permata yg hilang

Transcription

permata yg hilang

Australia – Indonesia
Partnership for Maternal and Neonatal Health
13th Progress Report
January – September 2015
Sept 2015
Version 2
AUSTRALIA INDONESIA PARTNERSHIP FOR MATERNAL AND NEONATAL HEALTH
13th PROGRESS REPORT Version 2 | September 2015
Map - AIPMNH Districts
i
Table of Contents
1
Executive Summary
1
2
Ringkasan Eksekutif
7
3
Background
13
4
Progress; Outcome & Objective Indicators
14
5
Work Plan Implementation & Budgets
21
5.1
Annual Work Plans
21
5.2
Work Plan Progress January to June 2015
21
5.3
Work Plans July to December 2015
23
6
Summary Component Progress
24
6.1
Component 1. Community Engagement and Service Delivery
24
6.2
Component 2. Health Systems Support
25
6.3
Component 3. System Reforms in Performance and Accountability
25
7
Personnel and Staff Movement
25
8
Cross Cutting Activities
26
8.1
Policies and Regulations supported
26
8.2
Poverty NTT and AIPMNH
26
8.3
Monitoring and Evaluation
26
8.4
Public Diplomacy
28
8.5
Child Protection
29
8.6
Gender Update
30
9
Coordination, Partnership & Monitoring Visits
31
9.1
Central level
31
9.2
MOH / WHO MNH Strategy 2015 - 2025
33
9.3
Province and District Levels
33
9.4
Partnership
33
9.5
Monitoring Visits
34
10
Replication & GOI Funding of AIPMNH Initiatives
34
11
Issues and Constraints
36
11.1
Reduced Budgets
36
11.2
Increase in Maternal Deaths Jan – June 2015
36
11.3
Contraceptive Uptake Constraints
39
11.4
Fraud Case TTU District
40
ANNEX 1.
Output Progress by Component
41
Component 1.Community Engagement and Service Delivery
42
Component 2.Health systems support
55
Component 3.System reforms in performance and accountability
67
ANNEX 2.
What causes a reduction in Maternal Mortality
69
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ANNEX 3.
Sister Hospital Program Activity Report
83
ANNEX 4.
Sister Hospital by year of intervention
102
ANNEX 5.
Partnership with Religious Organisations
104
ANNEX 6.
DFAT Feedback 12 Progress Report
th
108
ANNEX 7.
District and Puskesmas by year of Intervention
112
ANNEX 8.
Training Data January – June 2015
116
ANNEX 9.
Operational and AAIF Expenditure Jan – June 2015
123
ANNEX 10.
Personnel Movement & Schedule Jan – June 2015
125
Tables
Table 1.
Maternal and Neonatal Deaths 2009 – June 2015 14 AIPMNH Districts
4
Table 2.
Progress in AIPMNH indicators to June 2015
14
Table 3.
No. Females & Males Heads of District Partner Govt. Agencies June 2015
31
Table 4.
Participation in National Technical & Policy Dialogue Jan - Oct 2015
31
Table 5.
DFAT Monitoring visits January – September 2015
34
Table 6.
GOI funding by Activity and District Jan – Dec 2015
34
Table 7.
Replication Desa Siaga, Posyandu and Puskesmas Reformasi until September 2015
35
Table 8.
Materials and products to support replication as at June 2015
35
Table 9.
Maternal death Jan – June 2015 compared to 2014
37
Table 10.
In-hospital deaths & as % of total catchment deaths
37
Table 11.
Complications, deaths, CFR comparing Jan-Jun 2015 and Jan-Dec 2104
38
Table 12.
Workload indicators compared by RSUD, Jan-June 2015 and Jan-Dec 2014
39
Table 13.
APBD Funding for Desa Siaga / Posyandu 2013, 2014 and 2015
49
Table 14.
Number of PERDES KIA by District as at June 2015
49
Table 15.
Number Desa Siaga by district, AIPMNH and Partner funded as at June 2015
49
Table 16.
Progress status of Puskesmas Reformasi Program June 2015
51
Table 17.
Progress against Indicators (Reformasi Puskesmas) to June 2015
52
Table 18.
Numbers trained in SIKDA NTT by District to June 2015
55
Table 19.
Use of Planning & Budgeting tools by Districts 2013 - 2015
57
Table 20.
No. districts pro-MNCH regulations by commencing group (as at June 2015)
60
Table 21.
Procurement completed Jan – Jun 2015
62
Table 22.
Sub-contracts, Expiry Date and Value as at December 2014
63
Table 23.
Absorption of BOK funds by District 2012 - 2015
67
Table 24.
District Coordination Meetings by District Jan – June 2015
68
Table 25.
Comparative indicators for medium sized districts (AIPMNH and non-AIPMNH)
72
Table 26.
Comparative indicators for smaller districts (AIPMNH and non AIPMNH)
76
Table 27.
79
Table 28.
Districts of NTT grouped by FD:MRMR ratio
82
Table 29.
Group 1 RSUD deliveries as % of estimated deliveries in catchment area
86
Table 30.
Group 1. In-hospital deliveries as % of total catchment estimated deliveries
87
Table 31.
Group 1 in-hospital maternal mortality as % of hospital deliveries – all causes
87
Table 32.
Group 1 in-hospital maternal deaths direct obstetric causes as % of hospital deliveries
88
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Table 33.
Group 1 total obstetric complications treated as % of in-hospital deliveries
88
Table 34.
Group 1 total direct obstetric complications treated as % of in-hospital deliveries
88
Table 35.
Group 1 Case Fatality Rate for Direct Obstetric Complications
89
Table 36.
Group 1 Obstetric referrals as % of estimated district deliveries
89
Table 37.
Group 1 Caesarean sections as percentage of hospital deliveries
90
Table 38.
Group 1 Caesarean Sections as percentage of estimated district deliveries
90
Table 39.
Group 1 In-hospital neonatal mortality
90
Table 40.
Group 1 total neonates treated in hospitals
91
Table 41.
Group 1 neonatal complications treated as % of total hospital neonates
91
Table 42.
Group 1 Neonatal complications treated as % of estimated district complications
91
Table 43.
Group 1 Neonatal Case Fertility (CFR) for neonatal complications
92
Table 44.
Group 1 Neonatal referrals as % of est. catchment live births
92
Table 45.
Group 2 in-hospital deliveries as a % estimated deliveries in catchment area
92
Table 46.
Group 2 in-hospital maternal mortality – all causes & direct obstetric causes
93
Table 47.
Group 2 Total obstetric complications & % estimated catchment complications
93
Table 48.
Group 2 Case Fatality Rate for direct obstetric complications
94
Table 49.
Group 2 Obstetric referrals as a percentage of estimated district deliveries
94
Table 50.
Group 2 Caesarean sections total and as % of estimated catchment deliveries
94
Table 51.
Group 2 in-hospital neonatal mortality
95
Table 52.
Group 2 Neonatal complications treated in hospitals
95
Table 53.
Group 2 Neonatal Case Fatality Rate – neonatal complications
95
Table 54.
Group 2 Neonatal referrals as a % of estimated district live births
95
Table 55.
Sister hospital partners and RSUD by year of intervention
103
Table 56.
Districts by year of intervention 2008 – June 2015
113
Table 57.
District Puskesmas by year of intervention 2008 – June2015
113
Table 58.
Training Codes and Abbreviations
122
Table 59.
Operational Account Expenditure January – June 2015 (AUD)
124
Table 60.
AAIF Account Expenditure January – June 2015 (AUD)
124
Table 61.
Total Monthly Expenditure January – June 2015 (AUD)
124
Table 62.
Personnel Movement January – June 2015
126
Table 63.
Adviser staff
127
Table 64.
District, Provincial Staff
127
Table 65.
Program Support Unit staff (PSU)
127
Table 66.
AAIF Funded Staff
128
Table 67.
Sister Hospital Teams
128
Figures
Figure 1.
Budgets and Expenditure District Workplans January to June 2015
21
Figure 2.
Workplan expenditure by month January to June 2015
22
Figure 3.
Number of planned and completed Activities January to June 2015
22
Figure 4.
% Expenditure vs. % completed activities District AWP January to June 2015
22
Figure 5.
Planned and Actual Expenditure by Logframe Output January to June 2015
23
Figure 6.
Medium size districts AIPMNH supported (2014 data)
72
Figure 7.
Medium size districts non-AIPMNH supported (2014 data)
74
Figure 8.
Smaller Districts AIPMNH supported
77
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Figure 9.
Smaller Districts non-AIPMNH supported
78
Figure 10.
Larger AIPMNH supported Districts
80
Photograph
Front cover; Kader (volunteer) Posyandu Manutapen and Midwife making a home visit to a mother
and her first newborn. Home visits are part of the regular activities of the Posyandu. Photo by Edel
Mary Quin Mole
v
Abbreviations
AAIF
ADD
AIPD
AIPHSS
ANC
APBD
APBDes
APBN
AMP
APN
AusAID
AWP
BAPELKES
Bappeda
BAPPENAS
BCC
BEONC
BKB
BKKBN
BLUD
BOK
BPD
BPMPD
BPP
BPPK
BPPSDM
BUK
Bupati
Camat
CE
CEONC
CFR
CTU/ CTU-KB
Dasolin
DCC
Desa
Desa Siaga
DFAA
DGC
DHA
DHO
Dinkes
DPC
DPRD
DTPS
GFP
GOI
Jamkesmas
Jampersal
Approved Activity Implementation Fund
Alokasi Dana Desa (Village Fund Allocation)
Australia Indonesia Partnership for Decentralization
Australia-Indonesia Partnership for Health Systems Strengthening
Antenatal care
Anggaran Pendapatan Belanja Daerah (District or Provincial Government Consolidated Budget)
Anggaran Pendapatan Belanja Desa (Village Government Consolidated Budget)
Anggaran Pendapatan Belanja Nasional (National Government Consolidated Budget)
Audit of Maternal and Perinatal Mortality
Asuhan Persalinan Normal (Normal Delivery Care)
Australian Agency for International Development
Annual Work Plan
Balai Pelatihan Kesehatan (Health Training Centre usually at Provincial level)
Badan Perencanaan Pembangunan Daerah (Regional Development Planning Agency at provincial and district
levels)
Badan Perencanaan Pembangunan Nasional (National Development Planning Agency)
Behaviour Change Communication
Basic Emergency Obstetric and Neonatal Care (PONED)
Badan Keluarga Berencana (District level family planning agency)
Badan Kependudukan dan Keluarga Berencana Nasional (National Population and Family Planning Board)
Badan Layanan Umum Daerah (District Government public service unit that can manage their own operations and
financing)
Bantuan Operasional Kesehatan (Operational Fund provided by MoH for Operational Costs at Puskesmas Level)
Badan Permusyawaratan Desa – (Village Consultation Board)
Badan Pemberdayaan Masyarakat dan Pemerintahan Desa (Community Development and Village Governance
Agency at Provincial and District level)
Biro Pemberdayaan Perempuan (Women’s Empowerment Bureau)
Badan Pembinaan Potensi Keluarga
Badan Pengembangan dan Perencanaan Sumber Daya Manusia (MOH Human Resource Planning and
Development Board)
Bina Upaya Kesehatan (MOH Directorate General for Medical Services)
Elected Head of a District
Administrative Head of Kecamatan ( head of subdistrict)
Community Engagement
Comprehensive Emergency Obstetric and Neonatal Care (PONEK)
Case Fatality Rate
Contraceptive Training Update
Dana Sosial Bersalin (funds collected by the community to assist in delivery)
District Coordinating Committee
Village
Health aware and alert villages
District Finance and Administration Assistant
District Gender Coordinator
District Health Accounts
District Health Office
Dinas Kesehatan (Provincial/District Health Office)
District Program Coordinator
Dewan Perwakilan Rakyat Daerah (Provincial/District Level Parliament)
District Team for Problem Solving
Gender Focal Point
Government of Indonesia
Jaminan Kesehatan Masyarakat (national health insurance for the poor)
Jaminan Persalinan (community insurance for ante-natal, child birth and post natal care)
vi
Kas Desa
KB
KIA
KIBBLA
KIP/K
KKRB
LKMD
LOGICA
LOPP
M&E
MC
MCH
MDG
Memadai
Mini lokakarya
MMR
MNCH
MNH
MoH
MPS
MTBM
Muskus
Musrenbang
NGO
NMR
NTT
OHRMx
P3MD Plus
P4K
PCC
Pedoman Umum
Perda
Perdes
PGE
PHA
PHO
PKK
PMPK-UGM
P2K3 UNDANA
PNC
PNPM
PNPM GSC
PNPM MPd
POKJA
POKJANAL
Polindes
POLTEKES
PONED
PONEK
Village Funds
Keluarga Berencana (Family Planning)
Kesehatan Ibu dan Anak (Maternal and Child Health)
Kesehatan Ibu dan Bayi Baru Lahir (Maternal and Neonatal Health)
Komunikasi Inter Personal/konseling (Interpersonal/Counselling Communication)
Kementrian Penertiban Aparatur Negara dan Reformasi Birokrasi, Ministry of State Procedures and Bureaucracy
Reform
Lembaga Ketahanan Masyarakat Desa (Village Community Resilience Body)
Local Governance and Infrastructure for Communities Project in Aceh
Life of Program Plan
Managing Contractor
Maternal Child Health
Millennium Development Goal
Satisfactory, adequate
Mini workshop, generally used in terms of the 3 monthly Puskesmas planning meeting
Maternal Mortality Ratio
Maternal Neonatal and Child Health
Maternal and Neonatal Health
Ministry of Health
Making Pregnancy Safer
Manajemen Terpadu Bayi Muda (Integrated Management for Neonates)
Musyawarah Khusus Perempuan –Women’s Planning Meeting.
Musyawarah Perencanaan Pembangunan (Participatory Development Planning Meeting)
Non-Government Organisation
Neonatal Mortality Rate
Nusa Tenggara Timur (East Nusa Tenggara)
Obstetric High Risk Management
Perencanaan Partisipatif Pembangunan Masyarakat Desa Plus Penganggaran – Participatory Village Planning and
Budgeting
Program Perencanaan Persalinan dan Pencegahan Komplikasi (Birth Preparedness Planning Program)
Provincial Coordinating Committee
General Guidelines
Peraturan Daerah (Local Government Regulation)
Peraturan Desa (Village Regulation)
Provincial Gender Expert
Provincial Health Accounts
Provincial Health Office (Dinas Kesehatan or Dinkes)
Pembinaan Kesejahteraan Keluarga (Family Welfare Movement)
Pusat Manajemen Pelayanan Kesehatan (Centre for Health Service Management) – Universitas Gajah Mada
Pusat Penelitian Kebijakan Kesehatan dan Kedokteran ( Centre for Study of Medical and Health Policy) – University
of Nusa Cendana
Post Natal Care
Program Nasional Pemberdayaan Masyarakat (National Program for Community Empowerment providing
unconditional cash grants to community at village level)
Program Nasional Pemberdayaan Masyarakat Generasi Sehat dan Cerdas ( National Community Empowerment
Program for a Healthy and Clever Generation providing conditional cash grants to community at village level)
Program Nasional Pemberdayaan Masyarakat Mandiri Perdesaan (National Community Empowerment Program for
Village Development)
Kelompok Kerja – Working Group (for Posyandu)
Kelompok Kerja Operasional – Operational Working Group (for Posyandu)
Poliklinik Bersalin Desa (Village Maternity Clinic or Village Birthing Centre)
Politeknik Kesehatan (Health Polytechnic)
Penanganan Obstetri Neonatal Emergensi Dasar (Basic Emergency Obstetric Neonatal Care/BEONC)
Pelayanan Obstetri Neonatal Emergensi Komprehensif (Comprehensive Emergency Obstetric Neonatal
vii
Poskesdes
Posyandu
PPGDON
Pra-musrenbang
PRC
Progsus
PUG
Puskesmas
PWS
RAKONTEK
Reformasi
Puskesmas
Renstra
Revolusi KIA
RKPD
ROREN
RPJMDES
RSPP
RSUD
Satker
SDM
Sekber
SEKDA
SIKDA
SK
SKPD
SOP
SoS
SPM
Tabulin
TBA
Tokoh masyarakat
TOR
TOT
TTS
TTU
TWG
UGM
UNFPA
UNICEF
UPK
Care/CEONC)
Pos Kesehatan Desa – Village Health Post
Pos Pelayanan Terpadu (Integrated Health Post for MCH)
Pertolongan Pertama Gawat Darurat Obstetri dan Neonatal (Basic First Aid for Maternal and Neonatal)
Pra-Musyarawarah Rencana Pembangunan Desa – Preparatory Village Level Development Planning Meeting
Project Review Committee
Program Khusus (In service training program to upgrade qualifications of midwives)
Pengarusutamaan Gender (Gender Mainstreaming)
Pusat Kesehatan Masyarakat (Community Health Centre at the sub-district level)
Pemantauan Wilayah Setempat (Local Area Monitoring)
Rapat Koordinasi Tehnis Kesehatan (Health Technical Coordination Meeting)
Health Centre Reform Program
Rencana Strategis (Strategic Plan)
Revolusi Kesehatan Ibu dan Anak – Revolution in Maternal and Child Health
Rencana Kerja Pemerintah Daerah (Work Plan of Local Government)
Planning and Budgeting Unit of Ministry of Health
Rencana Pembangunan Jangka Menengah Desa ( Medium-Term Village Level Plan)
Rumah Sakit Penyangga Perbatasan (Public Hospital near National Border)
Rumah Sakit Umum Daerah (District Public Hospital)
Satuan Kerja (Work Unit)
Sumber Daya Manusia (Human Resources)
Sekretariat Bersama (Local government donor coordination unit)
Sekretariat Daerah (District Secretariat)
Sistem Informasi Kesehatan Daerah (Provincial/District Health Information System)
Surat Keputusan (Decree or Written form of decision of a government official)
Satuan Kerja Perangkat Daerah (Local government agency or department)
Standard Operating Procedures
Scope of Services
Standar Pelayanan Minum (Minimum Service Standards)
Tabungan Ibu Bersalin (Pregnant mothers’ savings fund)
Traditional Birth Attendant
Community leaders
Terms of Reference
Training of Trainers
Timor Tengah Selatan (South-Central Timor)
Timor Tengah Utara (North-Central Timor)
Technical Working Group
Universitas Gajah Mada (Gajah Mada University)
United National Family Planning Association
United Nations Children’s Fund
Unit Pelaksana Kegiatan (Activity Implementation Unit)
viii
1 Executive Summary
This is the thirteenth and final Progress Report for the Australia Indonesia Partnership for Maternal
and Neonatal Health (AIPMNH) program. The report covers the period January to September 2015,
which is also the second six months of Part II of the Transition Phase. The Transition Phase purpose
was to provide a bridge to the new Primary Health Care Strengthening and Maternal and Newborn
Health Program (PERMATA). PERMATA was tendered in late 2014 with interviews in March 2015. In
mid-August 2015, DFAT announced that PERMATA would not proceed.
