active CHCs appeared to be those that had
successfully involved volunteers and PKK members. The CHC/P4K that had active participation of
community volunteers and PKK members also seemed to have more women in leadership positions.
3. The seed funds were also effective in leveraging community resources for funds to support
transportation of women and their families to health facilities when there were complications.
4. In many places, in addition to drafting birth preparedness plans, CHCs established environmental
health committees to work on ofwater and sanitation problems in conjunction with hand-washing
activities.
32 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
Weaknesses
BCC
1. The BCC process requires large numbers ofstaff and resources, which raises questions about its
sustainability without an outside funding source. This might be partially compensated by generating
private funding. PromKes staff voiced concerns about their limited numbers of central and regional
staff and capacity to continue BCC activities without HSP support. Similarly, the DHO has limited
resources, so continuation will depend on the capacity of local BCC teams to raise money from
private sources.
2. The BCC training takes a relatively long time (10 days), which limits who can participate and also
has cost implications for replicability and sustainability.
3. Often suggestions and the results of pretesting media were not taken into consideration in the final
production ofmaterials by the advertising agency. Although the suggestions indicate creativity and
skills retained by district staff and were justified in terms of decentralized management, there were
indications that the BCC teams did not understand the agency's production processes and constraints.
4. At times there were problems in coordinating BCC activities between HSP, local BCC teams, and
PromKes due to staffturnover and the exigencies oftheir respective commitments.
5. The BCC process did not have an institutionalized way to test the impact of campaigns and messages.
Nor was it possible to examine whether the efforts served to upgrade practices.
6. There was not always a good sequencing ofBCC with other interventions. For instance, in some
districts BCe activities preceded DTPS and advocacy activities, so there was no opportunity for
synergy among them.
CHC/P4K
1. HSP worked in too few communities in each district to measure the district-wide impact of
CHCIP4K.
2. The evaluation team had concerns about the effectiveness of what appeared to be a cookie-cutter
approach to CH/P4K, which insisted on a fairly uniform organization despite different sociocultural
contexts. MOH policies on allow for communities tbchoose their own organizational mechanisms
according to what is most compatible with local practice.
3. The CHCIP4K process had no follow-up on registering birth outcomes for mothers and newborns.
This was a missed opportunity for building in more accountability for outcomes.
Issues
1. There are concerns about the sustainability ofthe BCC training due to limited budgets at district and
municipal levels. The high cost oftraining will permit PromKes to scale up only modestly. Its
sustainability depends on how district governments perceive its importance and effectiveness and on
the interest of corporate sponsors.
2. The high-profile activities ofBCC posters, radio messages, and public events are unlikely to
transform practices alone. There is a need to follow through on large-scale public events and mass
media with community mobilization activities and with healthcare providers.
3. Discussions with WRI and Fatayat NU indicated that more could be done to address gender
inequalities. These relate both to practices that affect pregnant women and to midwives who are
mostly women and face gender challenges that men may not. Specific issues are sensitizing the
community to (a) the importance oflocating community birthing facilities in safe and accessible sites
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 33
to ensure the safety of midwives and their clients21
; (b) the risks of early marriage and pregnancy; (c)
the need for birth preparedness plans to also focus on alleviating gender-based constraints beyond
transportation, such as childcare and expectations that women immediately resume their domestic
duties after birth22
; (d) the need to cover the transportation costs of community midwives so that they
can reach their clients, especially in remote areas; and (e) the ban against allowing married midwives
to live at the village birthing facility.
Recommendations
1. There should be a closer link between BCC and the DTPS process so that the DHO and the advocacy
team better understand the value ofBCC for supporting health practices in the district. As BCC may
take place separately from planning for other service delivery, it may not always be on the planners'
radar screen.
2. Community mobilization activities seem to be quite dependent on the HSP district and community
facilitators, and it remains to be seen ifthe activities can be sustained without outside facilitation.
Health center staff were not integrated into the community mobilization, so it is not clear who is
prepared to step in to support CHCIP4K committees after the project. HSP should consider working
with district-level PromKes on a process to fully engaging health center staff and community
volunteers on health promotion.
3. HSP should concentrate on increasing BCC and CHC team capacity to raise funds from private
donors and corporate sponsors. It is important that both governmental and nongovernmental members
ofthe teams acquire skills in fundraising and advocacy.
4. There should be additional emphasis on community-level information, education, and communication
linked to the wider BCC campaigns. There are opportunities to broaden the content ofCHCIP4K
training to include more on newborn care, data collection and analysis, EIBF, and exclusive
breastfeeding, and give clearer guidance on where go in case of emergency. It would also be useful to
have community midwives collect information on birth outcomes for every woman registered by the
CHC.
5. There should be more emphasis on hand-washing by healthcare providers, as well as targeted
messages for healthcare providers on EIBF through job aids, DVDs, and other accessible media.
6. As with the advocacy component, it is recommended that HSP and the MOH Center ofHealth
Promotion train trainers from professional organizations and university-based schools of public health
in BCC methodology to ensure an additional home for BCC training.
7. Any future BCC programs should include baseline and impact surveys on changes in knowledge,
attitudes, and practices linked to mass media campaigns.
21 The WRI study ofseven provinces noted that communities often locate community birthing facilities in isolated or
unsafe places, such as the remote margins ofrural communities or near cemeteries, which are perceived to be
spiritually dangerous.
22 This was one ofthe reasons given for women preferring to give birth at home rather than at a health facility. It is
also one ofthe reasons given in some areas for preferring traditional birth attendants, who also help with cooking
and childcare in the postpartum period.
34 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
SUMMARY OF STRENGTHS AND WEAKNESSES OF HSP TO DATE
In large measure the project has produced results that are replicable, sustainable, and consistent with GO!
policies, and has implemented its activities through collaborative relationships with GO! and civil society
partnerships. HSP has many strengths:
1. As a USAID partner organization, HSP met or exceeded all ofits targets. It produced high-quality
reports and strong communications materials on project progress and achievements. HSP also
responded to USAID requests with skill and alacrity (e.g., tsunami, national call to action for health)
even when they were outside the original scope ofwork.
2. HSP's principal strategy for ensuring that its technical inputs will be replicated and sustained is its
collaboration with the MOH in updating guidelines and tools to reflect current evidence-based best
practices. Although this strategy was not contemplated in the original design, which emphasized
scale-up and replication, HSP seized upon the MOH's desire to update policies at first glance
appeared to be a constraint to scale-up, and turned it into an opportunity to strengthen the
environment for reducing maternal and neonatal mortality. In addition, many ofHSP's district and
village-level interventions, such as P4K and DTPS, helped to improve and facilitate implementation
ofMOH strategies.
3. HSP worked very hard at the district level to ensure that most interventions had a sustainable home
with a GOI, NGO, or professional organization and had prospects for financial support beyond the
end ofthe project. HSP supported NGOs, district advocacy and BCC teams, and professional
organizations to mobilize corporate support to the extent possible within the constraints of being a
USAID project. HSP worked with MOH and other national organizations (e.g., JNPK) to update
national evidence-based training modules (MPS, APN, BEONC, CEONC, and IMCI). It has also
collaborated with other donors in efforts to identify partners, such as JNPK, IBI, UNICEF, CARE,
and AusAID, that can replicate its activities in districts other than those where HSP works.
4. Similarly, HSP adapted successful strategies developed by USAID and NGO partners for use in
improving MNCH in HSP districts. Among these were the approaches developed by LGSP for
drafting local laws and getting them passed, and BCC events proposed by NGO partners, such as the
1,001 mothers and the 2,010 couples EIBF rallies.
5. The project has a good track record oflearning from first-round application ofits tools to refine
sequencing, quality, and integration of district, subdistrict, and village interventions (DTPS, TOT,
fundraising, BCC, and advocacy). Throughout, it has done a good job ofsharing information with
other donors and USAID projects, supporting MCC, collaborating with LGSP, and facilitating a
smooth transition ofthe Bidan Delima program from the STARH Project.
The evaluation also perceived some weaknesses:
1. From the beginning, HSP has faced the challenge of a trade-off between pressures to scale up and
replicate across a large number of districts and giving attention to adapting strategies to the local
context, which in some circumstances may have inhibited more sustainable community creativity and
decision-making.
2. There was too much emphasis on replication through a TOT approach, without adequate assessment
ofwhether this leads to capable implementation (clinical, DTPS, and BCC). Except for its assistance
to the MOH on national guidelines, the project has used TOT as the replication strategy, rather than
exploring others, such as district-to-district TA, peer-to-peer coaching, and whole-site training. There
are indications that without a much longer time frame for repetitive training and continued TA, this
strategy is not sustainable in most districts once the project ends.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 35
3. HSP incentives and supports may be intrinsic to the replicability and sustainability of activities (e.g.,
seed money for CHC and advocacy; facilitation and TA on advocacy, BCC, and DTPS activities; and
support for materials). It is not clear ifreplication in new areas is possible without similar incentives.
36 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
III. HSP AS A FOUNDATION FOR REDUCING MATERNAL AND
NEONATAL MORTALITY IN INDONESIA
STOCKTAKING
As HSP moves into its last year of operation, there appears to be consensus among USAID, HSP, and the
MOH that the primary focus of USAID support in the future should be to build on HSP's
accomplishments by helping districts to address more directly and systematically the causes ofmaternal
and neonatal mortality in the context ofdecentralization. The evaluators posed two questions in order to
provide guidance to USAID on how to build HSP's accomplishments into integrated approaches to
reducing MMR and NMR at the district level:
1. To what extent were HSP activities effective in changing the practices of healthcare providers, policy
makers, women, and their families to contribute to greater maternal and neonatal survival?
2. Are HSP's activities, in the aggregate, the right combination and types ofinterventions necessary to
reduce maternal and neonatal mortality and morbidity in Indonesia? If not, why not, and what else is
necessary?
Even though HSP has met or exceeded its targets on all project indicators, the evaluators had difficulty
responding to the first question conclusively because the project did not have the opportunity to conduct
formative and operations research to ascertain the extent to which health practices were more closely
linked to better outcomes. HSP conducted a baseline survey and a midterm rapid assessment that showed
mixed results. The findings from an impact survey scheduled for the end ofthe year may be more
definitive. Nevertheless, it is difficult to link HSP interventions directly to positive changes in practices
because the reach ofthe interventions is diffuse (e.g., only a relatively small number ofvillages) and the
scope of activities does not include key components (e.g., hospital-based activity) required to lower MMR
andIMR.
To address the second question, the extent to which HSP activities provide a foundation for future USAID
MNCH programming, the evaluators examined HSP against a results framework that postulates critical
interventions for reducing maternal and neonatal mortality based on current international consensus on
what is necessary and effective (evidence-based) as shown in Figure 3.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 37
Figure 3. HSP Goal and Objectives
HSP Goal and Objectives
-{H(/NK
-8((
-Advocacy
-Villa,g~
MlIsr~nb..mg
-DTPS
-PIIsl<~sm as
Planning
-SlIb-villag~
MlIsr~nbang
-Training
(APN,PONED.
PONEK.IMCI)
-SlIpportiw
Sll p~rvision
-Bidan D~lillla
-Adv<)cac-y
for f'~rda
--R~vi~d
MOH
6uidE'linE's
SPM!Mf'S
-DTPS
-Advocacy
-MlisrE'nbang
-DE'kon
guidE'linE's
-1'1'1'
The results framework demonstrates how HSP's accomplishments fit within a comprehensive and
integrated structure and provides a strong foundation for future programming. It elucidates how HSP's
primary interventions contribute to establishing the conditions necessary to reduce MMR and NMR,
1. Strengthening the enabling environment: encompasses the policies and governance structures
necessary to ensure universal access to skilled antenatal, delivery, postpartum, and essential newborn
care and to basic and comprehensive EONC in the case of complications.
The project effectively improved policies and governance related to MNCH. Through its work with the
MOH, HSP revised national guidelines and tools (e.g., MPS, SPM, DTPS) in line with current evidence￾based practice in a readily accessible form. It also contributed to strengthening governance through
support to advocacy and DTPS committees, which were able to improve their planning and budgeting.
This also reinforced the legal foundation for ensuring funding for MNCH through the drafting and
passage of local regulations.
2. Improving the capacity ofthe health system to effectively respond to the primary causes of maternal
and neonatal mortality by improving the quality, availability, acceptability, affordability, and
timeliness of MNH services. This applies to both basic and comprehensive emergency obstetric and
neonatal care in public and private sectors, supported by effective health management systems and
evidence-based protocols.
HSP improved training modules to reflect current standards of practice, such as AMSTL, neonatal
resuscitation, IMCI, and EIBF. The project updated BEONC and CEONC training modules and
procedures for certifYing facilities in BEONC or CEONC care. The supportive supervision module
provides health center midwives with a tool for supervising village midwives. HSP support to FBI's Bidan
38 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
Delima program provided a similar supervision tool for private midwives. Its recent support for improved
health center planning also helps improve service delivery in subdistricts and below. HSP also introduced
diversified learning opportunities for healthcare providers, such as the EIBF DVD and the KMC study
tour for NICU perinatologists, both of which appear to have had major impact in changing practices of
healthcare providers.
3. Empowering civil society to be full and active participants in improving maternal and neonatal
outcomes through increased involvement ofCSOs in planning, management, and oversight of public
and private healthcare, advocating for the rights of pregnant women and children, and monitoring
maternal and neonatal outcomes.
HSP training of diverse civil society stakeholders, including NGOs, parliamentarians, and professional
organizations, has provided citizens with the tools to advocate for policies, strategies, and funds for
MNH. It is expected that, empowered with the advocacy toolkit, these same stakeholders will also assume
a role in monitoring implementation ofthe laws, plans, and budgets they have fought for. HSP also
helped the MOH to improve social mobilization processes so that communities can draft develop
operational and funded birth-preparedness plans (P4K). The project's investment and training in BCC
also empowered multisectoral BCC teams to create district BCC campaigns and raise funds from private
donors in support ofthem. The remaining challenge is to measure the impact ofthese campaigns on
changes in the knowledge, attitudes, and practices of district residents and healthcare providers.
While HSP made substantial contributions to the objectives required to reduce MMR and IMR, what is
missing is full integration ofthese interventions with other necessary activities at a district level. These
include attention to improving the quality of care at BEONC and CEONC facilities by focusing on
information, referral, and supervision and accountability systems that are critical to identifYing the causes
of MMR and NMR, decreasing delays in reaching care, and improving the quality of care.