AIPMNH will therefore
finalise in December 2015 without transition to a new program. Senior DFAT staff made a visit to
Kupang (9–10 September) to meet with the Governor and other stakeholders to discuss these
changes in the Development Cooperation program.
Despite not transitioning to a new program,
progress in this period has been good with a focus on documentation and dissemination of initiatives.
There has also been success in advocating for increased local government funding of initiatives,
institutionalisation of initiatives through development and promulgation of provincial and district
regulations and consolidation of demand side activities through partnering with religious organisations.
The main text of this report covers progress towards program outcomes while details on progress with
outputs and activities is at ANNEX 1 (with a summary in the main text under section 6, page 24). A
separate report on the Sister Hospital Program activities is at ANNEX 3. Routine annexes on training
(ANNEX 8) expenditure (ANNEX 9) and staffing (ANNEX 10) are also included.
Program Management
As per the 2012 Strategic Review, the aim of the Transition Phase was to maintain essential activities
and continuity of specific interventions to prevent a loss of investment. The range of activities was
reduced along with budgets, directly employed staff and as from July 1
st
2014, the number of
operational districts was reduced from 14 to 10 Districts. The four Districts ‘graduated’ from the
program were Kota Kupang, Kabupaten Kupang, Sikka and Belu. These districts were identified as
being most capable of continuing to improve MNH with their own resources, although some limited
assistance did continue for a short period (principally Community Engagement and the Health
Information System (SIKDA)).
The Independent Completion Review (ICR) commenced in November 2014 with a draft report sent to
AIPMNH for review and written comments in April 2015. The ICR was generally positive including
acknowledging that in AIPMNH districts there has been a 40% fall in maternal deaths between 2009
and 2014. While the ICR process has been finalised, the report is yet to be published. The Activity
Completion (ACR) Report for the program was submitted in April 2015 and finalised in June 2015.
AIPMNH continues to operate in the absence of an extension to the Subsidiary Agreement (SA).
Ongoing endeavours to assist include support for conducting a Technical Working Group (TWG)
meeting, field visits and a Project Review Committee (PRC) meeting (see section 9.1). All necessary
documentation of BAST is complete, however as at early September, there remains uncertainty as to
which level of government is responsible for final sign off. Dialogue with the MOH and Ministry of
Finance is ongoing to find a solution.
The Provincial Coordinating Committee (PCC) and Sister
Hospital (SH) coordination meetings were held in late May in Denpasar with 15 Central Level
Government of Indonesia (GOI) representatives attending and the usual excellent representation from
NTT, recommendations from the PCC are at section 9.3 on page 33.
Knowledge Management
Documentation and publication of AIPMNH initiatives will be complete for all activities and studies by
November 2015 (see Table 8 on page 35 for a complete list). Active dissemination of lessons learned
1
is continuing through a variety of mechanisms including presentations and distribution of materials at
conferences and meetings (see Table 4 on page 31 for details). Good coverage in local media has
continued with over twenty articles being published in this period (section 8.4 on page 28). The
th
AIPMNH website is currently being updated and will be completed before the 30 of September.
Key Achievements
Support for policy and regulation development has continued; the Integrated Health Planning and
Budgeting Gender Responsive (IHPB-GR) is now incorporated into a Governors Regulation (PerGub);
an SK for SIKDA is also signed; also signed is a PerGub on integration between Puskesmas and
Village Planning to take advantage of Dana Desa; and the Revolusi KIA revisions to become a
Provincial Regulation (PerDa) were successfully passed by the Provincial Parliament (DPRD) in early
September (see section 8.1 page 26 for further details).
Accreditation of the PML Puskesmas
(Management and Leadership program for Puskesmas) training package is also almost complete.
Active involvement by the Community Engagement (CE) Advisers with development of guidelines,
procedures and local regulations for implementation of the Dana Desa program is continuing and this
will ensure allocation of village budgets to MNH activities.
Focus on promoting the demand side for services has also continued by collaborating with the NTT
government initiative for home based monitoring of newborns by village PKK kader (Family Welfare
Movement volunteers). Involvement with religious organisations continues and this has shown great
potential as a communication mechanism to provide information to the community on the benefits of
delivery in a health facility and acceptance of referral to hospital when required.
chronology and approach is documented in ANNEX 5 at page 104.
The process,
The booklet on marriage
counselling which emphasises reproductive health and the first 1,000 days of an infant’s life is now on
the Indonesian side of the AIPMNH website. Similar booklets for other faiths will be finalised and
published before the end of the program.
Commitment from the Provincial and District governments remains strong, as evidenced by the almost
doubling of funding to support replication and sustainability of program initiations. Total funding in
2014 was Rp.19 billion and this year it is Rp. 37 billion. See section 10 page 34 for details.
th
A Gender Policy Dialogue Workshop was held in Kupang on the 7 of August that brought together a
cross section of participants to discuss and debate examine existing policies in relation to informed
consent and impact of gender inequality of the health status of women. See section 8.6 page 30 for
details.
Private Sector Engagement
While AIPMNH was designed without any specific objectives of working or partnering with the private
sector, the instances where this occurred was through sub-contracting of private sector firms for
technical and construction services as well as for supply of equipment. Under Component Three,
there was capacity building for government staff in procurement and contracting with the private
sector. Finally, there has been successful advocacy to the private sector in terms of accessing
Corporate Social Responsibility funds for Puskesmas equipment and construction of Rumah Tunggu
(pregnancy waiting houses).
M&E and Lessons Learned
The following lessons learned are based on the ongoing monitoring, including the studies and
documentation. Section 8.3 on page 26 details M&E activities for the period.
•
Response to potential increase in maternal deaths: The recent reports of increased maternal
deaths emphasise the need for health systems to have capacity to identify changes and respond
2
to them. The NTT system now has better capacity to identify potential problems with maternal
deaths through the maternal audit process, but the system has yet to initiate a significant
response.
At the least, dissemination of the findings, and alerting district health offices and
hospitals of the need to maintain responsiveness to obstetric emergencies, particularly
haemorrhage, is warranted. Further investigation of possible factors, including overload on newly
returned and newly graduated specialist doctors, and the loss of PONED capacity through transfer
•
of Puskesmas staff, could also be undertaken.
The need to improve communication and engagement between regional PHO and the MoH:
This report details two areas where there is potential poor alignment between central level policy
development, and innovations at the regional level. These refer to the NTT development of a local
HMIS (SIKDA), and a workforce management system (SIMKA). Despite efforts to ensure central
level engagement, and to ensure regional level tools are aligned to national policy and systems,
there has been relatively low levels of engagement from the central level, and a tendency to
impose centrally developed policies and systems, even where there are well functioning local
•
policy and systems.
Maintaining PONED capacity in Puskesmas:
The study on complications management
highlighted the low capacity of non-PONED Puskesmas to address maternal and neonatal
complications, and the importance of maintaining PONED capacity. However, other reports have
found that transfer of PONED trained staff from Puskesmas have severely reduced PONED
teams, and therefore significantly limited PONED service provision.
With greater capacity in
district hospitals to provide PONED training and follow up internships, district health offices have
the capacity to replace or rotate staff with PONED skills. More flexibility and responsiveness from
•
workforce deployment policy is needed to enable maintenance of PONED capacity.
Puskesmas Midwife Coordinators: The midwife coordinator at the Puskesmas (Bikor) plays an
important role in providing technical supervision and support to midwives in the Puskesmas and its
networks, including in the village (bidan desa). The study of knowledge and competencies of the
Bikor indicated that many had low levels of both knowledge and competencies, and would not be
able to fulfil their roles. The study recommended that candidates for the Bikor position be selected
on strict criteria including knowledge and skills and ability to supervise and instruct, not just
seniority. A further recommendation was that all Bikor should be qualified as Clinical Instructors.
A fully competent Bikor could then provide structured ongoing training and supervision to all the
midwives thereby alleviating some of the need for the current practice of expensive and timeconsuming in-service training.
Key Challenges
Unfortunately, a marked increase in reported maternal deaths has been recorded from both current
and former AIPMNH districts in the period January to June 2015, and an analysis of this is under
Issues (section 11.2, page 36). At ANNEX 2 on page 69, the association between increased coverage
of facility delivery and reductions in maternal mortality in NTT districts over the period 2009 to 2014 is
further explored to identify variations in this association among individual districts. While a majority of
districts demonstrate the expected reduction in maternal mortality as coverage of facility delivery
increased, some districts with widely distributed populations and/or poor access to referral hospitals
did not achieve as a large a reduction in maternal mortality, or achieved no reduction.
In this period a fraud case occurred, the perpetrator being a staff member of AIPMNH. Funds have
been returned, and DFAT has officially closed the case. See section 11.4 on page 40 for details. This
is only the second fraud case in the program and given the amount of funds that have been managed
since 2009 is indicative of sound financial management.
3
Relevance: At the time of the design, NTT had amongst the highest maternal and neonatal mortality
rates and was one of the poorest provinces in Indonesia (and remains so).
The high maternal
mortality is a good indicator of a poorly functioning and little used health system. AIPMNH’s focus on
maternal mortality is relevant to the needs of local communities, and its approach of building
engagement between service providers and the community is relevant to the context of NTT.
AIPMNH is also relevant to national and local government priorities. Achievement of the Millennium
Development Goals (MDGs) is a GOI priority and AIPMNH supports goals 4 and 5 and contributes to
goal 3. AIPMNH also supports the Province’s own strategy to reduce mortality through the Revolusi
KIA.
Purpose: The AIPMNH purpose is to contribute to reduced maternal and neonatal mortality in NTT
and the strategy addresses known (evidence based) causes of maternal and neonatal deaths from
village to District level.
Effectiveness: The project goal is to reduce maternal and neonatal mortality in intervention districts.
Absolute numbers of reported maternal deaths declined by 40% between 2009 and 2014 (as per the
ICR report) while absolute numbers of live births have remained approximately constant. In this sixmonth period, there has been an apparent increase in maternal deaths and, while the data has yet to
be validated and it is just six months data, it is very concerning (Table 1). A full analysis is in the
Issues section of the main report (section 11.2 page 36), which finds that haemorrhage is the main
cause of reported maternal deaths, and that the increased deaths are occurring both in hospital and in
the community. There has also been an apparent increase in neonatal deaths this period. As in
previous reports, it is likely that there has been considerable underreporting of neonatal deaths and
therefore the apparent increase could be due to a real increase, an increase in reporting or a
combination of both. As per previous reports, it is considered that almost all maternal deaths are now
being reported.
Table 1. Maternal and Neonatal Deaths 2009 – June 2015 14 AIPMNH Districts
Year
Live births
Reported Maternal Deaths
(absolute nos)
Reported Neonatal deaths
(absolute nos)
2009
2010
2011
2012
2013
2014
Jan – June 2015 un-validated
70,981
69,264
73,225
74,184
72,563
72,087
33,860
186
182
148
125
123
109
72
756
682
585
794
753
696
404
Note; AIPMNH commenced in 3 districts in 2008, 9 in 2009, 14 from 2010 and reduced to 10 from July 2014 (see ANNEX 7 for
the complete schedule). For the purpose of comparison, all 14 are included in the 2009 data in Table 1
As per Table 1 if current trends continue, there is likely to be a significant increase in both maternal
and neonatal reported deaths over this year.
Component 1 objective is to increase facility-based deliveries in intervention districts
Between 2009 and 2014, facility-based deliveries increased by 31% (42% to 73%) but since 2012
have plateaued, with a further increase of only 2% (71% to 73%). See ANNEX 2 for analysis of this
and other indicators over the past five years and the relationship to Maternal Mortality.
Component 2 objective is allocation of ≥ 10% local government budgets (APBD II) for Health.
Average District budget allocation for Health over the 10 districts for 2015 is approximately 16%. In
2011, the average was less than 10%, thus demonstrating a continued upward.
Note: Budget
information for 2016 is not yet available.
4
Component 3 objective is that the Districts competently and transparently manage various funding
resources for Puskesmas (BOK, Jamkesmas, Jampersal) and AIPMNH funds by the end of 2012
Apart from the UPK (Unit Pengalola Kemitraan or Partnership Management Unit) and partner
coordination, all other activities under component three are now complete. BOK allocations for 2015
are approximately 10% of those for 2014 (see Table 23) but it is understood that allocations for 2016
will be restored to previous levels.
Efficiency: All intervention Districts are demonstrating engagement and support for the program and
are replicating and sustaining initiatives using local (APBDII), ADD (Village funds), Dana Desa, BOK
(MoH Operational funds) and JKN (National Insurance funds) funds.
Details of partner support
funding for ongoing support and replication is at Section 10 (page 34) of the main report.
Sustainability: All activities are planned with relevant GOI agencies following GOI processes and
procedures and use local unit costs. Introduction of all new initiatives, or modification of existing
programs, follows a process of dialogue and negotiation and this approach has fostered both local
ownership and a sense of genuine partnership. Districts themselves also develop innovations that the
flexibility of AIPMNH funding and technical assistance can foster. All provincial and district workplan
activities have been managed though the Bappeda UPKs for four and a half years which supports
improved district coordination, prevents duplication of activities and again fosters local ownership. No
AIPMNH funds are provided for operation of the UPKs.
All districts are continuing to replicate and provide funding for ongoing support of a number of the
project-introduced initiatives including Sister Hospital, Puskesmas Reformasi, Desa Siaga, Revitalised
Posyandu, on-the-job training for midwives and PML Puskesmas. Communities too are contributing
time, resources and funds to many activities and this too supports sustainability. The private sector
through their Community Social Responsibility (CSR) funds are contributing to facilities in several
districts including in Ende where three Rumah Tunggu (maternity waiting rooms) are being
constructed with these funds.
AIPMNH funding for NTT SIKDA has markedly decreased in 2015. SIKDA is being implemented in all
NTT Districts and continues to have strong government support at both provincial and district levels.
An SK DinKes was finalised this period and the Provincial Health Office (PHO) will support a
Provincial Regulation (PerDa) in 2016. The NTT SIKDA is recognised by the MOH Centre for Health
Data (Pusdatin) as an effective system.
Relevant Health & Social Context NTT: The NTT Health Profile published in September 2015
provides the following relevant facility based data for 2014.
•
Of the ten most reported diseases at Puskesmas, respiratory illnesses comprise 55%,
musculoskeletal problems 11%, diarrhoea 4% and the other leading diseases cover, skin
diseases, aches and pains, fevers etc.
•
TB new cases detected in 2014 are 3,603 and total cases 5,079
•
New cases of HIV are 219 (2013 = 178) and AIDS 383 (2013 = 283)
•
Measles total cases 411 up from 308 in 2013 and again the majority in TTS
•
Neonatal tetanus 3 cases (also 3 in 2013)
•
Malaria annual parasite incidence rate of 13 (down from 20 in 2013 and 23 in 2012) test based
The decrease in Malaria continues the positive trend from previous years but the increase in reported
measles cases indicates continuing issues with the immunisation program.
5
Expenditure: Expenditure for the six-month period, including the AAIF funds is at ANNEX 9.
Expenditure details for workplans and completion rates of activities for this reporting period are at
section 5.2 and graphed in Figure 1 to Figure 5.
Personnel: Personnel movement is at section 7 of the main report and the schedules are at ANNEX
10 and include details on all staff including Sister Hospital staff.
Constraints and Major Issues:
These are detailed under section 11 of the report and are (1)
Budgets (2) Increase in Maternal Deaths, (3) Fraud Case and (4) Contraceptive Uptake Constraints.
Next Six Months: This is the final six months of AIPMNH. All District activities will be completed by
early November and detailed planning is complete for closure and handover of the District Offices.
The Handover Plan submitted in 2014 will be updated and resubmitted. The ACR, finalised in June
2015 will be updated once final procurement and financial information is available. The Provincial
AIPMNH office will close on December 23 (prior to the 2015 Christmas break). A final PCC will be
held in October 2015.
6
2 Ringkasan Eksekutif
Dokumen ini adalah Laporan Kemajuan ketigabelas dari program Kemitraan Australia Indonesia untuk
Kesehatan Ibu dan Bayi Baru Lahir (AIPMNH). Laporan ini mencakup periode Januari sampai Juni
2015, yang juga merupakan enam bulan ke-dua, Bagian II dari Fase Transisi. Tujuan dari Fase
Transisi adalah sebagai jembatan untuk Program Primary Health Care Strengthening and Maternal
and Newborn Health Program (PERMATA). PERMATA ditender pada akhir 2014 dan wawancara
dilakukan pada bulan Maret 2015. Pada pertengahan Agustus 2015, DFAT mengumumkan bahwa
PERMATA tidak akan diproses. Karena itu, AIPMNH akan berakhir pada bulan Desember 2015 tanpa
ada transisi untuk program baru. Pejabat dari DFAT berkunjung ke Kupang (9–10 September) dalam
rangka bertemu Gubernur dan para pemangku kepentingan untuk membahas mengenai perubahanperubahan dalam program Kerjasama Pembangunan ini. Meskipun tanpa transisi menuju program
baru, sudah ada kemajuan yang bagus selama periode ini dimana periode ini berfokus pada
pendokumentasian dan penyebaran berbagai inisiatif, berhasilnya advokasi untuk peningkatan APBD
dalam
mendanai
inisiatif-inisiatif
tersebut,
pelembagaan
inisiatif
melalui
penyusunan
dan
pengundangan Peraturan Daerah baik di tingkat Provinsi dan Kabupaten serta konsolidasi kegiatankegiatan dari sisi permintaan melalui kemitraan dengan lembaga-lembaga agama.
Bagian utama dari laporan ini mencakup kemajuan dari hasil-hasil program/outcomes sedangkan
rincian mengenai kemajuan beserta keluaran/outputs dan kegiatan-kegiatan terdapat pada
LAMPIRAN 1 (bersama rangkuman dalam laporan utama bagian 6). Laporan terpisah mengenai
Program Sister Hospital terdapat pada LAMPIRAN 3. Lampiran-lampiran rutin mengenai pelatihan
(LAMPIRAN 7) realisasi anggaran (LAMPIRAN 8) dan Staf (LAMPIRAN 9).
Pengelolaan Program
Sesuai dokumen 2012 Strategic Review, tujuan dari Fase Transisi adalah untuk mengawal kegiatankegiatan penting dan keberlanjutan berbagai intervensi spesifik agar investasi tidak hilang.
Serangkaian kegiatan dikurangi seiring dengan berkurangnya anggaran, staf, dan mulai 1 Juli 2014,
jumlah cakupan kabupaten berkurang dari 14 menjadi 10 Kabupaten. Empat Kabupaten yang ‘telah
lulus’ dari program AIPMNH adalah Kota Kupang, Kabupaten Kupang, Sikka dan Belu. Kabupatenkabupaten ini dianggap paling mampu untuk melanjutkan upaya peningkatan KIBBLA dengan sumber
daya sendiri, meskipun masih ada bantuan terbatas yang diberikan dalam periode yang singkat
(terutama untuk Community Engagement dan SIKDA).
Independent Completion Review (ICR) dimulai pada bulan November 2014 dan draf laporannya
dikirim ke AIPMNH untuk ditinjau dan diberi umpan balik pada bulan April 2015.
Laporan ICR
umumnya positif antara lain adanya pengakuan bahwa telah terjadi penurunan kematian ibu sebesar
40% di kabupaten-kabupaten wilayah kerja AIPMNH antara tahun 2009 dan 2014. Meskipun ICR
telah selesai namun laporannya belum dipublikasi. Laporan Activity Completion (ACR) mengenai
program AIPMNH telah diserahkan pada bulan April 2015 dan diselesaikan pada Juni 2015.
AIPMNH terus beroperasi meski tanpa perpanjangan Perjanjian Tambahan (SA).
Upaya
berkelanjutan untuk membantu termasuk dukungan untuk melakukan Technical Working Group
(TWG) pertemuan, kunjungan lapangan dan Project Review Committee (PRC) pertemuan (lihat
bagian 9.1). Semua dokumen BAST sudah lengkap, namun sampai awal September, masih terdapat
ketidakjelasan
mengenai
tingkatan
pemerintah
manakah
yang
bertanggungjawab
untuk
menandatangani dokumen tersebut. Dialog bersama Kemkes dan Kementerian Keuangan terus
dilakukan untuk menemukan solusinya. Pertemuan Komite Koordinasi Provinsi (PCC) dan Sister
Hospital (SH) diadakan pada akhir Mei di Denpasar dimana terdapat 15 perwakilan dari Pemerintah
Pusat dan perwakilan dari NTT yang hadir, rekomendasi PCC terdapat pada bagian 9.3.
7
Pengelolaan Pengetahuan
Dokumentasi dan publikasi berbagai inisiatif AIPMNH untuk semua kegiatan dan penelitian akan
diselesaikan pada bulan November 2015 (lihat Tabel 8 untuk daftar lengkapnya).
Berbagai
pembelajaran terus disebarkan secara aktif melalui berbagai cara seperti presentasi dan distribusi
materi saat konferensi dan pertemuan (lihat Tabel 4 untuk rinciannya). Liputan berita di media lokal
terus berlanjut dimana terdapat dua puluh artikel yang telah dipublikasi dalam periode ini (bagian 8.4).
Situs web AIPMNH saat ini sedang diperbarui dan akan selesai sebelum 30 September 2015.
Pencapaian-Pencapaian Utama
Dukungan untuk pengembangan kebijakan dan regulasi telah dilanjutkan; Perencanaan dan
Penganggaran Kesehatan Responsif Gender Terpadu (IHPB-GR) telah dimasukkan ke dalam
Peraturan Gubernur (PerGub); SK untuk SIKDA juga telah ditandatangani; juga yang telah
ditandatangani adalah PerGub mengenai integrasi Puskesmas dan Perencanaan Desa dalam
pemanfaatan Dana Desa; dan revisi Revolusi KIA untuk dijadikan Peraturan Daerah (PerDa) telah
disetujui oleh DPRD pada awal September (lihat bagian 8.1 untuk detailnya). Akreditasi paket
pelatihan PML Puskesmas juga hampir selesai. Keterlibatan aktif dari para Penasihat Community
Engagement (CE) dalam penyusunan panduan, prosedur dan peraturan daerah untuk implementasi
program Dana Desa terus berlanjut sehingga bisa memastikan bahwa dana desa dialokasikan untuk
kegiatan-kegiatan KIBBLA.
Sisi permintaan dari pelayanan kesehatan terus menjadi fokus dengan berkolaborasi bersama
pemerintah provinsi NTT dengan inisiatifnya berupa pemantauan bayi baru lahir berbasis KK (homebased monitoring) yang dilakukan oleh para kader PKK. Pelibatan organisasi keagamaan juga terus
dilanjutkan dan berpotensi besar sebagai mekanisme komunikasi dalam memberikan informasi
kepada masyarakat mengenai manfaat dari melahirkan di fasilitas kesehatan dan melakukan rujukan
ke RS. Proses, kronologi dan pendekatan dari pelibatan organisasi-organisasi keagamaan terdapat
dalam LAMPIRAN 5. Buklet mengenai konseling perkawinan dengan penekanan pada kesehatan
reproduksi dan 1000 hari pertama kehidupan saat ini telah tersedia dalam versi bahasa Indonesia
pada situs web AIPMNH.
Buklet yang sama untuk agama-agama lain akan diselesaikan dan
dipublikasikan sebelum program AIPMNH berakhir.
Komitmen Pemerintah Provinsi dan Kabupaten masih tetap kuat, hal ini dibuktikan dengan
penyediaan dana dua kali lipat dalam mendukung replikasi dan keberlanjutan berbagai inisiatif
Program. Total dana pada tahun 2014 adalah Rp.19 miliar dan tahun ini Rp 37 milyar. Lihat bagian
10 untuk rinciannya.
Lokakarya Dialog Kebijakan Gender diadakan di Kupang pada tanggal 7 Agustus dan dihadiri para
peserta dari lintas sektor untuk membahas dan mengkaji berbagai kebijakan yang ada, yang berkaitan
dengan pemberian persetujuan oleh pasien (informed consent) serta dampak dari ketidaksetaraan
gender terhadap derajat kesehatan ibu. Lihat bagian 8.6 untuk detailnya.
Keterlibatan Sektor Swasta
Meskipun program AIPMNH tidak secara khusus dirancang untuk bekerjasama atau bermitra dengan
sektor swasta namun kemitraan itu tetap ada melalui berbagai sub-kontrak dengan perusahaanperusahaan swasta dalam hal bantuan teknis dan kegiatan konstruksi serta pengadaan peralatan. Di
bawah Komponen Tiga, pengembangan kapasitas diadakan untuk para pegawai dari instansi-instansi
pemerintah dalam hal pengadaan dan kontrak dengan sektor swasta. Terakhir, advokasi telah
berhasil dilakukan bersama pihak swasta sehingga dana Corporate Social Responsibility bisa diakses
untuk pengadaan peralatan Puskesmas dan pembangunan Rumah Tunggu.
8
M&E dan Pembelajaran Yang Dipetik
Pelajaran-pelajaran yang dipetik berikut adalah berdasarkan hasil pemantauan berkelanjutan,
penelitian dan dokumentasi. Bagian 8.3 menyajikan rincian mengenai kegiatan M&E selama periode
ini.
•
Respons terhadap potensi peningkatan kematian ibu: Laporan terkini mengenai meningkatnya
kematian ibu menegaskan perlunya sistem kesehatan memiliki kapasitas dalam mengidentifikasi
perubahan dan meresponsnya. Saat ini sistem kesehatan di NTT memiliki kapasitas yang lebih
baik dalam mengidentifikasi berbagai potensi persoalan kematian ibu melalui proses AMP, tetapi
sistem masih perlu memberikan respons yang signifikan.
Paling tidak ada jaminan dalam
penyebaran berbagai hasil temuan, dan memberi peringatan kepada Dinkes dan RSUD agar tetap
siaga dalam pelayanan kedaruratan obstetrik, khususnya haemorrhage. Perlu juga dilakukan
penyelidikan lebih jauh mengenai berbagai faktor misalnya kelebihan dokter spesialis yang baru
•
kembali dan baru lulus, serta hilangnya kapasitas PONED akibat adanya mutasi staf Puskesmas.
Perlu meningkatkan komunikasi dan pelibatan DinKesProv dan Kemkes: Laporan Kemajuan
ini menyajikan uraian mengenai dua bidang dimana ada ketidaksesuaian antara penyusunan
kebijakan di tingkat pusat dan inovasi-inovasi yang ada di daerah. Yang dimaksud di sini adalah
pengembangan SIKDA NTT, dan sistem pengelolaan ketenagaan (SIMKA). Meskipun ada upaya
dalam memastikan keterlibatan pemerintah pusat, dan bahwa instrumen-instrumen yang
dikembangkan di daerah selaras dengan kebijakan dan sistem nasional, namun keterlibatan
pemerintah pusat relatif rendah, dan adanya kecenderungan untuk menerapkan kebijakan dan
sistem yang dikembangkan di pusat, meskipun sudah ada kebijakan dan sistem yang
•
dikembangkan di daerah dan berfungsi dengan baik.
Mempertahankan kapasitas PONED di Puskesmas:
Penelitian mengenai penanganan
komplikasi menyoroti rendahnya kapasitas Puskesmas non-PONED dalam menangani komplikasi
ibu dan bayi baru lahir, serta pentingnya mempertahankan kapasitas PONED. Namun demikian,
hasil kajian lainnya menemukan bahwa mutasi staf Puskesmas yang telah dilatih PONED
berpengaruh buruk terhadap tim PONED, sehingga penyajian pelayanan PONED sangat terbatas.
Dengan kapasitas yang lebih besar dalam menyajikan pelatihan dan magang PONED di RSUD,
DinKesKab memiliki kapasitas untuk menempatkan atau merotasi staf yang memiliki keterampilan
PONED. Kebijakan mengenai distribusi ketenagaan perlu lebih fleksibel dan responsif sehingga
•
kapasitas PONED tetap bisa dipertahankan.
Bidan Koordinator di Puskesmas: Bikor memainkan peran penting dalam memberikan
bimbingan dan dukungan teknis untuk para bidan di Puskesmas dan jejaringnya, termasuk bidan
desa. Penelitian tentang pengetahuan dan kompetensi Bikor menunjukkan bahwa banyak Bikor
yang memiliki tingkat pengetahuan dan kompetensi yang rendah, dan tidak mampu menjalankan
tugasnya.
Penelitian tersebut merekomendasikan agar jabatan Bikor diseleksi berdasarkan
kriteria yang ketat antara lain memiliki pengetahuan dan kemampuan untuk mendampingi dan
mengarahkan, bukan hanya sekadar senioritas. Rekomendasi lainnya adalah bahwa semua Bikor
harus berkualifikasi sebagai Instruktur Klinis (Clinical Instructors). Artinya, seorang Bikor yang
betul-betul berkompeten bisa memberikan pelatihan dan pendampingan terstruktur yang
berkelanjutan kepada rekan-rekan bidan lainnya dan dengan demikian, mengurangi beban
pelatihan kala-karya (in-service training) selama ini yang mahal dan memakan waktu.
Tantangan Utama
Sayangnya, meningkatnya laporan kematian ibu telah tercatat baik itu di kabupaten-kabupaten bekas
wilayah kerja AIPMNH maupun kabupaten yang masih aktif selama periode Januari sampai Juni
2015, dan analisis mengenai masalah ini terdapat pada bagian tentang Persoalan (bagian 11.2).
9
Pada LAMPIRAN 2 keterkaitan antara meningkatnya cakupan persalinan faskes dan menurunnya
angka kematian ibu di kabupaten-kabupaten di NTT selama periode 2009 sampai 2014 digali lebih
jauh untuk mengidentifikasi variasi keterkaitan tersebut di masing-masing kabupaten.
Meskipun
kebanyakan kabupaten menunjukkan penurunan tingkat kematian ibu sejalan dengan meningkatnya
cakupan persalinan faskes, namun beberapa kabupaten, dengan penyebaran penduduk yang luas
dan/atau akses yang buruk untuk rujukan ke RS, tidak menunjukkan penurunan angka kematian ibu
seperti kabupaten lain, atau bahkan tidak ada penurunan sama sekali.
Pada periode ini terjadi kasus penggelapan dana, pelakunya adalah staf AIPMNH. Dana tersebut
telah dikembalikan, dan DFAT telah secara resmi menutup kasus ini.
Lihat bagian 11.4 untuk
rinciannya. Kasus ini merupakan kasus kedua selama program ini berjalan dan mengingat bahwa
dana bantuan telah dikelola sejak tahun 2009, maka kasus yang terjadi menunjukkan pengelolaan
keuangan yang bagus.
Relevansi: Saat proses desain Program AIPMNH, NTT memiliki tingkat kematian ibu dan bayi
tertinggi dan merupakan salah satu provinsi termiskin di Indonesia (dan masih demikian). Tingkat
kematian ibu yang tinggi adalah indikator yang baik dari buruknya fungsi dan manfaat dari sistem
kesehatan yang ada. Fokus AIPMNH pada kematian ibu relevan dengan kebutuhan yang ada di
masyarakat, sedangkan pendekatan AIPMNH dalam membangun keterlibatan penyedia layanan
kesehatan dengan masyarakat relevan dengan konteks NTT. AIPMNH juga relevan dengan prioritas
pemerintah Indonesia dan pemerintah daerah. Pencapaian Tujuan Pembangunan Milennium (MDGs)
adalah prioritas Pemerintah RI dan AIPMNH mendukung tujuan 4 dan 5 serta berkontribusi terhadap
tujuan 3. AIPMNH juga mendukung strategi Pemerintah Provinsi NTT dalam mengurangi angka
kematian melalui Revolusi KIA.
Tujuan: Tujuan AIPMNH adalah berkontribusi terhadap pengurangan tingkat kematian ibu dan bayi di
NTT serta strategi untuk mengatasi penyebab kematian ibu dan neonatus (berbasis bukti) dari tingkat
desa sampai Kabupaten.
Efektivitas: Tujuan kemitraan adalah untuk mengurangi tingkat kematian ibu dan neonatus di
kabupaten intervensi. Jumlah absolut kematian ibu dilaporkan telah menurun sebesar 40% antara
tahun 2009 dan 2014 (sesuai laporan ICR) sedangkan jumlah absolut kelahiran hidup kurang lebih
tetap sama.
Dalam periode enam bulan ini, telah terjadi peningkatan jumlah kematian ibu dan,
meskipun datanya masih perlu divalidasi dan hanya dalam kurun waktu enam bulan, peningkatan
jumlah kematian ibu ini mengkhawatirkan (Tabel 1).
Analisis menyeluruh terdapat pada bagian
Persoalan dari laporan utama (bagian 11.2), dimana ditemukan bahwa perdarahan adalah penyebab
utama kematian ibu, dan bahwa peningkatan kematian ini terjadi di RS dan juga di masyarakat.