Another element that deserves attention is the role of private providers within the district health system
and how they can effectively help increase access to quality care. HSP also did not focus directly on
reducing financial barriers to care, except for providing seed money for village emergency transport funds
and encouraging CHCs to connect eligible women to askeskin/jamkesmas insurance. They did not
consider costs not covered by askeskinljamkesmas, such as for certain drugs and supplies that may not be
available in understocked health facilities. 23 It would be useful to at least understand the extent to which
cost is a barrier in HSP districts and how well national and municipal insurance schemes help reduce
those barriers. To fully empower civil society, it is necessary to actively engage them in collecting and
using information to monitor the capacity and responsiveness ofthe health system to reduce the major
causes ofmaternal and neonatal deaths and disabilities.
The recommendations proposed below suggest ways the HSP can move closer to a more integrated and
effective district model in the final year ofthe project and any extension period.
RECOMMENDATIONS FOR THE EXTENSION PERIOD
It is recommended that USAID extend HSP for an additional 12 months. The reasoning for this is based
on the following considerations:
• Many technical aspects of project start-up were delayed by a year because ofthe need to focus on the
emergency in Aceh caused by the tsunami and HSP's involvement in the Health Summit. As a result,
many activities have not been implemented long enough to fully understand their effectiveness or the
susceptibility to replication.
23 These issues are well documented in the study soon to be published study by WRI on access to maternal and
neonatal care in seven provinces.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 39
----------------------------------
• There were many changes in Cognizant Technical Officer leadership, resulting in different
interpretations ofthe core objectives ofHSP that affected selection and continuity of activities.
• The project spent considerable time updating guidelines with the MOH. These have now been applied
in most districts at least once but would benefit from additional application and assessment.
• The MOH has asked HSP to consolidate the package of interventions so that it is more integrated.
The MOH indicated that the many guidelines and modules have not been sufficiently integrated or
sequenced. An integrated package that includes not only HSP interventions but also UNICEF work on
computerized data collection systems at health centers and JICA's 'pink book' on MNCH could
become the MOH-recommended package for districts.
• The MOH is interested in moving forward with district-wide implementation with TA to different
districts by different organizations under the rubric of a common integrated package and a common
sentinel M&E framework. HSP could prepare the groundwork for such an effort by:
Going to scale in two HSP districts that have a firm foundation oflocallaws, district planning
(DTPS), advocacy groups, significant numbers of providers trained, health center planning and
musrenbang, and functioning CHCs.
Develop a district-wide M&E framework and recommendations for supporting information
systems, and establish safe motherhood (MPS) committees at different levels, with a link to
district planning to include maternal and perinatal audits at all facilities and in communities in
one demonstration district.
• A project extension would enable the project to work more closely with the MOH Directorate of
Hospital Services to review the availability and quality of data being collected on maternal and
neonatal deaths and near misses at hospitals, as well as the systems for reviewing and improving
procedures that contribute to deaths and near misses. This will serve as a foundation for new USAID
activities that incorporate attention to CEONC and referral and supervision/accountability systems.
• The extension would also enable the project to implement the recommendations set forth in the earlier
section for its various activities. Examples include:
Developing a process for monitoring DTPS and advocacy results, implementation of budgets,
plans, and MNCH regulations, and preparing guidelines for other districts on how to advocate for
effective implementation ofregulations once passed.
The CHCIP4K model could give more attention to tracking the outcome of mothers and newborns
and extending the model to include the newborn.
The website and data collection system ofBidan Delima could include midwife profiles, service
statistics, and outcomes, and a management committee for the program could be established.
• The extension would enable the project to further observe and document the replication process and
compare project subdistricts with replication subdistricts. This would make it clearer whether the
tools and guidelines can be implemented without the additional support the project offered its
intervention subdistricts (e.g., district coordinator, seed money, facilitation skills). Activities to assess
could start with DTPS, CHCIP4K, and supportive supervision.
• USAID's interest in the sustainability and replicability ofHSP interventions also argues for targeted
research and evaluation during the extension period to determine how much HSP interventions
contributed to achieving desired maternal and neonatal outcomes, which combination of interventions
might be considered best practices, and which combination is appropriate for districts with different
socioeconomic characteristics.
40 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
• Conduct evaluations of application oftools and research to understand how practices have changed as
a result of project interventions:
Compare P4K in HSP and non-HSP districts (outcomes and process).
Analyze implementation ofCEONC in hospitals trained in 2006: Have improvements been
sustained? Was the initiative taken up by other hospitals?
Analyze how district health budgets that resulted from 2007 DTPS were actually expended in
2008.
• Prepare case studies ofreputed best practices in non-HSP district-wide approaches (e.g., Subang, East
Lombok) for input into the design offuture activities. These districts merit examination because they
have introduced innovative payment schemes, taken a different approach to the passage oflocal
health laws than HSP districts, or introduced alternative health delivery systems.
• Assess representative districts where HSP has a presence to analyze what is needed to address MMR
and NMR from a comprehensive and integrated health systems perspective that takes in both public
and private health providers. This would entail identifying strengths and weaknesses and any critical
elements that may be missing to ensure high-quality integrated MNH services. The assessment could
include preparing briefing information on how to build up components that are critical for reducing
MMR and NMR (e.g., audit process, supervision, referral systems, hospitals, home births, access to
demand side financing, information systems) and how an integrated system might vary from one
district to another.
• In preparation for a future project to strengthen IBI and the Bidan Delima program, HSP can help IBI
conduct a needs assessment among members to gain an understanding of how the organization could
better meet members needs, members' views on IBI's strengths and weaknesses and
recommendations for the association, and their willingness to pay to be part of a more effective
organization. Analyze (a) how much has been invested in IBI over the years (documentation ofthe
LOE by MotherCare, STARH, and HSP) and the impact ofthis investment on the association and
lessons learned; and (b) IBI's current organizational capacity and an estimate ofthe time and cost that
would be required for IBI to become a more effective professional organization capable of running
the Bidan Delima program, representing the professional interests ofits members, and contributing to
quality maternal and neonatal healthcare in Indonesia.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 41
42 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
IV. RECOMMENDATIONS FOR NEW USAID PROGRAMMING
HSP has built a finn foundation for new USAID programming to reduce maternal and neonatal mortality.
Four challenges HSP has faced should be addressed in new programming:
1. The project has been spread too widely, both geographically and technically. Consequently, its health
impact is hard to detennine.
2. The project was discouraged from introducing interventions that are critical to reducing maternal and
neonatal mortality (e.g. information systems and audits, and emergency obstetric and neonatal care
among public and private providers). Without giving these two critical interventions priority it is
impossible to reduce maternal and neonatal mortality.
3. Although HSP supported many activities to engage and empower civil society, the project, as
highlighted earlier in the key issues sections earlier, missed opportunities to more fully address
gender and other sociocultural and economic constraints, in both communities and health facilities,
that impede women from activating their rights to life-saving care.
4. Finally, HSP did not sufficiently address the private health sector, which provides 30 percent of
outpatient healthcare, or the issue of dual public/private practice. Despite the large and growing
percentage of births taking place with private providers and in private facilities, these are not
integrated into national or local efforts to reduce maternal and newborn deaths. It will be difficult to
reach MDG targets without involving this sector in health service planning and delivery.
With these challenges in mind, the evaluation recommends that the USAID mission invest in two
programs: (1) an integrated district-wide approach and (2) development of a national network ofBidan
Delima and building up IEI to support this network. In support ofthese two programs, it is recommended
that the follow-on programs:
1. Give priority to reducing maternal and neonatal mortality: With the limited resources available,
the best option is to focus on maternal and neonatal mortality so that Indonesia can most effectively
reach its MDG 4 and 5 goals. MMR has been the most challenging. While there are some indications
of progress in unofficial results from the most recent DHS, Indonesia will have difficulty reaching its
MDG of 125/100,000 by 20 IS-it would have to cut its current rate in half. While there is progress
on child mortality rates generally, that does not apply to neonatal mortality. Two-thirds ofthe under-5
deaths occur during the first year of life; about two-thirds of infant deaths took place during the
neonatal period, the first month; and about two-thirds of neonatal deaths happened in the perinatal
period-the first week of life). Focusing on neonatal deaths, which are 90 percent preventable, would
make a large contribution to reducing overall child mortality. Other child survival activities, such as
IMCI (except as it relates to neonatal survival), nutrition (except for immediate and exclusive
breastfeeding), and water and sanitation (except as they relates to clinical and provider-focused
infection prevention) should not be part of new MNCH activities.
2. Narrow the geographic spread to implement integrated approaches in a few (three to seven)
districts based on a continuum of care or critical pathways model adapted to the local context
(see Results Framework 1 below): The National Strategic Plan for Making Pregnancy Safer (MPS)
provides the framework for district-wide approaches based on a baseline needs assessment that
implement interventions strategically throughout the district and cover all subdistricts. It is not
possible to reduce MMR and NMR without understanding why women and newborns are dying and
addressing weaknesses in the health system that contribute to their deaths, both of which require
considerable political will. During the evaluation, MOH staff expressed their commitment to testing
different district models for reducing MMR and NMR. HSP districts demonstrate that effective
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 43
advocacy can achieve significant political commitment at the local level. There is an opportunity for
USAID to team with the MOH, PHO, DHO, local governments, Bappeda, other donors, and CSOs as
learning partners for designing and assessing comprehensive district-focused models for reducing
MMRandNMR.
3. Engage the MOB and other GOI organizations, donors, and NGOs as learning partners: A
comprehensive integrated approach will allow USAID to collaborate with the MOH and other donors
to examine the effectiveness of different models. It is not necessary for USAID to be responsible for
strengthening all dimensions ofthe health system in each district where the new program works. An
initial needs assessment should identify strengths and weaknesses ofthe local health system, what
other organizations and programs are active in the district, and what unique sociocultural and
geographic challenges need to be addressed.24 Involvement ofthe PHO and relevant MOH
directorates will directly engage the MOH in improving district performance and translating
knowledge (guidelines and training) into practice in other provinces and districts. Multiple MOH
directorates should be engaged in reviewing needs assessments, participating in design ofdistrict
models, and routinely reviewing research and outcomes. The project could support periodic site visits
by MOH representatives to ensure their engagement.
4. See criteria for selecting districts: The districts selected for USAID programming should be
representative ofthe diversity of circumstances found in Indonesia so that the approaches and tools
developed will be appropriate for replication in similar contexts if proven effective. Some possible
criteria for selecting districts are:
• Political support ofthe Bupati, district parliament, DHO, and PHO (determined by previous HSP
experience, existence of an MNCH law or general health law, and allocation of budget for MNH)
• Low to mid-level performance on MPS service indicators
• Coverage by other donors, to ascertain need for technical support
• Potential for links with other projects of USAID or other donors
• Priority areas for the BAPPENAS, MenkoKesra, and MOH
• Poverty of population, as measured by income and access to services
• Potential for partnering with CSOs, especially NGOs, gender advocacy and rights groups, private
health providers, professional organizations, active community organizations, and corporations.
5. Give priority to building up information systems in communities, integrated service posts, primary
health centers, and hospitals. At the community and integrated service post levels, engage local health
committees and others to extend registration of pregnant women to the collection and analysis of
information on maternal and neonatal outcomes. At hospitals and health centers, activate and
strengthen MOH-mandated maternal and perinatal audit systems that are not yet fully operational or
effective. The audit systems should also cover private providers and maternal and neonatal healthcare
facilities so they can be held equally accountable for outcomes. The new program should also develop
a district-wide surveillance and response system with oversight from safe motherhood committees
established at different levels ofthe district health system, with ultimate accountability residing with
the DHO, PHO, and civil society monitoring groups.
24 The project needs to conduct research to shape an MNCH health system needs assessment to detennine the health
system interventions that would have the most impact in achieving district MMR and IMR reduction objectives.
Project activities should be designed from the beginning with a focus on understanding the effectiveness, efficiency,
and efficacy ofthe approaches. This will entail taking an operations research approach to testing models. It might be
advisable to also propose up to four control districts to enable comparisons on key indicators.
44 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
6. Give priority to actions that increase access to and availability of quality 24/7 BEONC and
CEONC. Currently, 59 percent of births in Indonesia take place at home, of which approximately
half are assisted by skilled providers, who mayor may not be linked to higher levels of care. This
situation decreases the chance ofa woman and her baby receiving timely and adequate care ifthere is
a serious complication. Therefore, a priority focus ofthe new program must be on helping district
health officials to identify and remedy weaknesses in the referral and supervision systems. It is also
necessary to ensure availability of quality 24-hour BEONC and CEONC seven days a week. 25 In
some districts, there is also the need to upgrade facilities, improve the capacity of healthcare
providers, and rationalize the distribution of human resources. While these are not likely to be direct
activities ofthe new project, it is important that district planning and information systems address
these problems in a way that ensures availability of quality care.
7. Increase attention to gender-based, sociocultural, and economic constraints to accessing quality life￾saving MNH care through a rights-based approach to reducing MMR and NMR. A rights-based
approach empowers communities to ensure that every woman and newborn has access to skilled
delivery care and to EONC when complications arise. Such an approach also empowers communities
to constructively challenge gender norms, power structures, and relationships that limit women's
capacity to make informed decisions and exercise agency with regard to seeking prenatal, delivery,
and postpartum care. It also ensures that the community has a role in monitoring health services. The
new program has an opportunity to build the P4KJCHC work into a process that goes beyond birth
preparedness to monitor the degree to which women's rights to quality life-saving care are respected
and realized. This can be accomplished by involving women's advocacy and rights groups in district,
subdistrict, and village advocacy and social mobilization activities. The project can explore other
methodologies, such as those used by PNPM, that increase women's participation in local planning
and decision-making, and use targeted incentives through conditional cash transfers for communities
to address inequalities that hinder the access of women and newborns to care?6
8. Ensure that the private health sector is integrated into district models for reducing MMR and
NMR: Private providers are a major source ofmaternal and newborn care in Indonesia. Since many
public sector providers also work in the private sector, distinctions between the sectors are blurred. 27
Private hospitals and clinics are common in urban and periurban areas but can even be found in more
rural areas, and many ofthe midwives employed by the public sector in health centers or as
25 A new project might also test more innovative approaches to building and retaining skills by rotating providers
through various care settings. For example, the evaluation team visited one BEONC health center that was able to
achieve its 24/7 coverage requirements by having the village midwives rotate for a 12-hour shift through the facility
on a weekly basis. This gave the village midwife more opportunity to assist with facility births and interact with
peers and the OB/GYN in the clinic. Yet while these midwives seemed comfortable handling normal deliveries, they
were still reluctant to deal with complications despite having been through the BEONC training. A system that
would enable health center midwives to also rotate through the district hospital to gain more hands-on experience
with complicated deliveries and newborn care might enhance their confidence in handling these cases. Likewise,
district hospital-based midwives or doctors could rotate through the BEONC facilities to provide OJT support. An
integrated approach to addressing MNCH at the district level would facilitate such innovations that the current
project has not been able to address given its focus on community care and its spread over so many districts.