Terlihat juga peningkatan jumlah kematian bayi dalam periode ini. Sebagaimana laporan-laporan dari
periode-periode sebelumnya, kemungkinan terdapat sebagian besar kasus kematian bayi yang tidak
dilaporkan dan karena itu peningkatan tersebut bisa disebabkan oleh peningkatan yang nyata terjadi,
meningkatnya pelaporan atau bisa juga merupakan kombinasi keduanya.
Sebagaimana laporan-
laporan terdahulu, hampir semua kasus kematian ibu saat ini dianggap telah dilaporkan.
Tabel 1. Kematian Ibu dan Neonatus 2009 – Juni 2015 di 14 Kabupaten AIPMNH
Tahun
Kelahiran Hidup
Laporan Kematian Ibu (jumlah Laporan Kematian Neonatus
absolut)
(jumlah absolut)
2009
2010
2011
2012
2013
70.981
69.264
73.225
74.184
72.563
186
182
148
125
123
756
682
585
794
753
10
Tahun
Kelahiran Hidup
Laporan Kematian Ibu (jumlah Laporan Kematian Neonatus
absolut)
(jumlah absolut)
2014
Jan – June 2015 tak tervalidasi
72.087
33.860
109
72
696
404
Catatan; AIPMNH dimulai di 3 kabupaten pada tahun 2008, 9 kabupaten di tahun 2009, 14 kabupaten mulai tahun 2010 dan
berkurang menjadi 10 mulai Juli 2014 (lihat LAMPIRAN 6 untuk data lengkapnya). Sebagai pembanding, semua 14 kabupaten
dimasukkan dalam data tahun 2009 pada Tabel 1
Sesuai Tabel 1, bila tren yang ada berlanjut, maka kemungkinan akan terjadi peningkatan kematian
ibu maupun bayi dalam tahun ini.
Tujuan Komponen 1 adalah untuk meningkatkan persalinan di fasilitas kesehatan di kabupatenkabupaten intervensi.
Antara tahun 2009 dan 2014, persalinan di fasilitas kesehatan meningkat sebesar 31% (42% sampai
73%) tetapi sudah stabil sejak 2012 dengan hanya sedikit peningkatan sebesar 2% (71% sampai
73%). Lihat LAMPIRAN 2 untuk analisis dan indikator-indikator lain dalam lima tahun terakhir serta
hubungannya dengan Tingkat Kematian Ibu.
Tujuan Komponen 2 adanya alokasi anggaran pemerintah kabupaten (APBD) sebesar ≥ 10% untuk
Kesehatan.
Rata-rata alokasi anggaran untuk Kesehatan di 10 kabupaten pada tahun 2015 adalah sekitar 16%.
Pada tahun 2011, rata-rata alokasi anggaran untuk kesehatan kurang dari 10%, artinya telah terjadi
peningkatan alokasi anggaran.
Catatan: informasi mengenai anggaran untuk tahun 2016 belum
tersedia.
Tujuan Komponen 3 adalah bahwa Kabupaten memiliki kemampuan untuk secara transparan
mengelola berbagai sumber dana Puskesmas (BOK, Jamkesmas, Jampersal) serta dana dari
AIPMNH pada akhir tahun 2012
Selain koordinasi UPK (Unit Pengalola Kemitraan) dan mitra, semua kegiatan lain dari komponen tiga
telah berakhir. Alokasi dana BOK untuk tahun 2015 adalah sekitar 10% dari alokasi tahun 2014 (lihat
Tabel 23) tetapi dipahami bahwa untuk tahun 2016 jumlah alokasi dananya akan sama dengan tahun
sebelumnya.
Efisiensi:
Semua Kabupaten intervensi menunjukkan pelibatan dan dukungan aktif terhadap
keberlanjutan program serta mereplikasi dan melanjutkan berbagai inisiatif dengan menggunakan
anggaran APBD II, ADD (dana Desa), Dana Desa, BOK (dana Operasional Kemkes) dan JKN
(Jaminan Kesehatan Nasional).
Uraian mengenai dukungan dana mitra untuk keberlanjutan dan
replikasi terdapat Bagian 10 dari laporan utama.
Keberlanjutan: Semua kegiatan direncanakan bersama dengan instansi Pemerintah Indonesia dan
mengikuti proses dan prosedur Pemerintah Indonesia serta menggunakan biaya satuan lokal.
Pengenalan dari semua inisiatif baru, atau modifikasi dari program-program yang ada, selalu
mengikuti proses dialog dan negosiasi dan pendekatan ini telah mendorong adanya rasa kepemilikan
dan kemitraan yang tulus dari pemerintah daerah. Pihak kabupaten sendiri telah mengembangkan
berbagai inovasi yang bisa mendapat dukungan dana dan bantuan teknis dari AIPMNH yang sifatnya
fleksibel.
Semua kegiatan yang ada dalam rencana kerja provinsi dan kabupaten telah dikelola
melalui UPK Bappeda selama empat setengah tahun sehingga membantu peningkatan koordinasi ti
tingkat kabupaten, mencegah duplikasi kegiatan dan mendorong adanya rasa kepemilikan. AIPMNH
tidak menyediakan dana untuk operasional UPK.
Semua kabupaten terus mereplikasi dan menyediakan dana untuk mendukung keberlanjutan
sejumlah program yang diprakarsai oleh AIPMNH seperti Puskesmas Reformasi, Desa Siaga,
11
Revitalisasi Posyandu, magang untuk para bidan dan PML Puskesmas.
Masyarakat juga
menyumbangkan waktu, sumber daya dan dana untuk banyak kegiatan dengan demikian juga
mendukung keberlanjutan. Dana dari pihak swasta melalui Community Social Responsibility (CSR) di
beberapa kabupaten diberikan untuk fasilitas-fasilitas kesehatan antara lain di Ende dimana tiga
Rumah Tunggu sedang dibangun dengan menggunakan dana ini.
Pendanaan AIPMNH untuk SIKDA telah banyak dikurangi pada tahun 2015. SIKDA dilaksanakan di
semua kabupaten di NTT dan terus mendapat dukungan yang kuat dari provinsi dan kabupaten. SK
DinKes telah selesai disusun dalam periode ini dan DinKesProv akan mendukung Peraturan Daerah
(PerDa) pada tahun 2016. SIKDA NTT diakui oleh Pusdatin Kemkes sebagai sebuah sistem yang
efektif.
Konteks Kesehatan & Sosial Yang Relevan di NTT: Profil Kesehatan NTT yang dipublikasi pada
bulan September 2015 menyajikan data mengenai fasilitas kesehatan pada tahun 2014 sebagai
berikut.
•
Dari sepuluh penyakit yang paling banyak di Puskesmas, ISPA 55%, musculoskeletal 11%, diare
4% dan penyakit utama lainnya berkaitan dengan penyakit kulit, sakit dan nyeri, demam, dll.
•
Kasus baru TB yang ditemukan pada tahun 2014 adalah 3.603 dan total kasus 5.079
•
Kasus HIV baru 219 (2013 = 178) dan AIDS 383 (2013 = 283)
•
Total kasus campak 411 meningkat dari 308 pada tahun 2013 dan mayoritas, sekali lagi, terdapat
di TTS
•
3 kasus tetanus neonatus (juga 3 kasus pada tahun 2013)
•
Tingkat insiden parasit tahunan malaria, 13 kasus berbasis tes (menurun dari 20 kasus di tahun
2013 dan 23 kasus di tahun 2012)
Penurunan kasus Malaria menunjukkan tren positif yang masih berlanjut dari tahun sebelumnya,
tetapi peningkatan kasus Campak menunjukkan masih adanya persoalan dengan program imunisasi.
Belanja: Realisasi anggaran untuk periode enam bulan, termasuk dana-dana AAIF terdapat pada
LAMPIRAN 8. Rincian mengenai realisasi anggaran untuk rencana kerja dan tingkat penyelesaian
kegiatan dalam periode pelaporan ini terdapat pada bagian 5.2 dan grafisnya terdapat pada Gambar 1
sampai Gambar 5.
Personalia: Rincian mengenai personalia terdapat pada bagian 7 dari laporan utama sedangkan
jadwalnya terdapat pada LAMPIRAN 9 yang memuat rincian mengenai semua staf termasuk staf
Sister Hospital.
Hambatan dan Masalah Utama: Rinciannya terdapat pada bagian 11 dari laporan termasuk (1)
Anggaran (2) Peningkatan Kematian Ibu, (3) Kasus Penggelapan Dana dan (4) Hambatan
Penggunaan Kontraseptif.
Enam Bulan Berikut: Periode ini adalah periode enam bulan terakhir dari AIPMNH. Semua kegiatan
di Kabupaten akan diselesaikan pada awal November dan rincian mengenai rencana penutupan dan
serah terima Kantor AIPMNH di kabupaten-kabupaten telah diselesaikan. Dokumen Rencana Serah
Terima yang telah diserahkan pada tahun 2014 akan diperbarui dan diserahkan lagi. Dokumen ACR,
telah selesai pada bulan Juni 2015 dan akan diperbarui apabila informasi terakhir tentang pengadaan
dan keuangan telah tersedia. Kantor AIPMNH di Provinsi akan tutup pada tanggal 23 Desember
(sebelum liburan Natal 2015). Pertemuan PCC terakhir akan diadakan pada bulan Oktober 2015.
12
3 Background
This is the thirteenth and final Progress Report for the Australia Indonesia Partnership for Maternal
and Neonatal Health (AIPMNH) program, covering the second six months of Part II of the Transition
Phase, January to June 2015. In the main text, the report details progress towards program outcomes
and overall implementation, while progress with outputs and activities is set out in Annex 1.
The Australia Indonesia Partnership for Maternal and Neonatal Health (AIPMNH) works with Bappeda
(Planning), Kesehatan (Health), BPMD (Community), BPP (Women’s affairs) and BKKBN (Family
Planning) at provincial and district levels in NTT to support implementation of the central government’s
Making Pregnancy Safer program of 2001-2010, achievement of MDG goals 4 and 5, and the
provincial government’s Revolusi KIA (Maternal and Child Health Revolution). AIPMNH purpose is to
contribute to reduced Maternal and Neonatal mortality and morbidity in NTT and the strategy
addresses known (evidenced based) causes of maternal and neonatal deaths from village to District
level through improved access, quality and demand for MNH services.
Based on recommendations from the 2010 Independent Progress Review (IPR), the initial 2.5 years
th
duration of the program (January 2009 to June 2011) was extended to 30 June 2013. A Transition
Year, intending to bridge to the new MNH program (PERMATA) was approved for the period June
2013 – July 2014 and, due to delays in commencing the PERMATA program, a further 12 months to
June 2015 was agreed in January 2014. Further delays have resulted in a further final extension to
December 2015. In August 2015, DFAT announced that PERMATA would not be proceeding. From
st
1 July 2014, the number of AIPMNH districts was reduced to ten as per the PERMATA design. The
four districts of Kota Kupang, Kabupaten Kupang, Belu and Sikka were no longer provided with direct
funding, as these districts were assessed as being best capable of continuing to improve MNH
outcomes independently.
The Transition Period purpose was to ensure a smooth transition to
PERMATA and sustainability of critical activities that were demonstrating positive results.
The
program is now working to ensure handover and sustainability of the program, and to document and
disseminate lessons learnt, prior to ceasing all operations by 31 December 2015.
The total DFAT budget to the end of June 2015 is approximately AUD76 million (a further AUD5
million is included in the overall budget which was for the Padang Reconstruction project).
Implementation and funding of activities until end of June 2013 had been through two mechanisms, (i)
provincial and district Annual Work Plans (AWPs); (ii) eight directly managed technical Theme
categories. As from July 2013, all activities have been included in the AWPs. Preparation of the
AWPs follows the GOI planning and budgeting timing and processes. Activities in the AWPs are
based on individual Terms of Reference (TORs) prepared by the district and approved through an
iterative process with the province based Advisers. Quarterly meetings are conducted to review the
previous quarter and to approve activities and budgets to be implemented in the following quarter.
Since 2011, and in line with transfer of responsibility to GOI, the activity TORs and budgets have been
approved and managed by activity management units (UPKs) in district and provincial Bappeda
offices. This also ensures standardised costings and prevents activities being costed against multiple
budgets (double dipping).
Funds for each activity are provided to the relevant GOI agency or
Institution and then acquitted along with an activity completion report. Utilisation and acquittal of funds
are bound by strict timelines and subject to frequent spot checks from the AIPMNH Finance Section.
13
4 Progress; Outcome & Objective Indicators
Table 2 is a summary status of indicators and uses the same colour coding as for the previous progress reports (green = will achieve, orange = possibly will achieve
and red = unlikely to achieve). This is the full list of Indicators as per the schedule in the September 2013 revised Indicator Report. As this report covers the first six
months of the year, only those indicators where data is available have been updated; primarily SH9 (Jan-June 2015), budgets and SIKDA.
Table 2. Progress in AIPMNH indicators to June 2015
No (as per
M&E Ind)
Log Ref.
Comparative indicators
Findings
Comment
Goal: Reduced number of deaths among pregnant women and newborns reported by partner district hospitals and Puskesmas in AIPMNH program areas in NTT
1
Project Goal
Annual number of maternal deaths reported by
Puskesmas in each partner district (through F4)
reduces by 10% between 2009 and 2013 (5 years).
1
Project Goal
Annual number of neonatal deaths reported by
Puskesmas in each partner districts (through F4)
reduces by 10% between 2009 and 2013 (5 years).
2
Medium-Term Outcome
Higher than Project
Objective
Aggregate maternal and neonatal mortality of inhospital deliveries across each cohort of sister
hospitals reduces by at least 10% between baseline
and endline.
Maternal deaths
2008 = 159 (235/100,000 live births)
2009 = 186 (273/100,000 LB)
2010 = 182 (260/100,000 LB)
2011 = 148 (202/100,000 LB)
2012 = 125 (169/100,000 LB)
2013 = 123 (170/100,000 LB)
2014 = 109 (151/100,000 LB))
Neonatal deaths
2008 = 764 (11.3 / 1000 live births)
2009 = 756 (11.1 / 1000 LB)
2010 = 683 (9.8 / 1000 LB)
2011 = 585 (8.0 / 1000 LB)
2012 = 796 (10.7 / 1000 LB)
2013 = 760 (10.5/ 1000 LB)
2014 = 696 ( 9.7/ 1000 LB)
Maternal deaths Baseline = 14
(0.46 deliveries)
Group 1 hospitals [6]
Group 2 hospitals
SH1 = 6 (0.2%)
[ No. hospitals in group]
SH2 = 8 (0.21%)
SH3 = 10 (0.25%)
SH4 = 22 (0.56%)
SH4 = 16 (0.39%) - [5]
SH5 = 28 (0.63%)
SH5 = 13 (0.29%) – [5]
SH6 = 16 (0.42%)
SH6 = 15 (0.39%) – [5]
SH7 = 7 (0.16%)
SH7 = 10 (0.47%) – [3]
SH8 = 19 (0.51%)
SH8 = 5 (0.22%) - [3]
SH9 = 36 (0.87%)
SH9 = 8 (0.30%) - [3]
Maternal deaths in 2014 are 40% lower than in
2009 (based on absolute numbers).
Revised No. LB in 2009 = MMR = 260/100,000
Neonatal deaths in 2014 are 7% lower than in
2009 (based on absolute numbers).
(Revised No. LB 2009 = NMR = 10.7/1000 LB)
SH 1 – 9 indicates 6 month periods commencing
with SH1 – 2 in 2011; 3 -4 in 2012; 5 – 6 in 2013;
7 – 8 in 2014; SH9 = Jan-June 2015
Maternal mortality fluctuates considerably over
each 6 month period because of small numbers.
Group 1:Total maternal deaths in the SH9 period
rose to 36, well above baseline; if limited to direct
obstetric causes the number reduces to 28
(0.68%), still 48% above baseline. See special
report on increased maternal deaths under Issues.
Group 2: Total maternal deaths in the SH 9 period
increased to 8, but direct obstetric deaths were
less at 4 (0.15%)
14
No (as per
M&E Ind)
Log Ref.
Findings
Neonatal deaths Baseline =
Group 2 hospitals [No.
104 (3.7%) Group 1 hospitals
hospitals]
SH1 = 62 (2.1%)
SH2 = 88 (2.3%)
SH3 = 130 (2.9%)
SH4 = 153 (3.7%)
SH4 = 145 (3.7%) – [5]
SH5 = 124 (2.8%)
SH5 = 165 (3.9%) – [5]
SH6 = 106 (2.8%)
SH6 = 183 (4.9%) – [5]
SH7 = 89 (2.4%)
SH7 = 127 (6.3%) – [3]
SH8 = 78 (2.2%)
SH8 = 97 (5.1%) – [3]
SH9 = 89 (2.2%)
SH 9 = 95 (4.2%) – [3]
Still birth mortality Baseline =
116 (4.15 % deliveries)
hospitals]
SH1 = 89 (3.01%)
SH2 = 108 (2.80%)
SH3 = 128 (2.94%)
SH4 = 98 (2.47%)
SH4 = 113 (2.8%) – [5]
SH5 = 130 (2.91%)
SH5 = 150 (3.4%) – [5]
SH6 = 95 (2.5%)
SH6 = 84 (2.2%) - [5]
SH7 = 136 (3.2%)
SH7 = 69 (3.3%) – [3]
SH8 = 95 (2.5%)
SH8 = 34 (1.5%) - [3]
SH 9 =103 (2.5%)
SH9 = 65 (2.9%) – [3]
Outcomes between Goal and Project Objective: Improved outcome of maternal and neonatal complications managed in partner district hospitals
3
Medium-Term Outcome Average Case Fatality Rate (CFR) for direct obstetric Baseline Obstetric CFR of
Group 2 hospitals [ No.
Higher than Project
complications across district hospitals with sister
4.15% (Group 1 hospitals)
hospitals]
Objective
hospital partners is less than 60% of the preSH1 = 1.08%
intervention baseline.
SH2 = 0.72%
SH3 = 0.84%
SH4 = 2.12%
SH4 = 0.71% - [5]
SH5 = 4.44%
SH5 = 0.34% - [5]
SH6 = 3.51%
SH6 = 1.00% - [5]
SH7 = 0.88%
SH7 = 1.98% - [3]
SH8 = 2.17%
SH8 = 1.10% - [3]
SH 9 = 3.9 %
SH 9 = 0.6% - [3]
Comment
Latest period SH 9 = Jan- June 2015
Neonatal mortality and still birth rates are more
consistent.
Group 1: Neonatal mortality for the SH9 period is
steady at 2.2 % and 30% below Baseline.
Group 2: Neonatal mortality for the SH 9 period
has fallen slightly to 4.2% and is above the SH4
rate (Note reduction from 5 to 3 hospitals)
Latest period SH 9 = Jan- June 2015
Group 1: Still birth rate for the SH9 period remains
steady at 2.5% and is 40% below Baseline.
Group 2: Still birth rate for the SH9 period is 2.9%
and just above the SH4 rate. (Note reduction from
5 to 3 hospitals
CFR rates fluctuate between each six month
reporting period, mainly due to variability in the
extent of reporting of complications.
Group 1 obstetric CFR is 3.9% for the SH9 period,
an increase on previous periods, and is 94% of
baseline, above the target of 60%.
Group 2 obstetric CFR is 0.6% for the SH9 period,
a decrease on previous periods, and is 85% of
baseline, also above target. Two of three hospitals
reported no direct maternal deaths.
15
No (as per
M&E Ind)
4
Log Ref.
Medium-Term Outcome
Higher than Project
Objective
Average Case Fatality Rate (CFR) for neonatal
complications across district hospitals with sister
hospital partners is less than 60% of the preintervention baseline (CFR average of 12.5% for six
district hospitals Jan-July 2010)
Findings
Baseline Neonatal CFR of
12.5% Group 1 hospitals
SH1 = 5.6%
SH2 = 6.7%
SH3 = 10.9%
SH4 = 15.2%
SH5 = 9.4%
SH6 = 10.4%
SH7 = 6.4%
SH8 = 6.0%
SH 9 =4.2%
Project Objective: Increased utilisation of basic and emergency obstetric and neonatal services in partner health facilities
5
Project Objective
Annual coverage of managed obstetric complications 2008 = 30%
across AIP Districts increases by 45 percentage
2009 = 49%
points between 2008 and 2013 Estimated rate of
2010 = 41%
expected complications is 20% of all pregnancies
2011 = 51%
2012 = 50%
2013 = 46%
2014 = 59%
6
Project Objective
Annual coverage of managed neonatal complications 2008 = 16%
across AIP Districts increases by 25 percentage
2009 = 15%
points between 2009 and 2013
2010 = 19%
Estimated rate of expected complications is 15% of
2011 = 25%
live births
2012 = 26%
2013 = 34%
2014 = 43%
7
Project Objective
Average number of direct obstetric complications
Baseline of 10.1 % of district
treated by district hospitals with sister hospital
deliveries in catchment area
partners as percentage of estimated complications
(Group 1 hospitals)
(20%) arising from district deliveries in catchment
SH1 = 16.7%
area is higher in each six-month reporting period
SH2 = 22.3%
than baseline.
SH3 = 20.7%
Note: revise to 15% district deliveries in line with new SH4 = 21.2%
National Action Plan definition
SH5 = 15.3%
SH6 = 14.3%
SH7 = 22.2%
SH8 = 19.4%
SH9 = 23.1%
Comment
Group 2 hospitals [ No.
hospitals]
SH4 =14.8% - [5]
SH5 = 8.9% - [5]
SH6 = 12.2% - [5]
SH7 = 29.7% - [3]
SH8 = 21.7% - [3]
SH9 =14.4% - [3]
CFR rates fluctuate between each six month
reporting period, mainly due to variability in the
extent of reporting of complications.
The Group 1 neonatal CFR for SH9 is 4.2%, 33%
of baseline and below the target
The Group 2 neonatal CFR is 14.4%, equal to the
baseline, and above the target of 60%.
Increase between 2008 and 2014 = 29%
(Revised to 21 Kab database figures)
(Revised to 21 Kab database figures)
hospitals]
SH4 = 32.7% - [5]
SH5 = 41.3% - [5]
SH6 = 23.6% - [5]
SH7 = 27.6% - [3]
SH8 = 21.1% - [3]
SH9 = 37.5%- [3]
Considerable fluctuation between 6 month periods,
however group 1 remains well above baseline.
The percentage direct obstetric complications
treated in group 1 hospitals rises to 23.1% in SH9
period, much higher than baseline.
The percentage of direct obstetric complications
treated in group 2 hospitals during the SH9 period
rises to 37.5%, 5% above baseline, mainly due to
a rise in complications reported from Ruteng
hospital.
16
No (as per
M&E Ind)
Log Ref.
8
Project Objective
Average number of neonatal complications treated
by district hospitals with sister hospital partners as
percentage of estimated neonatal complications
(15%) arising from district deliveries in catchment
area is higher in each six-month reporting period
than the baseline average
Findings
Baseline 26.1 % of district
deliveries in catchment area
(Group 1 hospitals)
SH1 = 34.6 %
hospitals]
SH2 = 44.3 %.
SH3 = 43.8 %
SH4 = 36.5 %
SH 4 = 32.1% - [5]
SH5 = 49.6 %
SH 5 = 61.4% - [5]
SH6 = 43.5%
SH 6 = 47.3% - [5]
SH7 = 45.0%
SH7 = 23.4% - [3]
SH8 = 42.3%
SH8 = 25.8% - [3]
SH9 = 67.9%
SH9 = 38.1% - [3]
9
Project Objective
Increased no. of hospitals in AIPMNH program area
Baseline 3.29 %
where caesarean deliveries as % of all deliveries are (Group 1 hospitals)
Group 2 hospitals
between 5% and 15% of estimated total deliveries in
SH1 = 3.9%
district in July-Dec 2012 compared to Jan-July 2010
SH2 = 6.0%
pre-intervention baseline.
SH3 = 6.8%
Note: use catchment area rather than only local
SH4 = 6.4% (3/6)
SH4 = 5.4% (3/5)
district
SH5 = 6.7% (5/6)
SH5 = 6.1% (3/5)
SH6 = 5.5% (4/6)
SH6 = 5.6% (3/5)
SH7 = 6.5% (5/6)
SH7 = 6.0% (2/5) / 3.8% (1/3)
SH8 = 5.5% (4/6)
SH8 = 4.6% (1/3)
SH9 = 6.9% (5/6)
SH9 = 7.1% (3/3)
Component 1 Objective: Proportion of annual deliveries in health facilities in each partner district in NTT increases between 2008 and 2012
10
Component Objective
% of deliveries, occurring annually in health facilities in % Deliveries occurring in health facilities in 14 AIP districts
Indicator
AIP Districts, reported by Puskesmas, increases by
2008 = 44%
40% between 2008 and 2013
Rev KIA indicator
2009 = 42%
2010 = 49%
2011 = 65%
2012 = 71%
2013 = 73%
2014 = 73%
Comment
The percentage of estimated neonatal
complications treated in Group 1 hospitals
increased during the SH9 period to more than
double the baseline proportion.
The proportion in Group 2 hospitals during the SH9
period also increased to exceed the baseline
proportion.
Group 1 hospitals average rate of 6.2 % is higher
than Group 2 hospitals, and nearly twice the
baseline rate.
The number of hospitals with C/S proportion
exceeding 5% rose to 5/6 in the Group 1 hospitals
during the SH9 period, with an average of 6.9%;
and rose to 3/3 in the Group 2 hospitals, and an
average of 7.1%
Both exceed the target.
17
No (as per
M&E Ind)
Log Ref.
11
MPS and Rev-KIA
indicator
Increased proportion of pregnant women having four
ANC visits (K4) during pregnancy. The % of pregnant
women receiving at least four antenatal visits (K4)
increases in AIP districts by 10% between 2008 and
2013
12
1.2
% of AIP supported Puskesmas nominated as
PONED that achieve 50% or greater coverage of
managed obstetric complications.
13
1.4
Increased number of desa siaga implemented with
local government funding (replication desa siaga)
using the AIP model in AIP districts.
14
1.4
Findings
% Pregnant women having at least four ANC visits during
pregnancy
2008 = 63%
2009 = 65%
2010 = 74%
2011 = 69%
2012 = 71%
2013 = 65%
2014 = 65%
2011: 50 PONED AIP – 60% (30)
2012: 56 PONED AIP – 59% (33)
2013: 59 PONED AIP - 53%(31)
2012; 27 with shared funding
2013; 128 replicated with local government funds
2014; 512 replicated with local government funds
2011 = 62.7%
2014 = 93.3%
Percentage of pregnant women in AIPMNH-assisted
desa siaga that sign up with desi notification network
increases in 2014 compared to 2011.
Component 2 Objective: Increased proportion of district annual budgets in partner districts allocated to MNCH and health
15
Comp 2 objective
Fourteen partner districts allocate more than 10% of
Average % allocation by year and N ≥ 10%
indicator
annual district budget (APBDII) to health in 2014
2010 = 12.1%, N = 9
compared to 9 in 2010
2011 = 8.8%, N = 7
Note: Calculation is (BL+BTL Health)/ APBD. Does
2012 = 10.0%, N = 9
not include central level allocations such as BOK,
2013 = 10.4%, N = 9
Jampersal, Decon, BPJS etc.
2014 = 11.1%, N = 12
2015 = 12.2%, N= 12
16
Comp 2 objective
Seven districts allocating increased proportion of
11 districts allocated increased proportion of the annual health
indicator
their annual health budgets to MNCH in 2014
budget to MNCH between 2008 and 2014.
(compared to 2008 baseline year)
17
Comp 2 objective
Eleven of 14 districts reporting a percentage
2014 Data: compared with 2010 there are 12 districts with an
indicator
increase in MNCH expenditure as a proportion of
increased percentage of MNCH expenditure.
APBD budget allocation in 2013 compared to 2008
baseline year
18
2.1
Increase in number of districts preparing and
2010 = 80% (Baseline)
submitting Annual Health Profile to PHO
2011 = 100%
2012 = 100%
2013 = 100%
2014 = 100%
Comment
Some fluctuation but coverage remains above 50%
in 59 AIP PONED facilities
The figures for each year are cumulative
Number of districts allocating 10% or more of
budget has remained steady at 12/14, but the
aggregate proportion has risen to 12.2%, and the
aggregate amount increased by 35% compared to
2014.
All districts prepare and submit annual profile
18
No (as per
M&E Ind)
Log Ref.
Findings
Comment
19
2.1
Increase in number of districts showing presenting
data disaggregated by sex where appropriate in their
Annual Health Profile
All districts disaggregate data by sex where
appropriate.
20
2.2
70% of DTPS KIBBLA recommendations on planned
annual MNCH activities prepared by district partners
included in RKPD by 2013
21
2.3
22
2.4
2 out of 3 partner districts (Sumba Timur, TTU and
Flotim) have Bupati decrees on workforce
distribution (doctors, nurses, bidan at health
facilities) in 2013
NTT achieves its 2010, 2011, 2012 and 2013 RevKIA targets across 14 AIPMNH partner districts with
MCH regulations (perda)
2010 = 10% (Baseline)
2011 = 40%
2012 = 100%
2013 = 100%
2014 = 100%
All MNCH annual plans (included in Renja and RKPD) developed
based on DTPS KIBBLA recommendations through an integrated
health planning and budgeting mechanism. Only four districts used
the updated DTPS KIBBLA recommendation as only those
districts routinely conduct DTPS. The other districts use the 2012
DTPS recommendations as the basis for the MNCH annual plan.
All three districts now have Bupati decrees approved
All districts have an MCH regulation, with 11
districts having a parliamentary decree, and 3 a
Bupati decree.
23
2.4
11 of 14 districts implemented MNCH PerDa
3 districts still with PerBup and in process of PerDa approval (Kab.
Kupang, Sikka and Manggarai).
To June 2015 there are 298 PerDes MNCH implemented.
24
2.5
Total number of equipment items = 282
Total number audited = 192 (68%)
Total in good working order = 186 (97%)
Exceeds 90% target - based on audit in late 2013
25
2.5
Total number of equipment items = 578
Total number audited = 500 (87%)
Total number in good working order = 496 (99%)
Exceeds 90% target – based on audit in late 2013
26
2.8
All districts have increased MNH APB Des budgets
in Desa Siaga villages.
27
2.8
Pro-KIBBLA budgets in Desa Siaga villages.
Avg per village
2010 = 879,452 Rp (73 Desa)
2013 = 2,997,428 Rp (311 Desa)
2014 = 3,279,888 Rp. (343 Desa)
2010 = 224 Desa (33% of all program area Desa)
2014 = 594 Desa (55% of all program area Desa)
Total villages in all program sub-districts = 689 and in 2014 =
1,076
All partner districts showing increased percentage of
desa with pro-MNCH perdes between 2009 and
2013 compared to baseline year (2008)
Increased no. of district hospitals with adequate
infrastructure and equipment meeting MOH minimum
standards for PONEK
Indicator defined as >90% of equipment provided by
AIPMNH present and in good working order
Increased no. of PONED Puskesmas with adequate
infrastructure and equipment meeting MOH minimum
standards for PONED
Indicator defined as >90% of equipment provided by
AIPMNH present and in good working order
Ten of 14 partner districts showing increased no. of
villages that increased budget in Kas Desa/APBDes
for pro-KIBBLA activities in Musrenbangdes between
baseline (2010) and endline (2013) in AIPMNH
supported desa siaga
Twelve of 14 partner districts showing increased
number of villages conducting pra-musrenbang proKIBBLA (in program area) in 2014 compared to 2010
baseline
Based on planning and budgeting evaluation
results (May 2014)
All districts have PerDes (variable number).
All districts increased number of villages
conducting pro-KIBBLA pra-musrembang from
2010 to 2014.
19
No (as per
M&E Ind)
Log Ref.
Findings
Comment
Component 3Objective. Districts show competent and transparent management of BOK, Jamkesmas and Jampersal funds and of AIPMNH District programs by the end of 2012
28
Component objective
Twelve partner districts increase annual expenditure
2010 = Rp. 28 billion (absorption 89%)
BPJS commenced in 2014 with Jamkesmas and
indicator
of Jamkesmas Puskesmas funds as % of
other funds being rolled into this, so that this
2013 = Rp. 49 billion (absorption 90%).
Jamkesmas budget by 2013 compared to baseline
indicator cannot be calculated for 2014.
year (2010)
29
3.2
All districts involved in Reformasi Puskesmas have
Displays the vision and mission statements June 2012 = 20, June
All indicators of Puskesmas Reformasi have
increased number of Puskesmas Reformasi that
2013 = 35, Dec 2013 = 40, Dec 2014 = 60, June 2015 = 70
increased between 2011 and 2014
display in waiting room information about their vision, Displays the values and services statements June 2012 = 20,
mission, values, service strategy and
June 2013 = 35, Dec 2013 = 39, Dec 2014 = 60, June 2015 = 70
use/expenditure of BOK, Jamkesmas, Jampersal
Displays service information June 2012 = 20, Dec 2013 = 38, Dec
and service flow chart between 2011 and 2013
2014 = 54, June 2015 = 68
Displays BOK information June 2012 = 19, Dec 2013 = 36, Dec
2014 = 52, June 2015 = 68
Displays Jamkesmas/JKN information June 2012 = 19, Dec 2013
= 36, Dec 2014 = 52, June 2015 = 68
30
Gender
No. of districts showing increased number of SKPD
Baseline: less than 48 SKPDs in 10 districts in 2009/2010
Increase in number of SKPD (government
implementing gender mainstreaming strategies
participating in the gender audit that have applied gender
agencies) implementing gender mainstreaming,
(assessed by participatory-gender-audit) between
mainstreaming;
but not clear if increase has occurred in all
2009 and 2013
districts.
February 2013: at least 70 SKPDs in 14 districts have started
implementing gender mainstreaming strategies in their respective
office through GFPs and Pokja PUG facilitation, and total >700
SKPDs in 14 districts trained in PUG and are participating in Pokja
PUG
31
Gender
No. of districts where average score of partner
Baseline (2010): GMI score 21.06 (total average of 12 aspects
However, the result of KSGP monitoring and
agencies participating in gender-equality audit
scoring that was assessed from 48 SKPDs in 10 districts through
evaluation that was conducted in 3 districts that
increases between baseline (2010) and end line
the gender audit)
participated in the 2010 audit, showed that there
(2013)
has been significant improvement recorded in the
February 2013: no fixed scoring could be calculated since there is
12 aspects of assessment. At least in the level of
no record available in AIPMNH district and SKPDs to measure
knowledge and skills of related SKPDs on gender
progress. Hence difficult to apply consistent measurement using
issues and the existence of gender mainstreaming
the GMI tool as initiated in 2010 audit.
institutions in the district.