26 Current activities to mobilize the community about birth preparedness did not do much about also changing social
norms. For example, interviews in at least one village suggested that some women prefer home births because they
can be there to care for their other children and the husband and family can more easily participate in the birth
experience. Using this type of information the Desa SiAGa program could be a vehicle for helping families plan for
child care so that the woman can deliver in a facility or educate local providers about how to make families more
welcome in their facilities. Introducing financial incentives to encourage facility births would also help.
27 For example, 44 percent oflive births at home were attended by a skilled birth attendant, who may have been a
government employee or operating in a private capacity.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 45
community midwives also have private practices. It is recommended that the new program pilot a
variety of public-private partnerships to improve the quality and accessibility ofMNH services?8 To
more fully engage private providers in improving MNH health outcomes, more information will be
needed to assess whether the regulatory and reporting processes are adequate and how to improve
implementation at the national and district levels. A new project could provide TA at the central and
district levels to strengthen systems for supervision and licensing of private providers. Also, any
demand-side financing initiatives could include the private sector, using this financial incentive as a
way to enforce quality standards and offer choice and access to communities.
9. Build the Capacity of IBI as a Professional Organization: It is recommended that USAID develop
a separate but linked activity to strengthen the Bidan Delima program and IBI's capacity to
implement it (see Results Framework 2 below). Midwives are a major provider ofMNH services
especially in the community and in private practice. IBI is an association of over 70,000 public and
private midwives-a potential force for improving maternal and newborn survival. It is recommended
that IBI receive support to professionalize the association and build its ability to advocate for MNH
services and better help its members to deliver quality care.
10. Invest in Bidan Delima in Indonesia (IBI): IBI's Bidan Delima program has potential to strengthen
private provision of maternal and child health services, promote facility-based births and improve the
quality of care offered by private midwives. The association has demonstrated a commitment to the
program and has invested significant volunteer time in scaling it up. The program has attracted
sustained corporate sponsorship (from J&J) with the promise offinancial sustainability. It is
recommended that USAID invest in building Bidan Delima into a network that provides a uniformly
high standard of care with measurable outcomes at affordable prices.
11. Support learning from experiences on reducing MMR and NMR across Indonesia: Knowledge
management needs to be built into the future project because it will be important to widely
disseminate lessons learned and best practices that emerge from working comprehensively at the
district level. Knowledge management will be pivotal in enabling the achievements of a few districts
to benefit many more districts that can adapt program successes to their own contexts.
The two results frameworks below provide graphic pictures of a comprehensive district-level approach to
reducing maternal and neonatal mortality and a program for strengthening IBI and the Bidan Delima
program. Appendix C depicts the activities recommended by intermediate result for the proposed AIMS
Program; Appendix D presents illustrative activities for the IBI Program.
28 The new project could explore the feasibility of developing meaningful PPPs to reduce MMR and NMR that can
focus on the district level. Opportunities might include piloting an outsourced management approach for operating
health centers in which the district would contract with a management organization to run health center operations
and tie the management contract to specific performance expectations (This model has been successful in Cambodia
and elsewhere.). Another opportunity would be to organize and credential a network of private providers (which
could include Bidan Delima midwife clinics, private maternity homes, and private hospitals) that could serve as the
provider network for government and private insurance programs. A voucher program for pregnant women to seek
facility births is another option, with the voucher tied to meeting certain performance standards on behalfofthe
public and private providers offering the services.
46 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
Figure 4: Goals and Objectives: Results Framework
ccelerating Infant and Maternal Survival
IndinJfQr5: -MMR
-IMR& NMR
To reduce maternal and
neonatal mortality
Supportive Enablin
Environment
- - --. - ~.-
MNHFunds
ncreased&
~ff..r"v..lv
a1louted
Types ()J indico rO,.~: . -EqUJty
-lJ r;/i7Grinl1
Coverage
-SuswinobfUl y
Improved
polia.s &
regulations
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 47
Figure 5: Investing in IBI
-Number ofdeliveries by
midwives (1((ording to s(olldar(1S
-Number ofnewboms receiving
ENe
Professions
interests
rep' esented
Membership
onlled
Biclln Delilia Funding
increased and
diversified
Management
systems
strengthened
Professional
manafement
oflBl
established
48 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
APPENDIX A: SCOPE OF WORK
HEALTH SERVICES PROGRAM EVALUATION & FOLLOW-ON ACTIVITY PLANNING
Scheduled: ola August 18-September 11,2008
Final: 06·25·08
SUMMARY
USAIDlIndonesia wishes to conduct a forward-focused evaluation ofthe Health Services Program within
the context ofthe Mission's MCH (CSH-funded) portfolio. The two primary objectives ofthe evaluation
are
Obj 1: Achieve a thorough understanding ofthe outcomes/results ofHSP interventions and the
effectiveness ofHSP strategies for achieving results in the key focus areas listed below. Effectiveness
may be defined by the extent to which accomplishments are (1) replicable; (2) likely to be sustained by
GO! and/or local partners; (3) viewed by GO! (national and subnational) as consistent with policy and
programs; (4) viewed by GO! as developed through an appropriately collaborative process; and (5)
viewed positively by civil society partners as the outcome of a collaborative effort.
Obj 2: Develop recommendations for future activities and implementation strategies for both immediate
and mid-term time frames. Recommendations for future program activities/strategies should take into
account USAID/Indonesia's commitment to MOH priorities in MCH (i.e., achieving MDGs 4 & 5);
health system capacity-building where it can be directly linked to positive impact on MCH outcomes;
working closely with a broad range of civil society partners; and developing productive relationships with
the private business sector.
The above objectives apply to four key technical areas offocus:
1. Advocacy capacity-building activities that aim to improve MNCH budget and policies at national and
subnational government levels, in partnership with civil society organizations, local leaders, elected
officials, civil servants, the private sector, etc.
2. Behavior change interventions at individual, household, and community levels using a variety of
strategies---eommunity mobilization, community facilitators/trainers, district campaigns, radio, and
targeted IEC materials. Comment on the strengths and weaknesses ofthese strategies in relation to
specific technical areas emphasized. Comment on future recommendations for BCC investments,
particularly with regard to regional or national-level media approaches and with regard to linking
birth preparedness to increasing demand for facility deliveries.
3. Assess the role of private sector midwives in MCH care. Comment on how to maximize service
coverage and quality to (a) the poor and (b) rural areas? Comment on how to improve management
and leadership capacity within the Indonesian Midwives Association (IBI) to more effectively
mobilize midwives toward better coverage and quality, and to more effectively manage (and
successfully grow) the Bidan Delima program, a social midwife franchise with roughly 10% of all
midwives having j oined.
4. Review key technical areas in which the project has provided support to GOI (nationally and
subnationally). These areas include (a) decentralization (district planning and budgeting); (b) district
MCH program management and quality improvement capacity (supportive supervision, OJT); and (c)
quality of care (provider training).
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 49
BACKGROUND
Overview: Decentralization and Health Services in Indonesia
Landmark decentralization legislation in 1999 fundamentally altered Indonesia's governance system.
Indonesia transferred substantial responsibility and personnel to over 400 districts. Unfortunately, basic
services delivery to those most in need has decreased as well. Many local governments remain poorly
equipped to deliver quality services, particularly in health and education.
The laws were implemented rapidly, with little assistance to districts and no clarity in new national and
subnational roles. There remains confusion with regard to the provincial role in coordinating programs
administered by resources now largely allocated directly to the districts. Consistency and timeliness of
national guidance to districts and provinces has been lacking.
Local governments make strategic choices in investment priorities. Social welfare and other sectors
compete for limited resources against infrastructure and other investments that are typically viewed by
local leaders as visible and linked to perceptions of good leadership and re-election opportunity.
The central Ministry of Health has maintained functions overseeing health policy and national program
standards, indicators, and targets; communicable disease surveillance; overseeing standardized training
modules for health professionals (primarily in reproductive, maternal, and neonatal health); overseeing
pharmaceutical regulation and (some) essential drug distribution; and advocating to the national
government for continued investment in public health programs.
Despite seismic shifts underlying the planning, budgeting, and implementation systems supporting health
service delivery programs, some districts have responded in creative ways, and there are true "success
stories" showing democratic leadership, commitment, accountability and improved health systems. On the
other hand, there are many districts that have not yet made this transition work for the benefit oftheir
inhabitants.
In the past three years, new financing initiatives in health have added greater confusion and opportunity to
the mix. Additional funding to districts through provinces, from the national budget----dekonsentrasi
funds-have been made available for the years 2006 and 2007. Accessing these funds proved difficult for
most districts, and they were severely underutilized. The GOI's program of health insurance coverage for
the poor-Askeskin-was enacted, and many very poor, near-poor, (and non-poor) citizens have accessed
these funds for tertiary care. The program was under-funded, however, and hospital claims quickly ate the
allocated budget, resulting in unscheduled reductions in Ministry ofHealth national operating budgets for
2007 and 2008.
Finally, the "elephant in the room" is the predominance ofthe private sector and market forces that
hugely impact health-seeking and health-destroying behaviors (formula feeding, smoking, rising food
costs, poor regulation of pharmaceuticals, etc.). People at all income levels, including those in the poorest
wealth quintile, continue to "vote with their pocketbooks" by purchasing the health services they value for
various reasons (convenience, service factors, lack of awareness of quality indicators, etc.). There are few
systems in place to ensure that such services meet objective quality standards and are of "good value"
given their costs. Rates of "self-treatment" (among those reporting illness) have increased from 32% in
1997 to 51 % in 2005 (World Bank PER, 2007).
The central government faces growing responsibilities in stewardship and must consider ways to engage
local governments in licensing, accreditation, and quality assurance programs. The central government
also could playa far larger role in regulating industries that directly impact the health of all Indonesians.
National and local public allocations to the health sector constitute only 1% ofGDP, among the lowest in
the Asia/Near East region. Private health expenditure is double that amount at 2% of GDP, and three￾fourths of all private health expenditures are out-of-pocket. As GDP grows, however, overall health
50 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
expenditure per capita has increased nearly two-fold since 2000, from US$18 to US$32 in 2004. Despite
low proportionate investment, a population of about 240 million people and growing GDP mean that the
health sector commands substantial financial resources.
National health data systems do not show an obvious decline in services over the past few years of
decentralization, but there are several indications observed at the program level that point to a
deterioration ofservices in public health areas once hailed as extremely successful in Indonesia. These
include immunization, vitamin A coverage, and combating malnutrition. The rate of decline in infant and
child mortality rates has slowed, ifnot stopped, but this phenomenon may be better explained by a
worldwide weakness ofrecent public health programs in successfully targeting causes of neonatal
mortality. Maternal mortality has arguably not declined at allover the past 15 years.
MCH Indicators and Services in Indonesia
In the fourth most populous nation, significant numbers ofwomen ofreproductive age, newborns, and
children under 5 are affected by poor primary health systems, underdevelopment of water and sanitation
infrastructure, and cultural patterns of health care-seeking and hygiene behaviors that contribute to poor
health and mortality risk.
Through recent survey measurements, the most recently available estimate ofmaternal mortality is
307/100,000 live births (DHS, 2002/3). A new estimate from the DHS 2007 will be available by August
2008. WHO estimated maternal mortality to be 420 for 2005 according to their standardized adjustment
methods. The Ministry ofHealth recently collected actual reports ofmatemal deaths, country-wide. Their
results showed MMR to be 119 in 2007, 127 in 2006, and 151 in 2005. These national estimates are based
on reported deaths from nearly all Puskesmas in nearly all districts. They show substantial variability by
district, which is likely to reflect a real accuracy, but they are almost certainly underestimates by as much
as one-third (though some districts are likely to be far more accurate than others).
Although overall child mortality indicators appear good (IMR: 35; under-5 mortality: 46), they hide
considerable disparity by wealth quintile and urban-rural status. Indonesia is classified as a middle￾income country, but about one-quarter ofthe population (>50 million) lives below $2/day. Indonesia is
not accurately described by national or even provincial-level aggregate indicators, and misperceptions
about the scope and reach ofIndonesia's health system are a significant challenge for public health
advocates who work in the country's remote or rural areas.
The bottom two wealth quintiles (40% ofthe population; over 90 million people) have under-5 mortality
rates more than three times the rate in the top quintile. Under-5 mortality (DHS 2003) ranges from 22 in
the highest wealth quintile to 77 in the lowest.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 51
TABLE A 1 CHILD MORTALITY RATES (11000 LB) BY TIMING AND WEALTH QUINTILE
Post- Neonatal Neonatal
By Wealth Neonatal neonatal Child Total Mortality Mortality
Quintile Mortality Mortality Mortality Under-S as% of as% of
«1 mos) (1-11 (1-4 years) Mortality Under 5 Infant
months) Mortality
Overall 20 15 11 46 43% 57%
Poorest 20% 28 33 17 77 36 46
Near poor 30 20 15 64 47 60
Middle 21 23 12 56 38 48
Upper middle 20 16 9 45 44 56
Wealthiest 20% 13 4 5 22 59 76
Ratio (poorest / 2.2 8.3 3.4 3.5
wealthiest)
Source: DHS, 200213.
See Annex 11 for additional, technical background on health systems, policy, and trends in MCH in Indonesia.
The BHS Framework Within the USAID/lndonesia Strategy
Over the past decade USAID assistance has been focused largely in partnership with the central level of
the Indonesian government-the most appropriate and efficient strategy prior to decentralization.
Significant investments were also made in building the capacity of nongovernmental organizations,
professional associations, local health NGOs, and national faith-based organizations.
The current overall strategy in the MCH program is to build the capacity of government, private, and
nongovernment sectors to expand delivery of quality health care services and empower communities to
protect human life. The integrated MCH program implemented by the USAID Mission was developed
under the 2004-2008 country strategy guiding the investment of a planned $650-$700 million to
strengthen a moderate and productive Indonesia. This strategy is organized around four major program
areas: (l) improved quality of decentralized basic education, (2) higher-quality basic human services, (3)
effective democratic and decentralized governance, and (4) effective systems of economic governance to
increase trade and investment and drive new job creation. The MCH program falls under the Health Team
within the Basic Human Services Office at USAID. The BHS Office also includes food security and
nutrition, infectious disease, avian influenza, water/sanitation, environment! biodiversity and
conservation.
Specifically, the "Higher Quality Basic Human Services" Strategic Objective (SO) aimed to improve
access to and the quality of key human services, with special emphasis on implementation at the local
(district) level of government. Vulnerable populations, namely the urban poor, women, and children, were
the intended principal beneficiaries. The following intermediate results (IRs) were outlined and these IRs
guided the program design and set of activities of MCH as well as other BHS programs.