20
5 Work Plan Implementation & Budgets
5.1
Annual Work Plans
In Phase I and II, budgets were separated into workplans and themes. Due to the decreased numbers
of activities and as set out in the Annual Plan for the Transition Year, themes are no longer used and
all budgeting and planning is in the Provincial and District workplans.
Since 2011, AIPMNH UPK (Partnership Management Units) at District and Province level have
managed the workplans and these units continue to function effectively. The workplan process
includes review by the Local Government Budgeting Team (Tim Anggaran Permerintah Daerah or
TAPD) and commencing in 2014, the budgets for the Sister Hospital Program were also included.
Representatives from the Mitra A Hospitals attended the budget meetings and this resulted in
improved standardisation of costs and much greater understanding of the SH program by Bappeda
and other Partners. When these activities were under Themes, this oversight did not occur.
As from July 1
st
2014 Districts were reduced to ten and therefore only these are included in the
following budget report. AIPMNH continued to support mentors in the four graduated districts until end
of December 2014, but for this reporting period, no further support has been provided.
5.2
Work Plan Progress January to June 2015
Expenditure rates (vs. planned) for the districts are in Figure 1 with an average overall expenditure of
91% over all districts. Sumba Barat and Flotim exceeded budgets (123% and 110% respectively) and
Ende at 69% the lowest. Ende’s budget is greater due to establishment of the learning centre and has
the lowest rate of expenditure due to underspending on the same activity. At Provincial level, the
expenditure rate for the period was 90%.
Figure 1. Budgets and Expenditure District Workplans January to June 2015
1,800
1,600
1,400
1,200
Millions
1,000
800
600
WP Jan - Jun
2015
Actual Jan Jun 2015
400
200
-
Figure 2 graphs planned vs actual expenditure over the reporting period and in this graph, Provincial
Workplan figures are included. The demonstrated lag between planned and actual expenditure is due
to the generally delayed acquittals from the Sister Hospital program.
21
Figure 2. Workplan expenditure by month January to June 2015
8
7
6
Billions
5
Planned
4
Actual
3
2
1
-
Jan
Feb
Mar
April
May
June
Figure 3 sets out numbers of district planned activities vs. number fully completed and again as would
be expected from the district expenditure data the completion rates are high with an overall average of
94% (inclusive of Provincial agency workplans).
Figure 3. Number of planned and completed Activities January to June 2015
70
60
50
40
30
20
Planned
Activities
Completed
Activities
10
0
Figure 4. % Expenditure vs. % completed activities District AWP January to June 2015
120%
100%
80%
60%
40%
% Funds
Expended
% Activities
Completed
20%
0%
22
Figure 4 compares the percentage of activities completed vs. the percentage of funds expended and
is mainly reflective of over estimates in activity budget plans.
Figure 5 graphs planned and actual expenditure by output logframe number for the period and most
expenditure is at 1.2 (SH program), followed by 1.4 (community engagement), and 2.6 (PML).
Figure 5. Planned and Actual Expenditure by Logframe Output January to June 2015
14
12
10
WP Jan - Jun
2015
8
Actual Jan Jun 2015
6
4
2
0
1.1
1.2
1.3
1.4
2.1
2.2
2.3
2.5
2.6
3.2
3.4
Details of activities in the workplan and results are reported on in ANNEX 1 with a brief summary in
the following main section.
5.3
Work Plans July to December 2015
Work plans for the July - December 2015 period are as per the revised (reduced) budget and all
activities have been through the ‘asistensi’ process and are being implemented. Mentors have been
reduced to one in each district with the exception of the three districts implementing Puskesmas
Terpadu (MaBar, Ende and Sumba Timor). All activities will be completed by the end of the year.
23
6 Summary Component Progress
6.1
Component 1. Community Engagement and Service Delivery
Support for improvement in the Quality of Puskesmas service (and their networks) has continued in
the ten districts. Standard Operating Procedures (SOPs) and associated flowcharts for MNH were
reviewed and revised, to ensure compliance with Puskesmas Accreditation requirements. Facilitative
Supervision found improvement in compliance with SOPs and testing for anaemia and malaria. The
assessment also found 40% of the BiKor (midwife coordinators) were fully competent, 40% needed
some improvement and 20% needed a great deal of improvement in both skills and knowledge.
District Hospital (RSUD) based internship (magang) has continued for both neonatal care and for
Basic Emergency Obstetric Neonatal Care (PONED). A Training of Trainers (TOT) workshop was
held in Kupang for Kangaroo Method of Care (KMC) for the ten districts with an aim to reduce
neonatal deaths, particularly for low birth weight babies. Constraints on the uptake of contraceptives
is included in the Issues section of the report (section 11). The research on the competencies of BiKor
(and associated training in Clinical Instructor skills) was presented at the Health Quality Network
meeting in Padang in August, with an emphasis on the policy implications of such requirements. This
was well received and results are currently being prepared for publication.
A detailed report on the Sister Hospital (SH) program is at ANNEX 3. The number of RSUD in the
SH program is now nine due to Sikka and Belu no longer being covered. Provision of 24/7 PONEK
(CEONC), the main objective of the program, is continuing with local government funds (see Table 6
for details). In April 2015, a full Monev by the external monitors was conducted and this too has now
been fully localised through involvement of the local medical faculty and local specialist organisations.
The exception to this is the qualitative aspects, which are still reliant on non-NTT expertise (as there is
no one in NTT with the required level of expertise).
Results found that neonatal indicators had
improved, and that maternal referrals are now >10% of estimated district deliveries.
The major
concern is the increase in maternal deaths in the Group 1 RSUD and this is described in the SH
Annex and analysed in the Issues Section (section 11.2). A total of 32 local doctors have been
enrolled in specialist training that is funded by the local governments since the program commenced,
and 26 of these will return by the end of 2017 (10 have already returned to their RSUD). Cognisant of
the difficulties that a lone specialist in a district faces, both Manggarai and Sumba Timur have
continued the use of rotating residents to provide relief (using local government funds). The issue of
JKN (National Health Insurance scheme) and sufficiency of reimbursements for services provided in
small C Class hospitals remains under discussion with decision makers.
Behaviour Change and Communication (BCC) activities this reporting period were expansion of the
District Broadcasting Unit program and Interpersonal Communication (IPC) Training. A further comic
book specifically for Sumba has also been designed, printed and distributed.
Community Engagement (CE) activities in this reporting period continued to expand through
replication with Partner funds. Desa Siaga is now in 941 villages (343 from AIPMNH funds) and the
program is being replicated by Provincial BPMD in five other non-AIPMNH districts. Total GOI funds
for the program for 2015 is Rp. 4.75 billion. The Desa Siaga manual has been finalised and printed
and a Video on the program was the only video accepted for the GKIA Best Practice meeting in
Jakarta in August. Similarly, replication of the Puskesmas Reformasi continues and is now in 92
Puskesmas with funding from GOI and from AIPHSS in the shared districts. Expansion of the Rumah
Tunggu program continues and these are supported and managed by the Puskesmas Boards (BPP).
The Adviser for Puskesmas Reformasi was invited by AIPD Papua to train facilitators on formation of
24
sub-district and district level Health Governance Boards (BPKM).
All documentation of the CE
program is now complete and is being used by the Province and District BPMD to replicate the
program activities.
The CE Advisers continue to be active in providing technical assistance for implementation of the
Dana Desa (Law No.6/Year 14) program and have advocated successfully for significant proportions
of the funds to be used for MNH. Further activities conducted jointly with Provincial BPMD and the
Districts will be development of guidelines covering specific MNH activities and costings that can be
funded from Dana Desa.
6.2
Component 2. Health Systems Support
Good progress continues with SIKDA NTT with all Puskesmas in the 22 Districts now using the paperbased version. There is now a detailed SK KaDinKes for SIKDA and it is also included in the five year
strategic plans, therefore assuring funding. Unfortunately, the expected support from AIPHSS for a
Governors Regulation (PerGub) on SIKDA did not proceed. It is anticipated that the PHO will fund this
next year.
With finalisation of the Minimum Basic Data set, the electronic versions can also be
finalised and implemented. With regard to the issue over the introduction of a slightly different parallel
system (SP2TP), the planned visit by the SP2TP consultants and MOH to resolve the issue has yet to
occur (as at early September 2015).
A Governor’s Regulation (PerGub) to institutionalise the IHPB Gender Sensitive and fund its routine
use has been finalised and promulgated. AIPHSS supported revision to the DTPS modules and has
also funded training in the three common districts. Use of District Health Accounts continues to be
minimal due to skills required to conduct the analysis being effectively ‘lost’ with the constant staff
turnover.
The Health Workforce Activity now has Bupati Regulations in all three Districts. The improved
electronic and internet based HR information system (SIMKA) is being implemented in the four
districts (Ende added at its request). The MOH with AIPHSS funding has developed a system that
includes part of the AIPMNH developed SIMKA system, requiring further discussion at national level
on alignment among different systems.
The PML Puskesmas program as at September 2015 is in the final stages of accreditation by
PPSDM. As reported previously the independent evaluation of the PML Puskesmas program found
positive results and accreditation will both enable wider use and enable staff to claim credit points for
the training. There is no similar training package for Puskesmas management in Indonesia.
A checklist applied by the District Program Coordinators (DPCs) to all renovated / constructed facilities
found that with the exception of two, all were being maintained and appropriately cleaned.
6.3
Component 3. System Reforms in Performance and Accountability
The main activity during the period was the PCC held in Denpasar in late June (see section 9.3 of this
report for full details). All other activities under Component 3 have now concluded, with the exception
of District and Provincial Coordination, (including the UPK).
7 Personnel and Staff Movement
There were minor changes in staffing during the period including those of CE mentors and short-term
contracts for SIKDA. Details are set out in Table 62 of ANNEX 10 of this report. Listings of currently
25
employed staff are in Table 63 to Table 67 of the same Annex. The organisation structure as from
October 2013 remains current, and is as per Figure 6 in the 10th Progress Report.
8 Cross Cutting Activities
8.1
•
Policies and Regulations supported
AIPMNH has supported revision of the PerGub Rev KIA and for this to become a stronger
regulation, a Peraturan Daerah (PerDa). The revisions broaden the scope of Revolusi KIA (based
on evidence from lessons learned), including more focus on demand side aspects. On September
4 the regulation was passed by the Provincial DPR.
Full copies will be available once the
regulation is promulgated (expected to be in December 2015). It is hoped that other provinces
and district will replicate this strategy.
•
SIKDA
NTT
Uniform
Minimum
Basic
Data
Set
MBDS
Letter
of
Decree,
Number:
Dinkes.Sek.155/050/IV/2015 on the 1st of April 2015 (see page 55 of Annex 1 for more details).
•
AIPMNH has supported development and promulgation of a Governors Decree (PerGub IHPBRG
No.12, 2015) for Integrated Health Planning and Budgeting, Gender Responsive (IHPBRG). The
regulation supports increased budget allocation to health and makes the planning process
mandatory (through ensuring there are funds to conduct the planning process).
•
AIPMNH promoted and supported a Governors Instruction (PerGub) signed in August 2015 that
will ensure development and integration between Village Planning (Musrembang desa) and
Puskesmas Annual Planning to maximise health allocations from the Dana Desa (UU6).
8.2
Poverty NTT and AIPMNH
There are no new updates on poverty rates for the Province so the following is as per the previous
report. The Provincial Bureau of Statistics report on Poverty published in January 2015 (Berita Resmi
Statistik No. 05/01/53/Th.XVII) stated that for the period March to September 2014 the poverty rate for
NTT fell from 19.8% to 19.6%, with the latter now representing approximately 991,880 people. The
poverty rate increased by 0.45% in urban areas while decreasing by 0.37% in rural areas; however,
the overall rate for urban areas is 10.7% and for rural areas is more than double that rate, at 21.8%.
The poverty line rose by 0.97% in this period and was set in September 2014 at Rp.268,536 per
person per month (approximately AUD26 per person per month).
As reported previously; given these very high poverty rates and the extremely low setting of the
poverty line (<1AUD per person per day) the basic assumption from design until the current time is
that project benefits will be accessible to the poor and hence there are no specific activities directly
addressing poverty as such.
8.3
Dr Kris Hort, Senior Technical Adviser for the Consortium and Pak Asnawi ST Research Adviser both
completed two inputs during this reporting period, as well as desk-based inputs to provide oversight,
analysis and significant input for the Studies and Progress Report. Prarthna Dayal from the Nossal
Institute made an input in March for provision of Technical Assistance to the Data Validation Study. Dr
Kris Hort participated in the PCC/DPC meetings in May 2015 to finalise the details of documentation
and studies to be completed in the July – December 2015 period. Due to subsequent budget cuts
many of these had to be cancelled.
Major achievements and activities include;
26
•
Design and implementation of the Audit Study on Maternal and Neonatal Complications . As at
early September 2015, the data analysis and report have been drafted and will be published in
•
late September in both English and Indonesian.
Further analysis and finalisation of the Case Control Study of Neonatal Mortality Risk Factors and
publication in English and Indonesian; the manuscript has been submitted to the BMC journal
Pregnancy and Childbirth and the status is under peer review.
•
Completion of the Draft Report of the Level of Knowledge and Skills of Midwife Coordinators
before and after Clinical Training Skills /Clinical Instructor training.
•
Analysis and comparison of F1-F8 data against the Riskesdas and DHS surveys and preparation
•
of a report for the ICR and DFAT.
Analysis and preparation of a report on Comparison of AIPMNH supported and non-supported
•
Analysis of F1-F8 data Contribution of AIPMNH to changes in coverage with key MNH
Areas for the ICR and DFAT.
interventions for the ICR and DFAT
•
Constructing of a Puskesmas and District time-series/longitudinal F1-F8 Dataset in order to be
able to perform multiple regression analysis to identify the contributing factors for reducing
maternal mortality cases in NTT.
•
Ongoing collection, checking (for outliers) and analysis of the F1 – F8 data set and the Sister
Hospital program.
•
Updating the Key Indicators Fact Sheet.
•
Assistance across the three components and all activities to ensure that useful and reliable data is
being collected to enable effective monitoring and evaluation of the overall project.
There were also several presentations at national conferences as well as an international conference;
•
Preparation and submission of three abstracts of AIPMNH related work/research to 47th APACPH
International Conference "Public Health Challenge in the Asia Pacific Regions: Building Regional
Initiatives from Local Experiences and Best Practices, Bandung 21-23, October 2015. All three
abstracts have been accepted for Oral Presentation.
•
o
An Audit of Maternal and Neonatal Deaths in a Low Resource Setting in Indonesia:
o
Sustainability of Donating Blood through Blood Community Volunteer Model in Nusa
o
Risk Factors Associated with Early and Late Neonatal Deaths in a High Neonatal Mortality
Results of Analysis Over Three Years;
Tenggara Timur; and
Province in Indonesia: A Matched Case Control Study.
Participated in Forum Nasional VI: Jaringan Kebijakan Kesehatan Indonesia 2015 "Upaya
Pencapaian UHC 2019: Kendala, Manfaat dan Harapan", Padang, 24 -27 August 2015. Oral
Presentation. Paper titled Tingkat Pengetahuan dan Keterampilan Bidan dan Implikasinya
Terhadap Kebijakan Revolusi KIA di Provinsi Nusa Tenggara Timur (NTT).
Based on the monitoring and studies the following lessons learned were found for the period.
•
Response to potential increase in maternal deaths: The recent reports of increased maternal
deaths emphasise the need for health systems to have capacity to identify changes and respond
to them. The NTT system now has better capacity to identify potential problems with maternal
deaths through the maternal audit process, but the system has yet to initiate a significant
response.
At the least, dissemination of the findings, and alerting district health offices and
hospitals of the need to maintain responsiveness to obstetric emergencies, particularly
haemorrhage, is warranted. Further investigation of possible factors, including overload on newly
27
returned and newly graduated specialist doctors, and the loss of PONED capacity through transfer
•
of Puskesmas staff, could also be undertaken.
The need to improve communication and engagement between regional PHO and the MoH:
This report details two areas where there is potential poor alignment between central level policy
development, and innovations at the regional level. These refer to the NTT development of a local
HMIS (SIKDA), and a workforce management system (SIMKA). Despite efforts to ensure central
level engagement, and to ensure regional level tools are aligned to national policy and systems,
there have been relatively low levels of engagement from the central level, and a tendency to
impose centrally developed policies and systems, even where there are well functioning local
•
policy and systems.
Maintaining PONED capacity in Puskesmas:
The study on complications management
highlighted the low capacity of non-PONED Puskesmas to address maternal and neonatal
complications, and the importance of maintaining PONED capacity. However, other reports have
found that transfer of PONED trained staff from Puskesmas have severely reduced PONED
teams, and therefore significantly limited PONED service provision.
With greater capacity in
district hospitals to provide PONED training and follow up internships, district health offices have
the capacity to replace or rotate staff with PONED skills. More flexibility and responsiveness from
•
workforce deployment policy is needed to enable maintenance of PONED capacity.
Puskesmas Midwife Coordinators: The midwife coordinator at the Puskesmas (Bikor) plays an
important role in providing technical supervision and support to midwives in the Puskesmas and its
networks, including in the village (bidan desa). The study of knowledge and competencies of the
Bikor indicated that many had low levels of both knowledge and competencies, and would not be
able to fulfil their roles. The study recommended that candidates for the Bikor position be selected
on strict criteria including knowledge and skills and ability to supervise and instruct, not just
seniority. A further recommendation was that all Bikor should be qualified as Clinical Instructors.
A fully competent Bikor could then provide structured ongoing training and supervision to all the
midwives thereby alleviating some of the need for the current practice of expensive and time
consuming in-service training.
Maternal and perinatal mortality audit (AMP) data continues to be collected and there is now 3.5 years
of continuous data on maternal and neonatal deaths making this an extremely valuable source of
information. All 14 Districts have operational AMP teams with legal status (SK), good coordination
between the RSUD and the DHO and most have allocated sufficient budgets. All districts are now
focusing on establishing small teams at sub-district level. The support to AMP from the project is now
paying dividends with the Districts now perceiving that the AMP process is extremely important and
details behind the deaths are known i.e. the deaths are no longer numbers. The Provincial Health
Office (PHO) remains active and engaged in managing the AMP Provincial Technical Team.
8.4
Public Diplomacy
The Public Diplomacy objectives are to promote awareness and positive attitudes toward the Australia
Indonesia development cooperation in Indonesia as well as in Australia, and to promote key
messages and achievements of the partnership. Through a variety of media, Public Diplomacy shares
partnership success stories, achievements and lessons learned with main stakeholders and other
target audiences. Public diplomacy staff also ensure that all publications comply with Australian Aid
identifier and branding requirements.
28
Progress and Activities
The Public Diplomacy team has continued to produce materials that communicate AIPMNH’s results
and lessons learned to the Program’s target audiences in Australia and Indonesia.
During this reporting period:
•
The Public Diplomacy coordinator, together with AIPMNH’s former communication specialist
produced two Good News Stories (GNS) that were approved by DFAT and published. The GNS
will continue to be produced two monthly as agreed with DFAT Public Affairs.
•
AIPMNH Information packages consisting of brochures, bulletins, information sheets, GNS
Collections Book, Film/DVDs, and booklets have been distributed to partners and the general
public through various occasions such as provincial and districts Independence Day Exhibitions
and other districts events. Copies of the GNS Collections Book, Booklets, District Initiative Book,
as well as Booklets of the 2H2 Centre, in Bahasa were distributed to participants from other
provinces at at several national events held in Palembang, Padang, Yogyakarta, Makassar, and
Jakarta.
•
The Public Diplomacy Coordinator in close coordination with the AIPMNH Advisers and DPCs has
produced various publications to share best practices and to be used as practical guidelines.
These products were presented in national events such as: MNH Best Practices Symposium in
Jakarta, Indonesia Health Quality Network Seminar in Surabaya, and Technical Coordination
Meeting of Dirjen Bina Gizi KIA in Palembang
•
Brochures, posters, banners and bulletins have been provided regularly to provincial and district
partners by request to display during their events such as coordination meetings, Independence
Day exhibition in districts and at Provincial and National level meetings.
•
The revised AIPMNH's bilingual website has been regularly updated as new information and
publications have become available. In October the website had a significant revision and now
includes a number of the AIPMNH videos as well as all the previously included material. The
Public Relations & Communication Coordinator is responsible for the website with support from
the IT manager. Responsibility for maintenance of the website for one year post-AIPMNH will be
transferred to Coffey Adelaide and plans for this are complete.
•
Publications about AIPMNH have continued to increase in the Provincial and local newspapers
with more than twenty articles being published in printed and online media such as Pos Kupang,
Victory News, Timor Express, Berita Satu, Antara News, and other local media. The Program’s
achievements in Desa Siaga Liselewobora in Ende District were broadcast in a half an hour
special edition (Semangat Pagi) by the National Television (TVRI) on May 16, 2015.
Future Actions:
Continuing effort will be made to ensure ongoing coverage of AIPMNH in local and national media.
The Public Diplomacy Coordinator will continue to work in close coordination with all AIPMNH’s
advisers and DPCs to ensure all publications are of high quality and comply with the DFAT branding
guidelines.
The Public Diplomacy Coordinator will distribute complete packages of products
consisting of printed and soft copies (DVD and CD) to share lessons learned and guidelines to
relevant stakeholders.
8.5
Child Protection
AIPMNH fully complies with DFAT’s Child Protection polices including training and updating of training
for all staff. Details of compliance with the policies was submitted in the form of a matrix to DFAT in
April 2015. To date there have been no issues identified with Child Protection within the program.
29
8.6
Gender Update
th
A Gender and Reproductive Health Policy Dialogue Workshop was held on the 7 of August 2015 in
Kupang. This was organised by the Provincial Women’s Empowerment Board (BPP) and a wide
cross section of civil society, academic and social sector representatives attended (and three
members of the press). The Workshop was based around the themes of Reproductive Health Rights,
Informed Consent and Contraceptive Use in NTT (and which have a direct impact on maternal and
neonatal health). Several of the presentations resulted in spirited debate and reaching a consensus
on a set of joint recommendations at the end of the day was a lively and lengthy process. While it is
not expected that any immediate change occurs from the Workshop it is the first time that such a cross
section of interests were brought together and that these issues were discussed openly, at length and
forthrightly. It is hoped that this commences a process of ongoing debate and eventually change in
attitudes leading to change in practices and regulations. Recommendations (translated) from the
Workshop are as follows;
1. The awareness campaign on women’s reproductive health should adopt the socio-cultural
approach that is embedded in the community. It requires collaboration and involvement of all
stakeholders including men and women.
2. The lack of women’s capacity, including pregnant women, to make decisions for their own health
should be the concern of all programs. Therefore, it is important to bring awareness at all levels
while observing community cultural best practices.
3. It is important to improve interpersonal communication at the health facilities.
The midwifery
schools should include ‘Interpersonal Communication’ in their curriculum.
4. In order to increase the percentage of facility delivery (Puskesmas and hospitals), the village
midwives should actively inform and educate women early about the importance of giving birth at
the health facility. In addition, midwives should also inform about other health services including
the importance of family planning. Incentives for the village midwives should be provided for such
purpose.
5. Women’s Reproductive Health Programs will be more broadly effective when gender
mainstreaming is integrated into all programs.
6. Public policies or regulations on reproductive health need to be socialised and disseminated so
that they are known and understood by the community.
7. It is important to educate males on the importance of reproductive health and to respect women’s’
rights in making decisions for their own reproductive health.
8. To protect against women’s health being compromised by having children too close together and
too many they need to counselled about contraceptives early in their pregnancy.
9. All children, both girls and boys, must complete nine years of schooling.
In 2013, specific details of the issues of informed consent and access to contraceptives were
discussed with both MAMPU and the Justice program but unfortunately no further action was taken.
These issues need to be dealt with at a national level.
As per the previous reports, Gender sub-contracts are complete as well as extensions to two gender
coordinators. All data related to project funded activities continues to be disaggregated by sex and the
majority of training participants are usually women due to the predominance of midwives and nurses in
these activities (see ANNEX 8 for training data).
Work with religious organisations has progressed exceedingly well and a specific Annex on the
approach, processes and chronology is at ANNEX 5
30
There is now just one female head of a Provincial agency, the BPP (previously the BKKBN head was
female but this changed at the beginning of the year). At the district level the difference in the RSUD /
Dinkes heads and those for Bappeda and BPMD are marked, see Table 3. At the next level (Kepala
Bidang, Echelon IIIB); many positions are now occupied by women.
Table 3. No. Females & Males Heads of District Partner Govt. Agencies June 2015
Kepala Dinas
RSUD
DinKes
Bappeda*
BPMD
BPP*
BKKBN
BPP/BKKBN
Females
Males
Totals
8
6
14
6
9
15
0
15
15
1
14
15
1
1
2
1
1
2
2
10
12
Note; *Malaka is now included in the table, bringing total districts to 15. Note; eleven districts have amalgamated BPP and
BKKBN.
9 Coordination, Partnership & Monitoring Visits
9.1
Central level
As per the previous reporting period, neither the Technical Working Group (TWG) nor the
Performance Review Committee (PRC) have met, despite a previous agreement from MOH to make a
field visit to NTT, and subsequently to hold a TWG/PRC at the same time as the PCC in May (see
section 9.3). Representatives from MOH however did attend the PCC and SH meetings in May. Note;
as at September 2015 neither a field visit nor TWG/PRC meetings have been conducted.
At the request of DFAT, a total of Rp. 1.06 billion was provided to Directorate Anak MOH to design,
print and distribute the new Buku KIA and sticker. DFAT requested that approximately Rp. 600 million
be provided to MOH Directorate Ibu in the next reporting period to conduct a survey. However, in
early September the MOH decided not to go ahead with this activity.
As per the previous report, the 2013 expired Subsidiary Agreement (SA) was extended to the end of
December 2014. As at September 2015, the SA has not been further extended and the project is
therefore being implemented without an SA, however the program is covered by the general umbrella
agreement between the two countries.
Table 4 sets out specific interactions and participation in national level workshops, meetings and
conferences. Despite budget limitations, this continues the efforts to disseminate and share lessons
learned. Activities in the table do not include participation in the many meetings and workshops
attended at the local level.
Table 4. Participation in National Technical & Policy Dialogue Jan - Oct 2015
Visit Dates
Purpose and outcome of Visit
Name / Title of Adviser
Name / Title of Officials and
Institution
19-21 Jan 15
Meeting on preparation of a Module
on improving neonatal health
services (Pertemuan Persiapan
Penyusunan Modul Peningkatan
Pelayanan Neonatal)
Meeting for Preparation of New
edition of Buku KIA (2015 version)
Resource persons and facilitator ToF
for Provincial Health Offices Papua to
establishment of Community Board
of Puskesmas (Badan Penyantun
Puskesmas)
Dr. Henyo Kerong, Dr. Ida Trisno
EMAS, Direktur Anak, UI dan UGM
Dr. Henyo Kerong, Dr. Yuli Butu
Dr. Erna Muati MSc/ Dit. Anak, Pak
Jalin/ GAVI
AIPD-Platform Papua in Jayapura
10 Feb - 15
14 - 20 Feb
2015
Hadi Wibawa
31
Visit Dates
Institution
24 – 27 Feb
2015
To update MOH on progress with
SIKDA and discuss SP2TP
revitalisation.
NTT - PHO
1.Klemens Kesule Hala, SH,M.Hum
(Secretary of NTT PHO)
2. Ir. Erlina Salmun, M.Kes (Head of
PDE Subdivision)
3.Dona Hutahaean, SKM, M.Kes
(Data Coordinator – PDE)
4. Folkes Saudila SIP, M.Hum (M&E
Coordinator – PDE)
AIPMNH
Dr. Paula Tibuludji (M&E Program
Coordinator)
26 -27 Feb
2015
Preparation meeting for research on
referral systems in five provinces
(Kalimantan Tengah, Maluku, Papua,
NTB dan NTT di Cilandak Jakarta
Resource persons and facilitator ToF
for Provincial Health Offices West
Papua to establishment of
Community Board of Puskesmas
(Badan Penyantun Puskesmas)
Meeting on Innovative S
Pertemuan Inovasi Bedah Buku KIA
di Jogja
Participant and knowledge sharing at
DFAT booth at the Workshop on
Jamboree Reform “Regional and Civil
Society Messages for Sustainability
Reforms”
Consultation with MoH to compile
pocket book of F1-F8 data
operational definition on MCH
indicator coverage
Dr. Yuli Butu
PUSDATIN MOH
1.drg.Oscar Primadi, MPH (Head of
PUSDATIN – MOH). 2.drg. Vensya
Sitohang, M.Epid (Head of Health
Statistic Division – PUSDATINMOH) 3. drg. Rudi Kurniawan, M.Kes
(Head of HIS Development Subdivision – PUSDATIN-MOH)
The SP2TP Consultant Team:
1.Dr. Tris Eryando (FKM – UI).
2.Kuning Tiadi (SP2TP Expert).
3.Sholah Imari (Epidemiology
Expert)
Direktur Bina Kesehatan Ibu : dr.
Gita Maya Koemara Sakti, MHA
2 - 6 March
2015
18 March 2015
4-5 June 2015
22- 25 July
3 August 2015
6-7 August
2015
18 – 20 August
2015
19 – 20 August
2015
25 -26
8 Sep 2015
Donor meeting between Direktorat
Jendral Bina Gizi –KIA Kemenkes
with Development Partner donors and
NGOs in improving maternal and
child health and nutrition.
Participant at the Workshop on the
Strategic Framework inline of AIP
Pro-Poor Policy framework (AIP4)
organized by KSI
Techincal Coordination Meeting,
Direktorat Jendral Gizi dan KIA.
Presentation on AIPMNH assistance
for the Referral System by Dr Reny,
Kepala Dinas, Ngada.
Symposium on Best Practice MNH
(Simposium Praktik Cerdas GKIA)
Jakarta - SH poster and Desa Siaga
Video presented
AIPHSS workshop on Neonatal
Mortality
SH PML Evaluation Meeting To
evaluate implementation of clinical
pathway, quality improvement
program and clinical audits in RSUD
Hadi Wibawa
AIPD-Platform West Papua in
Manokwari
Dr. Yuli Butu
Fakultas Kedokteran UGM-Jogja
Hadi Wibawa
Reform the Reformers Continuation
Program (RTR-C) - DFAT
Ester Kana, Drg. Maria Silalahi,
MPHM, MCH Subsection Head, PHO
Yudistira R. Kikhau, SKM, MCH
section, PHO
Ronald Raya, SKM, M.Kes, MCH
Section PHO
Dr. Yuli Butu
dr. Gita Maya, Direktur Bina
Kesehatan Ibu, MoH
dr. Yuli Farianti, M.Epid, Kasubag
TU, MoH
Hadi Wibawa
Knowledge Sector Initiative (KSI) BAPPENAS, Jakarta in August 2015.
Drg. Emiritiana R.W (Kadinkes
Ngada), Dr. Henyp Kerong, Dr.
Yustina Yudha Nita, Ibu Quin
MOH Gizi KIA meeting.
John Ire
National level workshop on GKIA
Best Practice (the Desa Siaga video
was the only one accepted).
Direktur Jendral Bina Gizi KIA: dr.
Anung Sugihantono, MKes. Jakarta
Dr Henyo Kerong
Dr. Ida Trisno, Dr. Yustina Yudha
Nita
RSUD Soe, Kefa, Waingapu,
Waikabubak, Ruteng, Bajawa, Ende,
Larantuka, Lembata, and PKMK
UGM
32
Visit Dates
Institution
9-10 Sep 2015
Indonesia Health Quality Network
Meeting. To obtain on information
regarding implementation of BPJS
and health service quality issues
APACPH International Conference
Bandung. Present (1)findings of
complications (2) AMP (3) Blood
Donation program (4) Neonatal Study
Dr. Ida Trisno, Dr. Yustina Yudha
Nita. Dr Irene to present on
Complications Study and Ibu Susty
on Unit Cost Survey
Dr. Ida Trisno, Pak Asnawi,
RSUD Soe, Kefa, Waingapu,
Waikabubak, Ruteng, Bajawa, Ende,
Larantuka, Lembata, P2K3
UNDANA, and PKMK UGM
International, central level, donor
agency participants
21-23 Oct 2015
9.2
MOH / WHO MNH Strategy 2015 - 2025
As per the previous report, the Strategy is still being finalised. Copies have been provided to DFAT
but not, as at September 2015, to AIPMNH. At the request of DFAT, AIPMNH provided approximately
USD375,000 to WHO for development of the strategy in June 2012.
9.3
Province and District Levels
th
The PCC, SH and DPC meetings were held in Denpasar from the 27 – 29 of May. It was planned to
hold TWG/PRC meetings also and that these would be preceded by a field visit to NTT.
Unfortunately, MOH was occupied with other activities and this did not occur.
The PCC was, as usual, well attended (as per the numbers in brackets) by the Province (21), Districts
(45), Central Level Agencies (15) and DFAT (5).
The following is a shortened version of the
recommendations, full minutes of the meetings and lists of attendees are available on request.
•
NTT will continue to receive as much support as possible from the Australian government utilising
the same partnership mechanism pioneered and implemented by AIPMNH.
•
Best Practices developed by AIPMNH are being replicated by the province and districts with an
emphasis on increasing community engagement.
•
For sustainability of the Sister Hospital Program, district governments agreed to budget support.
•
To meet the needs of Health Personnel in NTT the MOH are requested to support PTT
placements.
•
The MOH are to assist to disseminate and replicate AIPMNH Best Practices.
•
Need to clarify responsibilities between levels of government to improve public health efforts.
•
The MOH should support the region in preparing standard incentives for specialists.
•
The PCC supports the local parliaments Commission 5 initiative to revise PerGub Revolusi KIA
and to become PERDA.
•
The PCC supports the proposal of the MOH to Kemenpan (Ministry of Labour) to revisit the
moratorium on appointment of health workers specifically for NTT via an official letter from the
Governor of NTT.
District Coordination Committees (DCCs) are functioning well in the 10 districts along with technical
working groups.
Bappeda leads the committees and, as all the DPC offices are located within
Bappeda offices, effective ongoing and daily coordination is facilitated (Sumba Timur and Sumba
Barat are the exceptions being in the DHO and BKKBN respectively). The UPK units are of course
also located within the Bappeda offices.