1. Governments, community organizations, and the private sector mobilized to advocate for higher￾quality basic health services
2. Basic human services delivered effectively at the local level
3. Improved practices and behaviors adopted at the community and household levels
52 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
USAID's technical assistance programs in BHS have been provided by cooperative agreements, grants,
and contracts with U.S. implementing partners and local nongovernmental organizations. The BHS
agreement with the Government (SOAG) is with MenkoKesra, the Coordinating Ministry of People's
Welfare. Prior to 2004, USAID's agreement with the GO! for bilateral assistance in health was under an
umbrella SOAG with the Ministry ofHealth, BKKBN, and the Ministry of Women's Empowerment.
The current MCH portfolio "mortgaged" to implementing partners is supported by CSH funding totaling
nearly $52 million from FY 2004-2008 (funqing projects largely from 2005-2009). This total does not
reflect USAID costs associated with program management and "design and learning." HSP claims about
57% ofthose funds as the "flagship" integrated MCH program. Additional programs implemented with
CSH funding include a Prevention ofMalaria in Pregnancy Program in Eastern Indonesia (4% CSH
funding); support to the Demographic Health Survey (3%); support to USAID/Washington-managed
programs in polio and child survival (6% total); a social marketing of point-of-use (POU) chlorine
solution program (11 %); and water and sanitation through the Environmental Services Program (18%).
Both the POU water program and the environmental program are managed by the water/environment
team within BHS.
The Health Services Program
The Health Services Program (HSP) addresses the major public health problems facing mothers,
newborns, and children in Indonesia. The program emphasizes a selected set ofinterventions that are
most compelling, given the MCH burden of disease, GO! priorities, and institutional (public and private)
opportunities. HSP provides technical assistance to government counterparts, civil society partners,
NGOs, and communities on the implementation ofselected evidence-based interventions. HSP is a 4.5
year program, starting April 2005 (to Sept 09 currently).
HSP is a cooperative agreement awarded to lSI Research and Training Institute. The original amount of
the award was nearly $30 million, but an additional $5.6 million was awarded after the December 2004
tsunami for programming in selected districts ofthe Nangroe Aceh Darussalam province. This included
$3.8 million to implement MCH technical and rehabilitation support to four districts in Aceh province,
and $1.8 million to implement a psychosocial support program.
The overall aim ofreducing maternal, neonatal, and child mortality guide the technical focus areas of
HSP. In order to impact the major causes ofmaternal and newborn death, HSP activities address
postpartum hemorrhage, neonatal asphyxia, complications ofprematuritylLBW, neonatal infection. To
address a predominant cause of postneonatal/child death, HSP also focuses on the prevention and
management of child diarrhea (& IMCI). Young child malnutrition is addressed through HSP's intensive
support to early initiation of breastfeeding and recommended breastfeeding practices up to two years.
Additional MCH issues may also be addressed but with reduced intensity of effort (e.g., vitamin A,
immunization, IMCI, comprehensive nutrition and young child feeding, etc.).
HSP's underlying strategy is to concentrate assistance on working with the Gal and civil society partners
to operationalize best practices (i.e., evidence-based interventions) through public and private sector
health systems at district, provincial, and national levels. This systems approach underlies all activities in
the following areas:
1. Partnerships with district health officials for district planning and budgeting
2. Partnerships with health provider professional associations and GO! to improve the quality and
impact of clinical training and supervision systems
3. Partnerships with local NGOs and community leaders, district health officials, and parliamentarians
to advocate for bigger budget support to MCH services
4. Engagement with village leaders and health providers in social mobilization for behavior change
5. Engagement with private sector midwives, enabling them to expand geographical coverage of a
quality assurance social franchise called Bidan Delima.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 53
The rationale for the systems-level capacity building approach is the beliefthat participation in technical
assistance processes fosters ownership of outputs and better-functioning and more sustainable systems,
and facilitates the replication of best practices to geographic areas beyond USAID-supported target areas
(through donor and GO! resources).
HSP's primary Ministry of Health counterpart, the Division ofCommunity Health, views the project
according to the conceptual framework below:
1. Behavior Change--community mobilization, national birth preparedness initiative (formerly Desa
SiAGa, now P4K), BCCIIEC.
2. Decentralization (governance, policy)-planning and budgeting capacity of local governments and
advocacy initiatives with CSOs, NGOs, local leaders, and local government representatives.
3. Clinical MNCHIRH-supportive supervision, provider training, clinical guidelines, and management
tools to improve quality at primary (and up to hospital) levels of care. This category also includes
current work and future opportunities to strengthen the quality and reach ofservices provided by
private providers, primarily midwives.
Performance Monitoring
HSP's Performance Monitoring Plan (PMP) has been designed to overlap the USAIDIBHS 2006
Performance Monitoring Plan of 2006---both to ensure consistency ofthinking and approach, and to
facilitate USAID's data acquisition for annual reporting purposes. The PMP is also aligned with the
Operational Plan (OP) framework which began during the mid-period of HSP implementation.
The PMP outlines two sets of indicators, which are referred to as "USAID PMP indicators" and "OP
indicators." The first set consists of 13 indicators which are HSP-specific and include the 9 BHS common
indicators. The second set ofindicators was selected from the FY2007 Operational Plan, first
implemented in FY2007. Official guidance and a standard set of common indicators were provided by
USAIDIF Bureau. HSP selected 14 ofthese indicators, 10 from MCH, one from FP, and three cross￾cutting indicators related to baseline/feasibility studies, evaluations and monitoring plans. Therefore, HSP
has a total of 27 uniquely defined indicators (% and #).
SCOPE AND OBJECTIVES OF THE EVALUATION
This evaluation will concentrate on the Health Services Program's activities related to MCH systems
capacity-building, support to decentralized governments, and behavior change aimed at reducing maternal
and child morbidity and mortality. Aceh-based activities related specifically to tsunami recovery and
outside the scope ofthe overall MCH systems approach applied in other project areas (e.g. psychosocial
services, physical rehabilitation of health facilities/training infrastructure or markets) are not within the
scope ofthis evaluation.
Obj 1: Achieve a thorough understanding ofthe outcomes/results ofHSP interventions, and the
effectiveness ofHSP strategies for achieving results in the key focus areas listed below. Effectiveness
may be defined by the extent to which accomplishments are (l) replicable; (2) likely to be sustained by
GO! and/or local partners; (3) viewed by GOI (national and subnational) as consistent with policy and
programs; (4) viewed by GO! as developed through an appropriately collaborative process; and (5)
viewed positively by civil society partners as the outcome of a collaborative effort.
NOTE: Replication is defined as other donors and/or localities implementing project tools/models at
their own expense with little or no TA from project staff. Replication requires proper design of
tools/modules and sufficient capacity of partners to implement project tools/models. Scale-up (linked
to sustainability) is defined as project tools and/or models being adopted by the Ministry of Health or
other national or "well-networked" civil society organizations. Scale-up has two phases: (l)
Adoption, indicating ownership and intention; and (2) implementation, indicating provincial/district
partners have demonstrated that they can access those tools/models, value them enough to cover costs
54 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
of implementation, and successfully implement them to a reasonable degree of compliance with what
was intended by their design and piloting. Scale-up may require continued TA support from the
projectlUSAID.
Obj 2: Develop recommendations for future activities and implementation strategies for both immediate
and mid-term time frames. Recommendations for future program activities/strategies should take into
account USAID/lndonesia's commitment to MOH priorities in MCH (i.e., achieving MDGs 4 & 5);
health system-capacity building where it can be directly linked to positive impact on MCH outcomes;
working closely with a broad range of civil society partners; and developing productive relationships with
the private business sector.
NOTE: Immediate time frame refers to HSP's current end-date (Sept. 2009). The mid-term time
frame refers to the follow-on project period of 4-5 years.
For the above two objectives, please focus on the following key areas or technical or strategic foci:
1. Advocacy capacity-building activities that aim to improve MNCH budget and policies at national and
subnational government levels, in partnership with civil society organizations, local leaders, elected
officials, civil servants, the private sector, etc.
2. Behavior change interventions at individual, household, and community levels using a variety of
strategies--community mobilization, community facilitators/trainers, district campaigns, radio, and
targeted IEC materials. Comment on the strengths and weaknesses ofthese strategies in relation to
specific technical areas emphasized (birth preparedness, breastfeeding, hand- washing with soap).
Comment on future recommendations for BCC investments, particularly with regard to regional or
national-level media approaches and with regard to linking birth preparedness to increasing demand
for facility deliveries.
3. Assess the role of private sector midwives in MCH care. Comment on how to maximize service
coverage and quality to (a) the poor and (b) rural areas? Comment on how to improve management
and leadership capacity within the Indonesian Midwives Association (IBI) to more effectively
mobilize midwives toward better coverage and quality, and to more effectively manage (and
successfully grow) the Bidan Delima program, a social midwife franchise with roughly 10% of all
midwives having joined.
4. Review of key technical areas in which the project has provided support to GOI (nationally and
subnationally). These areas include (a) decentralization (district planning and budgeting); (b) district
MCH program management and quality improvement capacity (supportive supervision, OJT); and (c)
quality of care (provider training).
Please refer to Annex I for further details on specific technical issues to address in the evaluation
investigations and final report.
Methodology
The evaluators should consider a range of possible methods and approaches for collecting and analyzing
the information that is required to assess the evaluation objectives. Data collection methodologies will be
discussed with, and approved by, the USAID prior to the start ofthe evaluation. The evaluation should be
a consultative and participatory process that includes key organizations from the GO!, civil society,
NGOs, and private sector providers (midwives). The team will work in close collaboration with both
national-level organizations and key district stakeholders including The Ministry of Health (including
relevant subdirectorates ofmother, child, nutrition, community health, health promotion, diarrhea
management, etc.); the National Clinical Training Network (JNPK), professional medical associations in
obstetrics (POGI), pediatrics (IDAI) and midwifery (IBI); Perinasia; partner NGOs; and other in-country
partners. The final methodology and work plan will be developed as a product ofthe team planning
meeting (TPM) and shared with the Mission prior to application.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 55
Document Review
• USAIDlIndonesia will provide the evaluation team with the key documents prior to the start ofthe in￾country work. All team members will review these documents in preparation for the initial team
planning meeting (refer to section 3.3 below)
• Secondary data may be assembled for background information. Most ofthese data should be available
from readily accessible sources listed in this SOW as resource material. Additional data from
institutions interviewed should be collected if available and relevant.
Team Planning Meeting
• A two-day team planning meeting will be held in Indonesia before the evaluation begins. This
meeting will allow USAID to present the team with the purpose, expectations, and agenda ofthe
assignment. In addition, the team will
clarify team members' roles and responsibilities;
establish a team atmosphere, share individual working styles, and agree on procedures for
resolving differences of opinion;
review and develop final evaluation questions (work out realistic expectations ofthe team within
each ofthe four topic areas during meetings with HSP, MOH, and USAID);
review and finalize the assignment timeline and share with USAID,
develop data collection methods, instruments, tools, and guidelines;
review and clarifY any logistical and administrative procedures for the assignment;
develop a preliminary draft outline ofthe team's report; and
assign drafting responsibilities for the final report.
Interviews and Site Visits
• The evaluation team will meet with key stakeholders to conduct qualitative, in-depth interviews. The
interviews should be loosely structured but follow a list of key discussion issues and questions as a
guide. The interviewer should probe for information and take notes as necessary. The team should
meet with and interview the institutions listed below, and others as they emerge and are considered
relevant during the field work. Meetings may be conducted individually or in groups.
• Site visits should be made to at least three trips outside ofJakarta (North Sumatra, West Java, East
Java-illustrative) in addition to one or two site visits in or near Jakarta. Evaluators may choose to
visit some sites together and some sites separately. All site visits should be well-coordinated with
HSP staffso that logistics are smooth, and proper introductions are made.
Organizations/institutions/individuals to meet:
• USAID staff in Washington and Jakarta
• MOH: National level counterparts in units related to maternal, neonatal, child, and nutrition at
community/primary health care levels; medical (hospital) services; essential drugs; diarrhea unit in
infectious diseases; health promotion; and provider training.
• MOH: provincial, district health teams
• Other key ministry officials at MenkoKesra, Ministry ofWomen's Empowerment, Bappenas,
Ministry ofInternal (Home) Affairs, BKKBN
• Indonesian Midwives Association (lEI)
• National Clinical Training Network (JNPK)
• Indonesian Association of Obstetrics/Gynecology
56 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
• Indonesian Association of Pediatrics
• Perinasia
• The Millennium Challenge Account program on immunization, currently entering the second year of
a two-year, $20 million program.
• BHS implementing partners: SWS/JHUCCP, ESP/DAI, ASA/FHI, LGSP/RTI, Malaria in
Pregnancy/UNICEF
• UNICEF (general programs and points of collaboration)
• WHO
• World Bank
• White Ribbon Alliance
• Women's Research Institute (WRI)
• Mercy Corps International (MCI)
• Others as appropriate
Applicable documents (additional documents will be provided in advance)
HSP annual reports
2008 Workplan
Decentralization working paper
Health sector reports (performance expenditure report, etc.)
Other reports/background information as assembled by USAID or HSP
Team composition and participation
The mission proposes a four-person team comprised oftwo international consultants from outside of
USAID (one designated as team leader) and two Indonesian consultants hired locally who have the
following expertise and qualifications:
1. (Independent Consultant) Team leader. The team leader should be expert in implementing public
health programs with a special emphasis on reducing maternal and neonatal mortality risk.
Experience in health systems capacity-building programs or activities and/or advocacy (community
mobilization, partnerships with NGOs, governance) is required. The team leader should have 10+
years experience in field implementation ofMCHprograms in at least two different developing
country settings. The team leader must also possess excellent interpersonal, management, and
communication (oral, written) skills. The team leader will be responsible for making an oral
presentation to the USAID Mission and delivering the written report. The team leader will be
expected to plan, manage, and facilitate a participatory process that allows for discussion and
consensus building among evaluation team members and maximizes the professional expertise that
HSP and other partners in Indonesia bring to the evaluation.
2. (Independent Consultant) Private provider network (franchise) expert. Must have background in
building capacity of professional organizations (doctors, midwives), implementing franchise
endeavors, and/or improving quality of care within private provider networks.
3. (Local Consultant) Behavior change through community mobilization and the media, with
background in public health.
4. (Local Consultant) Governance, health systems expertise. Some international experience (through
academia, study tours, consultancies) helpful but not required. Thorough understanding ofIndonesian
history and current challenges with decentralization of health services required. Demonstrated
understanding of private health providers in Indonesia, and private health seeking behaviors a plus.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 57
Although the MOH cannot designate full-time evaluation participants, all site visits should be open to
their attendance and they have expressed interest in several oftheir staff accompanying site visits.
USAID/Mission staff may also attend site visits (at their own expense).
Schedule and logistics
Duration, Timing and Schedule
It is anticipated that the preparation, field work, and writing ofthe draft report will take approximately
four to five weeks and that the final report will be submitted 5 days after comments are received from
USAID/lndonesia. The evaluation team will be authorized to work a six-day work week when in country.
The following is an illustrative schedule.
Task/Deliverable Est. LOE
1. Review background documents (out of country) 3 days
2. Travel to/from country (for international consultants) 4 days RT
3. Team planning meeting; meetings w/ USAID 2 days
4. Information and data collection. Includes interviews with key 13 days informants (including partners and USAID staff) and site visits.
5. Discussion, analysis, and draft evaluation report in country 5 days
6. Debrief with team and stakeholders 1 day
7. USAID & partners provide comments on draft report (out of
country)-5 days
8. Team reviews and revises report - final 3 days (TL)
I 2 days (team members)
9. USAID completes final review-10 days I
I
33 days (TL)
Total # days LOE 30 days (int. consultant)
26 days (local consultants)
The evaluation will occur in August. GH Tech will be responsible for all costs associated with the
evaluation, including international and local consultant participation; international and local travel of
team members and MOH staff accompanying site visits (per diem, hotel, transport hire); office and
logistical costs for the team; and all costs associated with producing and disseminating the deliverables.
USAID will supply necessary contact information and will work to "socialize" approved SOW with
MOH partners prior to the team's field work. USAlD will suggest potential areas to be visited and ensure
balance of project areas visited in the field.
Deliverables
Debriefing with USAID mission (BHS, Front Office) before completion of assignment, before
submission of draft report and departure ofteam from country. Frequent contact with the USAlD mission
(MCH Advisor) on field work progress, and reporting of any change in timeline or sites proposed to be
visited.
A written draft evaluation report, 110 longer than 30 pages, not including appendices, should be
completed prior to the team leader's departure from Indonesia. The written report should be organized by
objective but clearly describe sub-team findings and address cross-cutting themes. USAID will provide
comment on the draft report within 5 working days ofsubmission.
58 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
A PowerPoint presentation to be presented at dissemination meeting with MOH officials and other
stakeholders. A designated evaluation team member (Bahasa speaker) will be designated to present. The
evaluation team members should be present for commentary and discussion. USAID Mission staff will
assist in organizing the meeting, which should take place toward the end ofthe assignment.
A final repor(that incorporates the team responses to Mission and MOH discussion, comments, and
suggestions. The draft final report revisions should be completed within 5 working days after the team
receives all comments from the Mission and provided to the USAID Mission for final comment. The final
report (excluding executive summary and annexes) should be no more than 30 pages.
If the mission prefers to have two versions ofthe report: a version for public distribution and an internal
version that may include sensitive information, the content ofthe two versions will be agreed upon at the
time the first draft is submitted.
USAID will share the final but unedited report with the partners (without the forward-looking/future
directions components) to give them an opportunity to review and make comments. After the final but
unedited draft report has been reviewed by USAID and partners, GH Tech will have the documents edited
and formatted and will provide both versions ofthe final report to USAID/Indonesia for distribution. It
will take approximately 30 days for GH Tech to edit/format and print the final document.
The evaluation report will include, at minimum, the following: scope and methodology used; important
findings (empirical facts collected by evaluators); conclusions (evaluators' interpretations and judgments
based on the findings); recommendations (proposed actions for management based on the conclusions);
and lessons learned (implications for modifications and future designs and for others to incorporate into
similar programs) as well as the SOW, team composition, evaluation methods, documents consulted,
individuals/institutions consulted, summary offield work (sites, programs seen, people consulted with,
etc.).
Oversight and Management
The GHTech team will work under the direction of
Gretchen Antelman
USAID/]ndonesia MCH Advisor,
gantelman@usaid.gov
62812 1063576)
Responsibilities:
USAID/lndonesia and/or HSP will be responsible for the following:
• Obtain country clearances for travel.
• Coordinate and facilitate initial assessment-related field trips, interviews, and meetings.
• Assist the team with in-country logistical arrangements.
GH Tech will be responsible for the following technical and logistical support:
• IdentifY and recruit team members-international and local consultants.
• Provide funds to the team for all in-country logistics.
• Provide administrative and management support to the team while on assignment.
• Provide support and editing services for the preparation ofthe final versions ofthe deliverables.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 59
SCOPE OF WORK ANNEX 1
Specific Technical Issues to Investigate
Several cross-cutting technical issues and approachesshould be considered by each team member within
the context ofthe four technical focus areas ofinvestigation. These are:
a) Epidemiology. How does the current portfolio ofMCH activities appropriately address key MCH
health burdens in Indonesia?
b) Geography. How appropriate has the current geographical focus ofthe MCH portfolio been in tenns
ofreaching vulnerable populations, responding to GOI priorities, having national-level impact?
Recommend future criteria for detennining geographic focus.
c) Collaborative relationship and synergies with other BHS and donor partners. Where has collaboration
been helpful to one or both partners? Where has such collaboration diverted HSP attention, resources,
or energies from primary project aims? Distinguish between BHS (USAID) partners and non-USAID
partners.
d) Relationship with Ministry ofHealth partners at national level, Provincial and District Health teams,
and other key stakeholders representing local and national government. Responsiveness to emerging
needs within national and subnational governments.
e) Sustainability of activities after HSP assistance stops. This may be evaluated infonnally as activities
were implemented in a phased approach and some districts post-TA may be consulted.
f) Replication ofHSP tools/modules. The extent to which steps toward replication have been taken, as
well as actual replication achieved, should be noted.
g) Selection of evidence-based interventions. Are selected interventions appropriate for Indonesia? What
areas offocus are recommended in the future?
h) Program planning, monitoring, and evaluation systems. Program marketing communications tools
and dissemination ofresults to GOI, stakeholders, and USAID.
i) Leveraging resources through public-private partnerships (e.g., with private commercial business).
j) Effectiveness of "focus on the poor" underlying strategy and gender sensitivities of activities with
regard to technical content and implementation strategy.
k) How should USAID detennine the appropriate balance between investment in systems TA to national
and subnationallevels? Between facility and community-level interventions to increase access to
quality delivery services?
SCOPE OF WORK ANNEX 2
Additional background information on health systems, policy, and trends in MCH
Maternal, Child, and Neonatal Policy
Indonesia follows an adaptation ofthe Making Pregnancy Safer (MPS) policy which covers maternal
delivery care and the newborn up to one hour after birth. Indonesia does not currently have a child health
policy in place and the correct policy "placement" ofthe neonate is still under discussion. A draft child
health policy was finalized two years ago but tabled by the Minister for technical reasons and has not
been taken up again since. The MPS policy expires in 2010.
Indonesia has adopted the IMCI approach but has not actively implemented training, monitoring, and
evaluation activities over the past 10 years since this program began. It is placed within the subdirectorate
60 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
of child health but must also coordinate closely with other subdirectorates overseeing training, puskesmas
management and supervision, and infectious disease (diarrhea, malaria, HIV).
Facilities/Human Resources
The Government ofIndonesia has employed a tiered approach representing a continuum of care from
provincial and district public hospitals down to subdistrict and village health facilities. At the subdistrict
level, primary health centers (puskesmas) are staffed with doctors, nurses, and midwives and are equipped
to provide primary health care services to an area with about 30,000 people, or about 10 villages. There
are about 8,000 puskesmas in the country.
The clinics offer a package of basic services including maternal and child health, family planning, out￾patient care, and communicable disease control (TB DOTS, STIs). They also serve as primary level
referral facilities linking patients to district hospitals. A number of health centers with beds have been
established in order to provide service on site when referral to a district hospital is impractical. The
puskesmas are supported by over 20,000 subhealth centers (pustu), mobile health centers (posyandu), and
village-based maternity huts (polindes).
Puskesmas manage the pustu, and midwives hired on government contracts as part of an earlier program
called Bidan di Desa (midwife in the village) manage the polindes. In the 1980s when the Bidan di Desa
program was conceptualized, the midwives were meant to live in their assigned villages at the polindes.
This is not currently the norm, however, as polindes frequently do not have running water, electricity, or
toilets. Also, many "village midwives" now operate private clinics and therefore prefer to live in
neighboring peri-urban areas. Polindes typically operate as village health posts providing morning
primary health care services. The midwives provide delivery services in clients' homes or in their own
homes, which may be set up as a private clinic attached to the midwife's residence.
Integrated Service Posts (posyandu) were established in the 1980s in order to strengthen community
access to family planning and child health services. These are mobile health outreach activities at the
village level that provide nutrition interventions (counseling, growth monitoring, and in some places
positive deviance and nutrition rehabilitation activities), diarrhea management, family planning, routine
immunization, and antenatal counseling. Fieldworkers (PLKB) and community volunteers (kader),
organized initially in connection with the National Family Planning Coordinating Agency (BKKBN),
have played an important role in mobilizing community members by providing health information, and
encouraging women and adolescents to come to the posyandu. However, posyandu have weakened
substantially since decentralization for a variety ofreasons-human resources, puskesmas management,
commitment and financial support from district government, etc.
Midwifery and Skilled Birth Attendance
Indonesia addressed the challenge ofmaternal mortality by showing a very strong commitment to scaling￾up access to skilled birth attendants through an ambitious public health program called Bidan di Desa.
Launched in 1989, the aim ofthe program was to reduce maternal mortality by increasing the proportion
of deliveries managed by trained professionals, particularly among poor rural populations. There were
some 15,000 community midwives in villages in 1991, which increased to 54,000 by 1997. It is estimated
that about 30,000 midwives still participate in the program. This represents a ratio of one midwife per
2,400 population, or 54 births/year, far in excess ofthe international recommendation of one midwife per
175 births. District governments must now support the personnel costs ofthese midwives, and some are
more committed than others to maintaining the model of a "midwife in every village."
Despite relatively high rates of coverage with a skilled health provider, the majority of deliveries still
occur at home (76% in rural areas) and the quality of care provided by many skilled attendants is not at an
acceptable standard. Access to emergency obstetric care is very limited «2% c-section rate in rural areas,
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 61
DHS 2003). Over 50% of deliveries in the poorest quintile are NOT attended by a skilled provider
(Susenas, 2005).
The Indonesian Midwives Association (IBI) estimates that there are 104,000 midwives total in Indonesia;
70,000 are IBI members; and 7,000 are members of a private midwife franchise called Bidan Delima
(started 2004). Midwife training academies have burgeoned since the Bidan di Desa program. There are
now over 400 midwifery schools country-wide, 100 under the auspices ofthe Ministry of Health and 300
under the Ministry ofEducation. Midwifery is a popular career choice for young women, and district￾based schools of midwifery are reportedly profitable. They do follow a standard curriculum but are
extremely weak in their quality ofteaching and access to clinical sites for practice. There is no
requirement of professional internship after midwife school.
Immunization
Immunization services are largely provided through the public sector, are centrally procured (locally
produced), and are delivered at puskesmas and posyandu. Health service providers working at the
puskesmas also provide immunizations through their private practices outside ofthe puskesmas,
sometimes accessing the stocks from the puskesmas. Immunization coverage data suggests that services
are in decline, and the country is just now recovering from a polio outbreak which triggered an emergency
response and several NIDs. USAID currently manages a $20 million, 2-year MCC Threshold project in
immunization in order to help Indonesia qualify for Compact status. A recent WHOIMCC coverage
survey of7 provinces showed DPT3 coverage at 70% and measles 78%. Rates varied significantly by
province, however, with Banten's DPT3 only 38% and the highest coverage only 83% (Central Java).
There was wide variety in place of DPT3 service as well: private clinic coverage ranged from 0 to 42%;
outreach (posyandu) from 19% to 82%; and puskesmas from 3% to 28%. Child illness and mothers being
unaware of need or where to go seemed to be the predominant reasons for children not being immunized
properly. DHS data from 2002/3 showed fewer than 1/3 ofmothers could show their child's
immunization card to the interviewer. Service data reported by the MOH document higher rates of
coverage than reported in survey data.
Vitamin A
Vitamin A is provided twice yearly in February and August through public health centers and outreach
activities, and the national program has long been considered highly effective and internationally
renowned. Most recently available DHS estimates of coverage of children with vitamin A supplements
for 2002 show that urban coverage of children under 5 is 79% and rural coverage 71 %. Only 59% of
children aged 6-9 months were reported to have consumed vitamin A supplements, increasing to 75% or
higher in older age groups.
Household Level Water and Sanitation
Indonesia is still far behind in its goal of achieving its MDG10, to "halve, by 2015, the proportion of
people without sustainable access to safe drinking water and basic sanitation." Water supply data show
the number of people with access to piped drinking water was only 18% in 2006, far below the MDG
target of 57%. The number of people with access to non-piped drinking water is 57%, compared to the
MDG target of 69%. Furthermore, most water utilized by people for drinking and cooking is
contaminated and would not pass "drinkable" standards.
Indonesia is also behind in sanitation. Although 69% ofthe population has access to sanitation facilities,
most are public or individual latrines with a "soaking pit" or bottomless "septic tank" that simply leaks
into the water table and contaminates groundwater, including nearby wells. Only 11 cities have
centralized wastewater treatment facilities.
62 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
Minimum Service Standards and Local Area Monitoring (Health Information System)
The central MOH has developed a set of minimum service standards and indicators that all local public
health programs are required to follow. These relate to antenatal, postnatal, and neonatal visits, skilled
birth attendance, management of obstetric and neonatal complications, c-section, case fatality rate,
detection of danger signs during pregnancy, low birth weight, malnutrition, and mortality indicators.
Standard definitions are developed. Dissemination and training on these standardized indicators may not
have been fully implemented in all districts.
Local Area Monitoring describes the system by which much ofthe health management information
system data is collected, recorded, and reported. Midwives, fieldworkers, and cadres maintain detailed
records oftheir activities and services and health outcomes in their respective areas. These data are
reported to the district/subdistrict health centers, which then report them to district officials, who forward
them to provincial officials for consolidation and reporting to the national Ministry ofHealth. Districts
compile their reports quarterly; provinces compile reports and submit to central level annually. HIS data
are reported in Excel format on five separate worksheets. They outline data at district level, providing
provincial totals and simple indicator calculations. Data include demographics (population, pregnancies,
deliveries, infants born), number of people who received services according to a range of indicators
relevant to reproductive health and national targets, health facilities, health personnel, maternal and
neonatal deaths, stillbirths, causes ofmaternal death, and timing of neonatal death.
Public and private hospitals report directly to the province. Hospital data are not compiled by district;
only provincial totals are calculated. The hospital HIS data relevant to reproductive health includes total
births in hospital, total complications managed by type of complication (bleeding, infection, eclampsia,
abortion, other), c-sections, and mortality by cause. Hospital data are compiled at central level and
generally not reviewed at district of provincial levels in the context of primary health care data.
Child Nutrition and Breastfeeding
An estimated 28% of children under 5 have moderate or severe malnutrition, with the majority ofthese
cases occurring in children under 2. This is an important indicator to track because nutrition interventions
are best targeted at children under 2 for maximum long-term public health benefit, and malnutrition
among children under 2 is largely avoidable if proper breastfeeding behaviors were more prevalent. DHS
data show substantial increases in rates of early initiation «1 hour) increasing between 1994 (8%) and
2002 (38%), but only 61% had established breastfeeding within the first day (DHS 2002). Although less
than 10% of mothers are not breastfeeding infants aged 4--6 months, more than one-third ofmothers of
infants 0-3 months supplement breast milk with other foods or liquids, and this increases to almost three￾fourths among mothers of infants age 4--6 months. Overall rates of exclusive breastfeeding ofinfants <6
months are 39%. Infant formula and bottle+nipple use is relatively prevalent among infants <6 months
(DHS, 2002/3). There are numerous reports ofInternational Code violations, and high rates ofignClrance
among health providers about regulations against marketing of breast milk substitutes.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 63
64 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
APPENDIX B.
NAME
Government
Ms. Auly Altruiswaty
Ms. Henni S
Mr. Bagus Satriya Budi
Mr. Afrinaldi
Mr. Chatib Afwan
Ms. Henny Nendra
Ms. Nurbaeti Yuliana
Ms. Diana Sista Dewi
Mr. Fardhon Hanafiah
Ms. Henny Setiawab
Mr. Kusuma
Ms. Meida
Mr. Naalih Kelsum
Ms. Hafni R
Ms. Ratna Rosita
Mr. Rochman Arief
Ms. Suginarti
Ms. Annie Trisusilo
Mr. Noor Sardono
Mr. Chandra
Ms. Siti Romlah
Mr. Dony Ahmad M.
Mr. Dedy Ambara
Mr. Aat Permana
Mr. Rahmat
Mr. Choirun Anam
Mr. AriWahyu
Mr. Imron Rosyadi S
Mr. Akhmaddin
Ms. Hanny Ronosulistiyo
Ms. Damayanti
Mr. Achmad Rifai
Ms. Sri Indrawati
Mr. Sujud Pribadi
Ms. Lilis K.
Mr. Sonteri Manurung
Ms. Aflah Kahirani
Mr. Usep
Mr.lmron
Mr. Andri
Mr. Ferry
Ms. Ninung
Mr. Masdulhaq Srg
PERSONS CONTACTED
INSTITUTION
Asdep 1/111 KPP (Min of Women Empow)
Asdep 2/111 Coord Min of Welfare
Directorate of Child Health, MOH
KNPP (Min of Women Empow)
Coordinating Minister of Welfare
Coordinating Minister of Welfare
Coordinating Minister of Welfare
Coordinating, Minister of Welfare
Coordinating Minister of Welfare
Coordinating Minister of Welfare
Coordinating Minister of Welfare
Coordinating Minister of Welfare
Coordinating Minister of Welfare
Central Health Promotion, MOH
MOH Basic Medical Services
Health Specialist Service, MOH
Health Service, MOH
Health Service, MOH
Health Service, MOH
Health Service, MOH
Directorate General of Nursing, MOH
Local Parliament, Sumedang
Local Parliament, Sumedang
Local Parliament, Sumedang
Local Parliament, Sumedang
Local Parliament, Malang
Local Parliament, Malang
Local Parliament, Malang
Local Parliament, Deli Serdang
PHO Jabar
PHO Jatim
PHO Sumut
PHO Sumut
Local Government, Malang
Local Government, Sumedang, Law
Division
Local Superintendent, Deli Serdang
Locall Superintendent, Deli Serdang
Local Superintendent, Sumedang
Local Superintendent, Sumedang
Secretariat, District of Sumedang
Secretariat, District of Sumedang
Secretariat, District of Sumedang
DHO, Deli Serdang
FUNCTION
Assistant Deputy
Assistant Deputy
Staff of Directorate
Head, Division of Data
Division Head
Division Head
Division Head
Subdivision Head
Assistant Deputy, Population
Head, Division of HiIV/AIDS
Chief, Subdirectorate of Com. Facil.
Director
Head, Subdivision of Accreditation
Head, Subdivision of Health
Technology
Staff
Staff
Staff
Staff
Vice Chairman
Head, Commission C
Member, Commission C
Head, Commission B
Secretary, Commission B
Member
Head, PHO
Section Head, MCH
Province Facilitator
Province Facilitator
Regent Chief
Head, Properity Subdivision
Staff
Head, DHO
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 65
Mr. Erwanto Indroyono
Irsan
Ms. Nurhayati
Mr. Henrikus Sianturi
Ms. Aida R Hutabarat
Mr. Bahtera Barus
Ms. Elmi Haryani
Ms. Lusiana Nasution
Ms. Suriani
Mr. Hieronimus M
Ms. Lady Rosary
Mr. Erfan
Mr. Hotman Saragih
Ms. Nurhayati
Ms. Rindang Simbolon
Ms. Veronika Sembiring
Ms. Siti Asnah
Ms. Elina Malau
Mr. Agus Wahyu Arifin
Ms. Tutik Wahyuni
Ms. Anita Flora
Mr. Arbani MW
Mr. Joni ST
Ms. Enny Sekar
Ms. Asih Tri Rahmie
Ms. Ella Nurilla Sari
Ms. Retno Ernawati
Mr. Buddy K.
Mr. Cecep
Mr. Cecep N.
Mr. Dase S
Ms. Entin
Mr. Harry K
Ms. Tati
Ms. UyuW
Ms. Yeni
Ms. Diane Ocviyanti
Ms. Yuli
Ms. Esti
Ms. Wiwin Kuraesin
Ms. Imas Widowati
Mr. Eri Dadan H.
Ms. Juanita
Ms. Apon
Ms. Dedeh Sukmawati
Mr. Nanang
Mr. Puguh Y.
Mr. Wijayanto
Ms. Nurasiyah
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
DHO, Deli Serdang
District Information & Communication
Office
DHO, Malang
DHO, Malang
DHO, Malang
DHO, Malang
DHO, Malang
DHO, Malang City
DHO, Malang City
DHO, Malang City
DHO, Sumedang
DHO, Sumedang
DHO, Sumedang
DHO, Sumedang
DHO, Sumedang
DHO, Sumedang
DHO, Sumedang
DHO Sumedang
DHO Sumedang
DHO Sumedang
RSCM (top National Referral Hospital)
PHC, Turen
PHC, Turen
PHC, Jatinangor
PHC, Jatinangor
PHC, Jatinangor
PHC, Jatinangor
PHC, Sukamantri
PHC, Sukamantri
PHC, Tommo
PHC
P2KS (Secondary center of clinical
training)
P2KP (Primary center of clinical training)
Head, PPL Division
Head, Division of Family Welfare
Head, Subdivision Program
Head, Section of Health Promotion
Head, Section of Disease Prevention
Head, Section of Child Health
Head, Section of Family Nutrition
Head, Section of MCH
Staff
Staff
Staff
Staff
Staff
Staff
Staff
BCC Team
Staff
Head, DHO
Head, Subdivision of Public Health
Head, Section of MCH
Head, Section of Health Promotion
Head, Section of Prog. Development
Head, DHO
Head, Subdivision of Public Health
Head, Section of MCH
Head, Division of Family Welfare
Staff
Staff
Staff
Staff
Staff
Staff
Staff
Staff
Staff
Chief, Subdivision of Medical Services
Chief, Public Health Center
Midwife Coordinator
Staff
Staff
Staff
Staff
Staff
Staff
Staff
Staff
Head
Secretary, P2KP
66 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
Ms. Elis Rita
Ms. Wiwin K.
Ms. Heni Rohani
Ms. Lilis
Ms. ElyYani
Mr. Dedi Kuswenda
Ms. Sari Handayani
Directorate of Maternal Health, MOH
Perinasia
--_._-----_..-------------------
Midwife Coordinator
Midwife Coordinator
Midwife Coordinator
Protocol
Disduk (Population Office)
Subdivision Chief
Administrative director
USAID
USAID
HSP, Jakarta
HSP, Jakarta
HSP, Jakarta
HSP, Jakarta
HSP, Sumut
HSP, Sumut
HSP, Sumut
HSP, Sumut
HSP,NSRO
HSP, Sumut
HSP, Sumut
8YM
8YM
IDAI (Indonesian Pediatrics Society)
ISOG (POGI- Indo. Ob/Gyn Society)
JNPK (National Clinical Training Network)
POGI
RSCM, Div Neonatology
JNPK
RSCM (Top National Referral Hospital)
RSCM
RSCM
Perinatology Working Group at IDAI
Perinasia
Perinasia
Perinasia
Indon. Midwife Association (181)
181
181
181
181
West Java Midwife Association
West Java Midwife Association
West Java Midwife Association
East Java Midwife Association
Deli Serdang Midwife Association
8andung Midwife Association
8andung Midwife Association
Malang Midwife Association
USAID, Project staff, Professional Associations, NGOs
Mr. Charles Oliver
Ms. Gretchen A
Mr. Reginald Gipson
Mr. Anhari Achadi
Ms. Laurel McLaureen
Ms. Herlina
Ms. Dewi T
Ms. Fitri Irmadani
Mr. Imam
Mr. Jeffry S
Mr. Masroel Siregar
Mr. Muhtar Sijabat
Mr. Syah Sinar R
Mr. Rudi P
Ms. Susy H
Mr. 8adriul Hegar
Mr. Suryono S I Santoso
Mr. Gulardi Wiknjosastro
Mr. Ruslan Pandia
Mr. Asril A
Mr. 8udi Iman Santoso
Mr. Julianto W
Ms. Rinawati
Ms. Linda A
Mr. Indra S
Mr. Trijatmo Rachimhadhi
Ms. Rulina Suradi
Ms. Sari Handayani
Ms. Harni Koesno
Ms. Mustika Sotyan
Ms. Yumiarni
Ms. Nur Ainy Madjid
Ms. Indah Hartati
Ms. Tati R.
Ms. Mastinah
Ms. Sri Purwani
Ms. Soekaemi Soekir
Ms. Rosmini Sembiring
Ms. Titi Murdiati
Ms. Ipah Saripah
Ms. Sri Ambarwati
Senior MCH Advisor, 8HS
Chief of Party
Deputy Chief Officer
Deputy Chief Officer
PC Advocacy
Administration
PC Training
8CC Commob
ROD
District Facilitator
PC HSM
General Chainnan
General Chainnan
Chairman
Member
Professor
Master Trainer
Director of Medical Service
Staff
Nursing Division
Secretary of Working Group
General Chairman
Member of the Board (Professor)
Staff
President
Chairperson I
Chairperson II
Secretary General
Member
President
Vice President
Treasury
President
President
President
Secretary
President
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 67
Ms. Siti Chusnijah
Ms. Heri H
Ms. Agnia Restu S.
Ms. Ai Andriani
Ms. Emay
Mr. Syamsul Bahri
Ms. Siti Dahniar
Mr. Rurit Rudyanto
Mr. Chusnul Hakim
Mr. Rusli Barus
Mr. Nandang Suherman
Mr. Hendi Irawan
Mr. Deden Hilga S.
Ms. Noerony Hidayat
Ms. Zenni M.
Mr. Didin Nuradin
Mr. Waluyo
Mr. AA Raka
Ms. Teti Rahmayati
Ms. Tuti
Ms. Andi Mala Ummu R
Ms. Muzaenas Zein
Ms. Ulfah Mashfufah
Ms. Yusanti Mariyan
Ms. Sinta Istadi Priyono
Ms. Sayu Ngurah
Ms. Keety Salea
Mr. Yogy Fabretta
Mr. Sabur Pramadi
Mr. Anugraha
Ms. Heryanti
Ms. Janti
Mr. M Nisramudin
Mr. Etten
Mr. Herman
Mr. Cecep Ridwan
Ms. Dedeh K.
Ms. Sri Sulami
Ms. Tanti Budi
Ms. Fatimah
Ms. Ina
Ms. Muchlis
Ms. Iri S. Haryana
Ms. Nia K.
Ms. Anah Q.
Ms. Enok Wartiwi
Ms. Esih Kurniasih
Ms. Euis B.
Ms. Eva Susandiani
Ms. HaniW
Malang Midwife Association
Cimahi Midwife Association
Midwife Association
Midwife Association
Midwife Association
IPD (Institute for Village Development)
IPD
Malang Budgetting Watch (MADEWA)
Konsorsium Keadilan & Kesejahteraan
P2KS
Advocacy Team
P3MUTim Advokasi
FDAlP3ML
NGO SSS
LSS
Lakesdam
FD Sayang
PC Kota Bandung
Fatayat NU
Fatayat NU
Fatayat NU
PT Radio
PT Optima Nara Ekspresi
PT Optima Nara Ekspresi
PT Optima Nara Ekspresi
PT Optima Nara Ekspresi
PT Optima Nara Ekspresi
PT Optima Nara Ekspresi
HSP
USAID
RBS Fatimah
BPS (Private Midwife)
CHC, Mergosono District
CHC, Sumedang
CHC, Sumedang
CHC, Sumedang
CHC, Sumedang
CHC, Sumedang
CHC, Sumedang
CHC, Sumedang
CHC. Sumedang
President
President
Member
Member
Member
Executive Director
District Advocacy Team
District Advocacy Team
District Advocacy Team
Secretary
District Advocacy Team
District Advocacy Team
District Advocacy Team
District Advocacy Team
District Advocacy Team
District Advocacy Team
District Advocacy Team
Treasury
Facilitator
Facilitator
Member of the Board
Member of the Board
Member of the Board
Business Director
Account Executive
BCC Trainer
Art Director
Art Director
CopyWriter
Translator
Translator
Secretary
Bidan Delima
Bidan Delima, Malang City
Bidan Delima, Tumpang Village
Owner
Practitioner
Head
Head
Vice Head
Member
Member
Member
Member
Member
Member
68 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
Ms. Lilis N.
Ms. Mela
Mr. Syari
Mr. Tulus
Ms. Ruminawati
Ms. Sinansari
Ms. Yenny Makasudede
Others
Mr. Arum Atmawikarta
Ms. Sita Ari Purnami
Mr. James C. Sonnemann
Ms. Sri Duryati
Boedihardjo
Ms. Claudia Rokx
Mr. Martin Weber
Ms. Fitri Putjuk
Mr. PA Kodrat Pramudho
Ms. Meiwita Budiharsana
Ms. Sinta Istadi Priyono
Ms. Hermiyanti
Mr. Lukman
Hendrolaksono
Ms. Sulatni
Ms. Erna
Ms. Atikah Adyas
Prof. (M.r) Emil Salim
Mr. Ascobat Gani
Mr. Mahlil Ruby
Mr. Laksono T
Mr. Wijono
Mr. Adam
Mr. Djoko Soetikno
Mr. Budihardja
Ms. Widyastuty
Ms. Elsa Handayani
HSPJAKARTA
CHC, Sumedang
CHC, Sumedang
CHC, Sumedang
CHC, Tawangrejeni
CHC, Tawangrejeni
FKM UI (Faculty of Public Health)
FKMUI
Bappenas
Women's Research Institute
Millennium Challenge Corp. Indonesia
(MCCI)
MeC
World Bank
WHO
Johns Hopkins University
Center of Health Promotion, MOH
Ford Foundation
ONECOMM
Directorate of Maternal Health, MOH
Directorate of Maternal Health
Directorate of Child Health
Directorate of Child Health
Health Financing, MOH
President Advisor
Faculty of Public Health
Financing Specialist
Gajah Mada University
Local Governance Support Group (LGSP)
LGSP
JHPIEGO
MOH, Community Health
WHO
Johnson & Johnson
HSP
Member
Member
Member
Head
Village Midwife
Student
Student
Director of Health and Community
Nutrition
Executive Director
Chief of Party
Public Health and Immunization
Advisor
Lead Health Specialist
Child and Adolescents Advisor
Country Rep.
Chief of Partnership Division
Representative
Director
Director
Subdivision chief
Director
Subdivision chief
Member
Expert, Health Economics
Expert, Health Economics
Expert, Decentralization
Advisor, Planning
Advisor, Services
Director
Director General
Consultant on Health Financing
Advisors, Consultants, Staff
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP)IN INDONESIA 69
70 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
APPENDIX C: TOOLS AND GUIDELINES DEVELOPED WITH
HSP ASSISTANCE
Tool Contributors National Trainers (Ownership)
DTPS-MNCH: Planning Dir. Ibu, Dir. Anak, Dir. Gizi, 15 master trainers
Yanfar, UI, Pena/a Hati 84 national facilitators
34 province facilitator
DTPS-MNCH: Advocacy WRI, Dir. Ibu, Dir Anak, PromKes, 19 master trainers,
Pusdiklat, ADB, WHO, UNICEF 69 national trainers
IMCI, UKK-IDAI, Dir. Anak, Dir. Gizi, 10 national IMCI facilitators
Dir. Surveillance, Dir.P2ML and 9 PHO trainers from 4 provinces
Dir. P2B2, WHO, Save the 22 DHO trainers from 10
Children, GTZ, JlrCA, UNICEF districts
APN 2008 JNPK, IDAI, IBI, Dir. Ibu, Dir. Gizi, JNPK national network of
Dir. Anak, WHO, UNICEF, Save clinical trainers (P2KS/P)
the Children
APN Qualification & JNPK, Dir. Ibu JNPK national network of
Accreditation tool clinical trainers (P2KS/P)
PONED (BEONC) 2008 JNPK, Dir. Ibu, Dir. Anak JNPK national network of
clinical trainers (P2KS/P)
Supportive Supervision Dir. ibu, Dir. Anak, Dir P2PL, Dir 20 MOH national trainers
Yanmedik, Pusdiklat, JNPK, IBI, 5 JNPK national trainers
UNICEF, WHO 50 provincial trainers
111 district trainers
420 puskesmas staff trainees
Behavior Change PromKes, Dir. Ibu MOI-i and PHO trainers
Communications
P4K modules Dir Ibu, PromKes Desa SiAGa module produced
in 2006 - HSP trained trainers
from all 31 provinces
P4K - module pending approval
Breastfeeding - KADARZI Dir. Gizi, IBI 6 PHO trainers
Community Modules 16 DHO trainers
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 71
72 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
APPENDIX D. ACCELERATING INFANT AND MATERNAL
SURVIVAL (AIMS)
Indicators: -MMR
-IMR&NMR
7Y~s ofindicarors:.EQUity
-Utilization
-C_~
-Sustolnobillty
SUPPGl'tive Enablln&
Environment
-,....
1nU. a
-..... .........
To reduce maternal and
neonatal mortality
Improved utIlization of quality
MNH servICes through
decentralized dIstrict models
Supportive EnabUn,
Environment
-Legal drafting
-Advocacy
-Technical
guidelines
-Consultation w
constituents
-Advocacy
-Planni.ng tools
-:Information
system
-Eva Iuation
system
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) 'IN INDONESIA 73
ItJdicarof$: -MMR
-/MR&NMR
T~ofindicarOIS:_EQUity
-Utilization
-C~fO~
-Sustainobl/ity
To reduce maternal and
neonatal mortality
Improved ut,hzatlon of quahty
MNH servIces through
, decentrdhzed d"trlct models
-------- - ----
-Desa
Siaga/P4K
-SocMob
-BCC
-Posyandu
-Outreach by
C50s
-Beneficiary
tMgeting
-Administration
-Define benefit
package/ pricing/
subsidy polley
-Planning
-Management
-IIMIS
-DCM
-Referral
system
-Strategic
outsourcing
-Management
standards
-Training
-Supervision
-Certification
-Audit
-CiinicJI protocols &
procedures
-Needs assessnl!4t
-Accreditation
74 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
'''dicotors: -MMR
-/MR&NMR
Ty~sof;m1icotofS:., . -..qulty
-Utilization
-Cow:rafJt!
-Sustainabi/ity
Supportive E~blinB
Environment
......,.... Inc.. da
elf .......
...0(....
To ~educe mate~nal and
neonatal mo~tality
Improved utIlizatIOn of quality
MNH servIces through
decentralized d,stroct models
-Consultation w
clients
-Data collection
-Information
dissemination
-Accountability
mechanisms
·Planning
-Monitoring
·Information
dissemination
-Mapping
-Consultation with
constituents
-Musrenbang
-Organization
-Data collection
-Consultation w
facilities & clients
-Epidem iologica.1
surveillance
35
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 75
76 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
APPENIDIX E: INVEST,ING IN IBI
Indkators:
-Number 01deliveries by
midwivesaccording to standards
-Number 01newborns receiving
ENC
Management and gov«naJlce
strencltwned
To strengthen the ability of midwives
to reduce maternal, neonatal. and child
mortality
IElIIn<'UMS .... profusionaillatilln and quality
of midwif4llV Mrvlc41S
Up_.U....1WI Reprt'sentational stattlS
of 181 t'nhanc;ed
Profusion"
man-e4lm.nt
of/Bl
utab!l"'.d
Fundlnr
lncrusedand
cIlV41rstfi4ld
M.mber"'ip
olnra,td
Professions'
intereS1S
represented
To strengthen the ability of midwives
to reduce maternal, neonatal. and child
mortality
I
IBllnere sesthe professionallzation and quality
of milk fery S4r\l!ces
lr-------------IL
M~agem.ntand iOvem~Ce
strengthened
I
Professional m~tliement of
181 established
-Executive secretariat
-Management
committee
-Technical advisory
group
-Other association staff
-Strategic planning
- Expanded information
systems
-Budgeting and financial
systems
-Board /Ieadership
development
fundi", increased and diversified
-Improved fundraisingskills
-Outreach for govt , corporate and
donor
support
- Membership fee collection
-Income generating activities
-IBI clinic business plan
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 77
Indicators:
-Number0/tkliveriesby
midwivn occordimJ to standards
-Number0/fl#wbornsrecei!lifl9
ENe
To strengthen the ability of midwives
to reduce maternal. neonatal. and child
mortality
IBllne,..,.5 •• prof.atoNlIzalion and qualUy
ol.,ldwlf..yMr"(elI
Reprt'wnt.itiolYl st.ihlS
of 181 t'n'WIlCt'<!
P,ol••onAl
m..........nt
ollBl
.sIIbIl....d
Pro ,",ons'
InlUUU
rep,...nlotd
To strengthen the ability of midwives
to reduce maternal. neonatal, and child
mortality
1
181 on<rea~s 1M professionlllatJon MId quJIl.tv
of ml I erv~. us
-Trainingand technical support
-Sanctions for non-compliance
-Monitoring visits
-Data collection and reporting
-Periodicsurvcys
-recertification
-Benefits package
-Marketing strategies
-Provider network for
insurers, employers
BicbnDelma eJq)andfd in
-Facilitator
incentives Expediting
validation
-District selection criteria
-Decentralized leadership
and management
-Launching activities
78 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
Indicators:
-Number 0/deliv~ries by
midwives according to stondords
-Number 0/newborns reeming
EN(
To strengthen the ability of midwives
to reduce maternal. neonatal, and child
mortality
.11 IncreHOS !he profes;onaUullon and quality
ol.,idwllery ..rvIC.~
Rt>prewotatiolWlstatus
Q f 181 t'fIhan{ed
Prol_onal
manacement
01181
est.tllisIMd
Fundlnr
Incre_dand
<Ii_lilied
Men\bel$hip
enr·Ced
ProleS'Sions'
loterem
represented
To strengthen the ability of midwives
to reduce maternal, neonatal, and child
mortality
181 increasesthe professionalization and quality
of mid ifery services
Rel)resentationalstatus of 181
enhanced
Membership engaged
-Membership events/services
-Distance learning
-Leadership opportunities
-Outreach to members
-Support for new midwives
-Social networking
- Member communications
Profe~ons' interestsrepresented
- Advocacyfor midwifery
lawand council
- Advocacyfor midwifery
education
- Competency
certification
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 79
OPPORTUNIT,IES FOR GENERATING RESOURCES Fo.R IBI
Opportunities for Funding Support Value Proposition for Funder
Government Training support for facilitators Private providers can belp district improve
Training support for midwives (AP, MMR and IMR.
etc.) He'lping private providers helps the public
Participation in launch activities and sector, since many work in both areas.
promoting program in community Supporting IBI programs is in line with
Inclusion of qualified BD private obligation to support CSOs.
providers in government insurance Engaging with private providers through BD
programs win can give district leverage to ensure
Could outsource oversight function compliance with reporting, participation in
to professional association. audits by private providers. and participation
in community activities such as CHCs, P4K,
and integrated service posts.
Engaging private providers through insurance
eligibility strengthens ability to mandate
quality standards.
Part of the MOH obligation is to supervise
I private providers and this is an efficient way
to do so. I
Donor Same activities as government, Network with strong quality assurance and
since donors are supporting reporting mechanisms in place makes it
government to improve the health easier to roll out interventions; offers an
system organizational structure to an otherwise
Can use network to pilot new unorganized sector.
interventions or approaches (e.g.,
voucher scheme, CCT, cervical
cancer screening, etc.
Corporate Sponsor training of facilitators Entry point into a market for new or existing
Sponsor promotion of events products through provider referrals or
Sponsor launch and support of distribution
program in key geographic areas Fulfillment of CSR obligations
Use network to provide health Contribute to public relations objectives of
services to employees (at facility corporate sponsor.
and through outreach)
80 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
APPENDIX F: DIARY OF ANI ADVOCACY PARTICIPANT
HSP-MNCH ADVOCACY TEAM JOURNAL OF ACTIVITIES IN SUMEDANG DISTRICT, 2007-2008
No. Date Activity Output Remarks
1 May 2007 Meeting to establish an Advocacy Establishment of an The first multistakeholder meeting, which initiated advocacy work and
Team at the District Health Office Advocacy Team established an Advocacy Team.
2 23 May 2007 Coordinating Meeting on Team A list of stakeholders The second multistakeholder meeting, in which HSP programs were
Development at Hotel Karya supporting advocacy for introduced, especially one that focused on advocacy for MNCH to
Nunggal, Legok MNCH stakeholders and pushed for a Bupati Regulation (Perbup) on MNCH.
An ad hoc team for Perbup consisting of representatives of different
stakeholders was established during the meeting. The meeting was
attended by government staff, CSOs, and HSP.
3 19 June 2007 Advocacy Team Coordinating Establishment of 3 The coordinating meeting was attended by the Advocacy Team,
Meeting at the District Health working groups DHO, and HSP. Three working groups were established during the
Office meeting: Working Group on Policy Analysis, Working Group on I Program and Budget, and Working Group on Maternal & Perinatal
,Audit (MPA).
4 22 June 2007 Meeting on Follow-Up Plan Work Plan for the ad hoc The meeting produced a work plan for the ad hoc team, expected
between the Advocacy Team and team outputs, timeline for the activities, and persons in charge I
HSP at P3ML office
5 3 July 2007 Signing of a Cooperation Signed Agreement The meeting between HSP counterparts in West Java agreed to
Agreement at Aston Atrium Hotel I focus the activities on maternal, neonata'l, and child health.
to focus on MMRlNMR
6 22 July 2007 Development of Work Plan for the 3 TORs for study TORs were developed by the Advocacy Team. Pak Deden wrote the
Advocacy Team to advocate for a analysis TOR for Policy and Budget Analysis, Pak Hendi the TOR for
local regulation on MNCH Academic Paper, and Pak Zeni the TOR for Maternal & Perinatal
Audit (MPA).
7 25-26 July Search for MPA cases by the A film about MPA cases The MPA working group searched for and documented MPA cases in
2007 MPA working group in Sumedang Sumedang. The film was prepared by Pak Zeni and Pak Hendi.
8 3-4 August HSP meeting at the TOGA food Agreements between The meeting was a coordinating meeting to obtain commitment from
2007 stall stakeholders involved in all of stakeholders involved in MNCH advocacy work.
MNCH advocacy work ,
9 6 August 2007 Discussion on analysis design Overview of policy and It was a team meeting which tried to conclude the results of analysis
(M1) at P3ML Office budget allocation for conducted by the Working Group on Budget and Policy. The
reducing MNMR in conclusions were later used in FGD.
Sumedang
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 81
No. Date Activity Output Remarks
10 7 August 2007 FGD on Budget Priorities at P3ML FGD participants
Office learned what the local
govt. priorities were in
terms of policy and
budget to reduce MNMR
11 10 August MNCH Advocacy Team Meeting Input for the academic The meeting discussed division of work among Advocacy Team I
2007 at P3ML Office paper members. Pak Hendi was responsible for collecting and analyzing
data on Renstra (Strategic Plan) and regulations related to the health
sector and MNCH; Pak Deden was responsible for analyzing District
Health Office's Work & Budget Plan and District Annual BUdget and
budget allocation for MNCH activities from 2005-2007; Pak Zeni was
responsible for collecting data on MPA cases. -
12 14-15 August Training in academic paper at 3 members of the 3 members of the MNCH Advocacy Team (Pak Nandang, Pak
2007 Hotel BGG Jatinangor for HSP MNCH Advocacy Team Deden, Pak Zeni) participated in the training. The training really
counterparts in West Java learned how to draft a helped the team draft an academic paper on a regulation on MNCH
good academic paper. for the district.
13 23-24 August Making Pregnancy Safer (MPS) 3 members of the 3 members of the MNCH Advocacy Team (Pak Nandang, Pak
2007 Training in Garut MNCH Advocacy Team Deden, Pak Zeni) attended.
learned about MPS
14 24 August Discussion among the working Preliminary draft of The preliminary draft of academic paper was drafted based on the
2007 groups (M2) at P3ML office academic paper conclusions of analyses of the district strategic plan, health
regulations, district budget, and maternal and perinatal audit findings.
15 29 August Handing over the master copy of A short film made based The working group on MPA handed over the film that they created as
2007 a film created based on the on the MPA results advocacy material based on their MPA findings.
results of MPA
16 30 August Advocacy Team Coordinating Initial legal draft of The meeting was aimed at coordinating the work of the 3 working
2007 Meeting at P3ML office Perbup on MNCH groups. The meeting produced an initial draft of Perbup on MNCH.
17 31 August Revision by the Team (M3) at Revised academic paper
2007 P3ML office
18 4 September Mini-workshop on policy draft A preliminary draft of The preliminary draft of MNCH bill was developed based on the
2007 MNCH dilll academic paper.
19 4-6 September Training and Workshop on MNCH The stakeholders All stakeholders involved in MNCH advocacy work in Sumedang
2007 Advocacy in Sumedang at the involved in the MNCH received training in how to advocate. Participants included District
Hotel BGG Jatinangor advocacy work learned Parliament members, DHO, Advocacy Team, Media, and HSP.
about advocacy
20 6 September Meeting with Sumedang District Parliament Following the advocacy training, the participants did real advocacy to
2007 Parliament members members agreed that Parliament members (Commission C) and wrote a press release that
82 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
No. Date Activity Output Remarks
(Commission C) at the DPRD there should be a law was 'later distributed to all print media in Sumedang.
meeting room. specifically focused on
MNCH issues; they
appreciated the
I advocacy work.
21 6 September Evaluation of Advocacy training I Results of evaluation: After meeting with district Parliament members, the team evaluated
2007 and results of the meeting with : the meeting with the , the training and results of the meeting. It was concluded that the
Parliament members in Toga district Parliament was meeting with the district Pal'iliament was a success.
Village effective.
10 September Discussion with the NGO network Support from the
2007 community for the
Advocacy Team to
continue their efforts to
advocate for a policy
that focuses on MNCH
Input to improve the
draft policy
22 13 September Internal discussion on the draft Revised policy on This meeting was a follow-up to the previous discussion with the
2007 law maternal and child NGO network that provided input for revision of the legal draft.
health--
23 10 October Meeting between the Advocacy Review of academic The Advocacy Team. DHO, and HSP together reviewed the
2007 Team and HSP at P3ML office paper academic paper.
24 29 October Meeting between the Advocacy Revised MNCH The meeting discussed the revisions that need to be made to the
2007 Team, DHO, and Bureau of Law academic paper and academic paper and draft bill.
of BAPPEDA at P3ML Office draft bill
25 17 November Meeting to prepare a discussion Work plan and division Pak Deden developed the TOR for the activity.
2007 with the NGO/CSO network at of work
P3ML Office
3 December Coordinating meeting between Plan of MNCH activities Discussion among stakeholders involved in MNCH programs about
2007 HSP and stakeholders involved in in Sumedang, MNCH the HSP work plan in the district, progress achieved by the Advocacy
MNCH work in Kampung Toga problem map, and Team, DHO work plan, and the district planning and bUdgeting
stakeholders' process. They also discussed stakeholders' commitments. The
commitment meeting was attended by HSP, advocacy team, DHO, midwives,
I I Head of Subdistrict, and the Desa SiAGa team.
26 13 December Discussion to review the Reviewed academic The reviewed academic paper and draft bill was edited to be
2007 academic paper and draft bill on paper and draft bill. submitted to the Special Committee of the District Parliament. But
MNCH Division of roles among first, the DHO presented the maternal and child health profile in the
stakeholders. district and gave an overview of the current status of public health
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 83
No. Date Activity Output Remarks
facilities. The meeting was attended by: DHO, midwives (3),
parliamentarians (6), and P3ML.
27 27-28 Meeting to build common Common perception of Dr. Mahlil Ruby made a presentation on MNCH issues that received
December perception with the district the importance of MNCH a good response from Parliament members, who agreed to make a
1 2008 Parliament and passage of local local regulation on MNCH. The meeting was attended by HSP, the
Iregulation on MNCH Sumedang Advocacy Team, North Sumatra Advocacy Team,
parliamentarians, DHO, and BAPPEDA.
28 7 January 2008 Advocacy Team regular meeting Preparedness of the The meeting was meant to prepare the team to lobby and consult I
at P3ML office team with the district parliament.
29 8 and 22 Lobby and consultation with the Dissemination of
January 2008 district Parliament information on the work
of the Advocacy Team in
the district
Stronger commitment of
the district Parliament to
passing a regulation on
MNCH
Mapping of issues within
the Parliament that may
hamper the effort to
pass a regulation on
MNCH
list of inputs and
recommendations from
the Parliament for
revising, the draft bill
30 14 January Advocacy Team Coordinating Work plan and division The meeting discussed the inputs hat Dr. Mahlil Ruby gave during
2008 Meeting at P3ML Office of work. Inputs for the the meeting in Jatiluhur. Pak Deden was responsible for editing the
academic paper and draft bill, Pak Hendi was responsible for editing the academic paper,
draft bill and Ibu Maya was responsible for videotaping all activities involved in
advocacy for a regulation on MNCH.
31 16 January 08.00 AM: videotaping a radio talk A videotape on Ibu Maya and Pak Deden filmed Pak Nandang at his radio talk show
12008 show, which was part of the advocacy work carried on MNCH advocacy at the Citra FM station in Sumedang.
advocacy work. Pak Nandang out through a medium
Suherman (head of the advocacy (radio)
team) was cohost of the show.
32 116 January 10:00 AM P3ML internal meeting Revised draft bill on Discussion on the draft Bill edited by Pak Deden. Participant: P3ML.
2008 discussing the revised draft bill on MNCH
MNCH
84 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
No. Date Activity Output Remarks
33 16 January 01 :00 PM: Meeting on the draft bill Revised draft bill on Discussion on the revised draft bill on MNCH and inputs from
2008 on MNCH with DHO and district MNCH stakeholders. Participants: Advocacy Team, district Parliament. DHO.
Parliament midwives
34 17 January Discussion on revision of the Revised MNCH An internal meeting at P3ML to edit and revise the MNCH academic
2008 MNCH academic paper at P3ML academic paper paper. Editing team: Pak Hendi and Pak Didin
office
35 24 January Advocacy Team regular meeting Evaluation of activities The meeting was to evaluate all activities in January.
2008 at P3ML
36 6 February Advocacy Team regular meeting Optimal preparation for The meeting was to prepare activiNes to implement community
2008 at P3ML activities capacity-building and participatory budgeting process exercise in
, order to pilot-test the draft MNCH regulation.
37 9,11,15,18,22 Community capacity-building and The community had a
February 2008 participatory budgeting process better understanding of
exercise to pilot test the draft the District planning and I
MNCH regulation. budgeting process.
The community had a
better knowledge of
opportunities for
involvement in the
process.
The community had
better capacity to
analyze the district
government's budget
priority for the health
sector. especially for
MNCH services.
37 23 February FGD with the pro-health group Increased awareness of
2008 and religious organizations at high maternal and
P3ML office neonatal mortality rates
in the district.
Built commitment and
support from religious
leaders to promote
awareness of the
importance of MNCH
service improvement.
Schedule for regular
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 85
No. Date Activity Output Remarks
meetings between
religious leaders and the
community to discuss
development issues,
especially ones that are
related to the health
sector.
38 25 February Advocacy Team regular meeting Evaluation of activities The meeting was to evaluate all activities during February.
2008 at P3ML office
39 13 March 2008 Hearing of the draft bill on MNCH The parliament accepted The Parliament established a Special Committee on MNCH, which
at the local Parliament the MNCH draft bill to be was tasked with reviewing the draft bill as a follow-up.
included in their work
agenda.
140 14 March 2008 Coordinating meeting between Review of work of Review of advocacy work by the Head of the Advocacy Team
HSP, DHO, and Advocacy Team advocacy team and (Nandang Suherman), Head of DHO (Dr. Hilman), and HSP West
at Joglo Restaurant, Sumedang DHO Java regional director (Dr.Wahyu). Participants: Advocacy Team,
DHO, and HSP.
41 17 March 2008 Response from the Bupati
42 17-19 March Evaluation of HSP's work in the Results of performance 3 members of the Advocacy Team (Pak Nandang, Pak Zeni and Pak
2008 West Java region at Hotel BGG evaluation of the Didin) attended the meeting, which was evaluating the work of HSP
Sumedang Advocacy Tearn in the West Java region.
43 19 March 2008 Meeting to discuss the content of Revision of the MNCH
the MNCH bill bill
44 24 March 2008 Advocacy Team evaluation Results of internal Evaluation of the advocacy team and next follow-ups. It was decided
meeting at P3ML evaluation of the that Pak Zeni and Pak Didin would attend the Old District Work Plan
advocacy team meeting at Hotel BGG.
45 5 April 2008 Old District Work Plan meeting at District Work Plan The meeting decided among other things the follow-up activities of
Hotel BGG the advocacy team.
46 ! 9-110 April 2008 Strengthening the Advocacy I Strengthened Advocacy Pak Nandang, Pak Zeni, and Pak Didin attended.
Team in 7 Districts, Round I. Team
Venue: Puri Khatulistiwa
47 5 May 2008 Strengthening the Advocacy Strengthened Advocacy Pak Nandang, Pak Zeni, and Pak Didin attended.
Team in 7 Districts, Round II. Team
Venue: Puri Khatulistiwa
48 15 May 2008 Special Committee Meeting on Revision of the MNCH The Special Committee set up by the Parliament to review the bill
the MNCH bill at the Parliament Bill by the Special made some revision to the content. Participants: Special Committee,
meeting room Committee Expert Team, HSP, Bureau of Law of BAPPEDA, DHO, professional
86 EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA
No. Date Activity Output Remarks
organizations, and csa.
49 16 May 2008 Meeting between the Advocacy Plan to further revise the Since the revision of the bill made by the Special Committee was not
Team and HSP to evaluate the MNCH Bill with the yet optimal, a plan was made to further revise the bill by inviting the
revisions of the MNCH bill made Parliament and a Parliament and Dr. Mahlil as a resource person.
by the Special Committee resource person
50 19 May 2008 Discussion on the revision of the Agreement to further The meeting agreed to further revise the bill as a follow-up to the
MNCH Bill at Hotel Puri revise the MNCH bill revision made by the Special Committee. Dr. Mahlil Ruby would be
Khatulistiwa invited as an expert resource person. The Parliament recognized that
the revision they made was not yet optimal.
51 29 May 2008 Discussion on the MNCH BiU with Agreement to change After Dr. Mahlil Ruby made a presentation to the Special Committee
I
the Special Committee and Dr. the content of the bill and health professionals, it was agreed that the bill needed to be
Mahlil Ruby revised further.
52 I 2 June 2008 Plenary Session at the District Passage of the MNCH After going through a tough hearing, the bill was finally passed and
Parliament to pass the bill bill as a regulation became a regulation.
53 3 June 2008 Press Release: Dissemination of Press Release on the The press release was disseminated to local media in Sumedang and
information on the passage of the passage of the MNCH West Java.
MNCH bill to become a regulation bill
to the local media
54 15 June 2008 Meeting on Legal Framework for Advocacy Team work Pak Nandang, Pak Zeni, and Pak Didin attended the meeting'.
the MNCH regulation. Venue: plan
Hotel BGG
55 24-25 June Workshop on the Roles of Work map of The meeting mapped the work of different stakeholders to implement
2008 Stakeholders in the stakeholders in the MNCH regulation and its work plan. A lead team of 5 people from
Implementation of the MNCH implementation of the different institutions was named during the meeting.
regulation, in Cipanas, Garut MNCH regulation, and
establishment of a lead
team
56 16 July 2008 Advocacy Team Meeting with Results of Advocacy The meeting was to evaluate the work of the advocacy team and
HSP to evaluate the MNCH Team work evaluation draft a work plan for 2008-2009.
regulation at P3ML office. and a work plan for
2008-2009.
EVALUATION OF THE HEALTH SERVICES PROGRAM (HSP) IN INDONESIA 87
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APPENDIX G: REFERENCES
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Bhutta, Zulfiqar, Sarmana Ali, Simon Cousens, Talaha M. Ali, Batool azra Haider, Arjumand Rizi, Pius
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Address Maternal, Newborn, and Child Survival: What Difference Can Integrated Primary Health
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Coles, Tom. Training Consultation Report, January 17-September 30, 2006.
Eckman, Bjorn, Indra Pathmanathan, & Jerker Liljestrand. "Alma-Ata: Rebirth and Revision 7-
Integrating Health Interventions for Women, Newborn Babies, and Children: A Framework for
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De La Galvez Murillo Camberos, Alberto. Vigilancia Epidemiol6gica Comunitaria de la Mortalidad
Materna: Estudio de Caso San Lucas, La Paz, Bolivia: PAHO 2004.
Freedman, Lynn P., Ronald J. Waldman, Helen de Pinho, Meg E. Wirth, A. Mushtaque R. Chowdhury, &
Allan Rosenfield. Who's Got the Power? Transforming Health Systemsfor Women and Children.
London: Millennium Project, 2005.
Hatt, Laura, Cynthia Stanton, Krystyna Makowiecka, Asri Adisamita, Endang Achadi, & Carine
Ronsmams. "Did the Strategy ofSkilled Attendance at Birth Reach the Poor in Indonesia?" Bulletin
ofthe World Health Organization, 85 (October 2007):774-82.
Health Services Program. Annual Report, 2007. Jakarta, 2007.
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Health Services Program. "Evaluation of Workshops Promoting the Early Initiation ofBreastfeeding and
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92 EVALUATION OF THE HEALTH SERViCES PROGRAM (HSP) IN INDONESIA