9.4
Partnership
There is continuing active engagement with the Districts and ownership of the program continues to
be very positive, as demonstrated in the doubling of local government funds this year for replication of
33
AIPMNH initiatives. Compared to previous years AIPMNH funds have been minimal and used for TA,
some flexible funding for initiatives and dissemination of lessons learned. The UPK process and
system continues to be a particular success in terms of the partnership. Bappeda and BPMD at
provincial level continue to be particularly positive contributors to the Partnership with Bappeda
continuing to actively support development of the District UPKs as well as effectively performing their
role as the provincial UPK.
9.5
Monitoring Visits
Table 5. DFAT Monitoring visits January – September 2015
no
NAME
DATE of VISIT
DESTINATION
1.
Team 1
Rich Tobin
Ardi Kaptiningsih
Lea Suganda
Danielle Sever
Dewi Arilaha
(interpreter)
Jogja, 28 – 29 January 2015
Kupang, 28 – 29 January 2015
Ende, 29 January – 01 February 2015
Sumba Barat, 01 February – 04 February
2015
Sumba Barat Daya, 04 – 05 February
2015
Surabaya, 05 – 06 February 2015
Kupang, 30 – 31 January 2015
Manggarai 01 – 05 February 2015
Manggarai Timur, 04 February 2015
Manggarai Barat, 05 – 08 February 2015
Evaluation Mission (Independent Completion Review)
AIPMNH :
Visit Panti Rapih Hospital, Soetomo Hospital l and Sarjito
Hospital (Partner A) – Sister Hospital, PMPK UGM
Meeting with PHO, BPMD, Bappeda (Provincial level)
Meeting with Bupati, Bappeda and DHO, Visit RSUD,
Puskesmas, Desa Siaga, Rumah Tunggu, HSS sites at
District
Ende, 23-26 March 2015
Denpasar, 26 – 29 May 2015
DPC Meeting at Ende
PCC, Sister Hospital Meeting & DPC meeting at Denpasar
Kupang 8 – 10th September
Kupang
2.
3
4
Team 2
Fiona Duby
Wiwin Damayanti
(AIPMNH staff)
Adi Nugroho
Lea Suganda
John Leigh ,Lea
Suganda, Daniella
Sever, Sarah Ayu
JB Carrasco and team
(total of 4)
Evaluation Mission (Independent Completion Review)
AIPMNH :
Meeting with Walikota/Bupati, DHO, Bappeda, BPMD,
RSUD, Puskesmas, Desa Siaga, Posyandu visiting at
District
As per Table 5 the main visits during the period were related to the Independent Completion Review
and participation in the PPC, DPC and SH meetings in Denpasar. The visit by senior DFAT staff in
early September was to convey the news of the cancellation of PERMATA and to discuss current and
future assistance.
10 Replication & GOI Funding of AIPMNH Initiatives
Final budget figures for 2015 are now available and Table 6 is an update on the previous progress
report.
Total allocations for 2015, at Rp.36.6 billion are almost twice that of 2014 (total of
approximately Rp. 19 billion). Funding from ADD is not included in the table and these funds are used
extensively for CE activities at the village level. Data in the table is from District and Provincial level
budgets.
Table 6. GOI funding by Activity and District Jan – Dec 2015
Total District and Provincial Allocation per Activity for Calendar Year 2015
No.
Districts
A
1
2
3
4
5
AIPMNH Districts
Kota Kupang
Kabupaten Kupang
TTS
TTU
Belu
Desa Siaga/
Posyandu
(Rp.)
Puskesmas
Reformasi
(Rp.)
867,500,000
212,339,000
607,862,100
134,570,000
259,828,000
56,000,000
238,255,000
108,500,000
-
Sister
Hospital
/Clinical
Services (Rp.)
3,625,795,000
5,621,414,070
SIKDA (Rp.)
458,840,850
316,000,000
235,000,000
61,000,000
61,000,000
AMP
63,950,000
64,533,562
Totals per
District
1,382,340,850
528,339,000
4,770,862,100
5,990,017,632
320,828,000
34
Total District and Provincial Allocation per Activity for Calendar Year 2015
No.
Districts
6
7
8
9
10
11
12
13
14
15
Lembata
Flores Timur
Sikka
Ende
Ngada
Manggarai
Manggarai Barat
Sumba Timur
Sumba Barat
Province
Totals
Non-AIPMNH
Districts
Nagekeo
Manggarai Timur
B
1
3
Desa Siaga/
Posyandu
(Rp.)
Puskesmas
Reformasi
(Rp.)
Sister
Hospital
/Clinical
Services (Rp.)
SIKDA (Rp.)
AMP
Totals per
District
125,116,400
241,542,000
62,500,000
996,477,000
205,000,000
235,500,000
295,000,000
260,000,000
247,910,200
35,000,000
60,000,000
28,000,000
329,000,000
218,499,950
200,000,000
72,570,000
25,000,000
1,884,850,500
1,295,278,000
33,510,600
-
4,751,144,700
1,370,824,950
26,801,039,370
10,250,000
350,000,000
278,850,000
37,250,000
156,940,000
43,000,000
44,000,000
490,599,500
114,643,400
532,992,000
3,190,365,750
2,088,727,500
1,886,820,000
401,350,000
2,933,516,000
5,670,001,500
4,698,592,550
626,600,000
2,720,887,000
1,984,578,600
577,992,000
36,581,452,732
185,465,000
128,000,000
230,000,000
150,000,000
1,866,789,000
4,963,771,500
4,048,398,800
1,897,717,500
1,597,025,000
5,000,000
15,290,000
153,193,800
87,600,000
42.920.000
5,000,000
45,000,000
468,077,962
52,250,000
365,057,250
282,250,000
515,057,250
Total numbers of CE activities replicated in each District as at the end of June 2015 are set out in
Table 7. All districts are now replicating Desa Siaga and the majority are now replicating Puskesmas
Reformasi.
Table 7. Replication Desa Siaga, Posyandu and Puskesmas Reformasi until September 2015
No.
Districts
Total No. Desa Siaga and Puskesmas Reformasi funded by AIPMNH and No. District funded
Replication to September 2015
Desa Siaga/ Posyandu
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Kota Kupang
Kabupaten Kupang
TTS
TTU
Belu
Lembata
Flores Timur
Sikka
Ende
Ngada
Manggarai
Manggarai Barat
Sumba Barat
Sumba Timur
Totals
Puskesmas Reformasi
AIPMNH
Replication
(GOI funds)
Sum
AIPMNH
Replication
(GOI funds)
Sum
15
10
13
15
12
15
26
18
50
30
37
43
25
34
343
36
26
22
52
93
30
36
71
16
32
71
52
6
65
608
51
36
35
67
105
45
62
89
66
62
108
95
31
99
951
3
2
4
3
2
1
2
4
5
3
2
2
9
3
45
3
0
5
8
2
3
2
1
6
6
3
4
1
3
47
6
2
9
11
4
4
4
5
11
9
5
6
10
6
92
Table 8. Materials and products to support replication as at June 2015
Title
Current Status
2H2 guide and video from Flotim
Printed, distributed, soft and hard copies available; Flotim District has
duplicated and distributed within district using its own budget
Printed, distributed, copies available – also distributed via pdf due to strong
demand.
Revised and reprinted this reporting period to include new indicators from
BUK guidelines for Puskesmas Berprestasi
Printed 1st Edition limited distribution and 2nd Edition also distributed; soft
Reformasi Puskesmas detailed manual prepared by Kota
Kupang (in use)
District Initiatives – documentation of 18 initiatives from the
35
Title
Current Status
14 Districts
Manual and system for Clinical Instructors (Magang in
RSUD for Puskesmas staff)
SIKDA - complete sets of guides and manuals
IPHB gender sensitive
PWS KIA - manual and guide available
DQS - manual available
SIMKA - training guide and system developed
and hard copies available; 2nd edition has been distributed to all 22 districts
Materials available but not printed
Printed, distributed, copies available
Distributed in May 2014, copies available
Training guide printed and available and operational in the three districts
and Ende will implement in the next period
Printed and distributed
All 11 districts have finalized their referral manuals and are legalized by SK
Dinkes Kabupaten: Manggarai, Ngada, Ende, Sikka, Flotim, Lembata,
Sumba Barat, Sumba Timur, TTS, TTU, Belu. Sikka, Ende and Ngada also
legalized by SK Bupati.
Printed 650 copies and distributed to AIPMNH Districts and Manggarai
Timur and Nagakeo
Printed and distributed. English and Indonesian version are combined in one
book
Now printed and distributed
AMP formats
District Referral manuals
Community management of rumah tunggu guidelines
UPK guidelines / manual both English and Indonesian
Desa Siaga, POKJANAL, Posyandu manual
A Guideline for Community Engagement in Maternal and
Neonatal Health – this includes: Desa Siaga, Posyandu,
Blood Donor Community, Villager Regulation (Perdes),
Rumah Tunggu, Community Health Board (BKPM),
Reformasi Puskesmas, and CE Mentor
Performance Leadership Management Booklet
Sister Hospital Booklet
SIKDA (Sistem Informasi Kesehatan Daerah) / Regional
Health Information System – Booklet
PONED Service to Improve MNH Services in Puskesmas
Booklet
Behaviour Change and Communication Design Booklet
Guidelines for Premarital Catechism and MNH
Guidelines for Desa Siaga Development
Engaging Community and Kader PKK to Reduce Neonatal
Deaths
Note; for most of the materials, electronic copies are available on www.aipmnh.org those which are in Bahasa Indonesia are
only on the Indonesia side of the website.
11 Issues and Constraints
11.1 Reduced Budgets
Information on actual budget DFAT allocation was received in late June 2015. The amount allocated
was less than previously planned for the Workplans (and these Workplans had already been through
the Partner Asistansi process). To adjust to the reduced budget; many activities were cancelled,
District DFAAs will complete their contracts at the end of November, district vehicle contracts have
been cancelled and many other cost-cutting measures undertaken.
With these actions, it is
anticipated that the project can continue to be implemented effectively until the end of December
2015.
11.2 Increase in Maternal Deaths Jan – June 2015
Preliminary reports of maternal deaths in districts of NTT over the period January to June 2015
suggest an increase compared to 2014.
This follows several years of consistent declines.
The
increase appears to be quite widespread, with most districts reporting more than 50% of the total
36
number of deaths reported in 2014, and many already reporting as many deaths as in 2014. The
largest increase is in the Sister Hospital group 1 districts (=50% compared to what would be expected
on the 2014 rate); with an increase of 32% for the Group 2 sister hospitals. Full data for Kota and
Kabupaten Kupang is not yet available, while for non AIP districts the increase is + 10% (although
missing data for Sumba Tengah may mean no increase). (Table 9)
Table 9. Maternal death Jan – June 2015 compared to 2014
Sister hospital group
District
Total maternal
deaths 2014
Maternal deaths
Jan-June 2015
AIP-SH1
Ende
Sumba Barat
Ngada
Lembata
Flores Timur
TTS
Total
Sikka
Sumba Timur
TTU
Belu + Malaka
Manggarai
Manggarai Barat
Total
Kota Kupang
Kab Kupang
Alor
Rote Ndao
Nagakeo
Sumba Barat Daya
Sumba Tengah
Manggarai Timur
Sabu Raijua
Total
AIP
Non AIP
4
3
4
2
4
23
40
6
19
7
10
4
10
56
7
6
6
5
4
13
2
10
9
49
109
49
3
3
3
4
3
14
30
6
10
5
7
4
5
37
5
6
1
4
6
7
3
27
72
27
AIP-SH2
AIP-KK
Non AIP
TOTAL
Note: Data for Kota Kupang and Sumba Tengah not yet available.
% increase on
2014 rate
+50%
+32%
+10%
Of the 99 reported deaths, 39 were due to haemorrhage, 9 infection, 1 prolonged labour and 38 due to
other causes (not specified).
In terms of ratio of reported death per 100,000 live births, this would result in a similar rate of maternal
deaths in the 14 original AIPMNH districts (213/100,000) as in the non-AIP districts (255/100,000). A
similar pattern is seen in reported maternal deaths from the district hospitals involved in the sister
hospital program when comparing the same period: January to June 2015, and January to December
2014. There are clearly more deaths in the sister hospital group 1 in the first six months of 2015 (36)
than in the whole of 2014 (26); while the number of deaths in the sister hospital group 2 for the first six
months is about what would be expected at the 2014 rate, for the three remaining hospitals of group
2. (Table 10)
Table 10.
In-hospital deaths & as % of total catchment deaths
Group 1
Jan -June 2015
% catchment
Jan-Dec 2014
% catchment
Soe
Lewoleba
Larantuka
12
3
4
86%
75%
133%
9
0
8
39%
0%
200%
37
Group 1
Jan -June 2015
% catchment
Jan-Dec 2014
% catchment
Ende
Waikabubak
Bajawa
Total Group 1
5
8
4
36
100%
133%
80%
97%
1
3
5
26
17%
29%
83%
50%
0
2
0
6
0
8
0%
20%
0%
67%
0%
22%
5
4
71%
20%
0%
43%
0%
29%
Group 2
Kefa
Waingapu
Atambua
Ruteng
TC Hilliers
Total Group 2
6
15
It is also notable that the proportion of catchment district deaths occurring in hospital is higher in the
group 1 sister hospitals for the first six months of 2015 (97%) compared to 2014 (50%), while the
proportion is similar for the group 2 sister hospitals. This suggests better functioning of the referral
system, with fewer deaths occurring at home, but raises questions about the quality of care at the
referral hospital.
Comparison of causes of death in hospital identifies some important differences between the groups
and between the two periods of time (See Table 11). For the period January to June 2015, the major
cause of death is haemorrhage (16 cases), followed by pre-eclampsia / eclampsia (9 cases) in the
group 1 hospitals. Compared to the 12 months January to December 2014, the number of cases of
haemorrhage has fallen, (from 362 in 12 months, to 99 in 6 months), but the case fatality rate (CFR)
has increased from 1.1% to 16.2%.
While the number of cases of prolonged labour and pre-
eclampsia /eclampsia has risen in the first 6 months of 2015, the CFR for these conditions are lower
than in 2014. Among group 2 hospitals, the number of cases of haemorrhage has also risen in the
first 6 months of 2015, but the case fatality rate is a much lower 1.7%, similar to the rate in 2014. This
suggests that the main cause of the increased maternal deaths in group 1 hospitals is an increased
CFR for cases of haemorrhage. This was not seen in group 2 hospitals.
Table 11.
Complications, deaths, CFR comparing Jan-Jun 2015 and Jan-Dec 2104
Jan-June2015
Jan-Dec 2014
Group 1
Number
Deaths
CFR
Number
Deaths
CFR
Haemorrhage ante or post partum
Prolonged / obstructed labour
Uterine rupture
Puerperal sepsis
Pre-eclampsia / eclampsia
Induced / septic abortion
Ectopic pregnancy
Direct cause total
99
136
1
6
461
1
8
713
16
1
0
1
9
1
0
28
16.2%
0.7%
0.0%
16.7%
2.0%
100.0%
0.0%
3.9%
362
183
16
6
663
25
45
1284
4
2
3
3
5
1
2
19
1.1%
1.1%
18.8%
50.0%
0.8%
4.0%
4.4%
1.5%
120
95
5
9
349
58
14
650
2
0
0
0
2
0
0
4
1.7%
0.0%
0.0%
0.0%
0.6%
0.0%
0.0%
0.6%
197
219
4
8
544
222
38
1227
4
0
2
2
4
3
0
15
2.0%
0.0%
50.0%
25.0%
0.7%
1.4%
0.0%
1.2%
Group 2
Haemorrhage ante or post partum
Prolonged / obstructed labour
Uterine rupture
Puerperal sepsis
Pre-eclampsia / eclampsia
Induced / septic abortion
Ectopic pregnancy
Direct cause total
38
In terms of specific hospitals, Soe had the largest number of maternal deaths from haemorrhage (9
deaths from 16 cases, a CFR of over 50%); followed by Ende (3 deaths from 0 cases), Bajawa (2
deaths from 34 cases), Waikabubak (1 death from 31 cases) and Lewoleba (1 death from 6 cases).
Ende did not report any cases of haemorrhage, although there were 3 deaths reported.
CFR for the other common complications of prolonged labour (0.7%) and pre-eclampsia/eclampsia
(2.0%) were low, and indicate good quality of care for these conditions, which require intensive care
and complex interventions. However, the high mortality rates for haemorrhage suggest problems of
late presentation and/or in obtaining blood for transfusion rather than overload of services.
Comparison of indicators of workload, such as number of deliveries, complications managed or
caesarean sections (Table 12) does not suggest major changes in workload for group 1 hospitals.
Larger increases can be seen for group 2 hospitals.
In particular, RSUD Soe, with the highest
mortality rates, has seen decreases in deliveries, complications and caesarean sections.
Table 12.
Workload indicators compared by RSUD, Jan-June 2015 and Jan-Dec 2014
Workload
indicators
Deliveries
Group 1
Jan-June
2015
Jan-Dec
2014
%
change
Jan-June
2015
Jan-Dec
2014
%
change
Jan-June
2015
Jan-Dec
2014
%
change
Soe
Lewoleba
Larantuka
Ende
Waikabubak
Bajawa
Total
471
337
764
928
719
904
4123
1084
963
1343
1740
1357
1530
8017
-13%
-30%
14%
7%
6%
18%
3%
59
82
87
129
182
174
713
242
41
205
233
332
231
1284
-51%
300%
-15%
11%
10%
51%
11%
105
211
208
262
272
368
1426
274
341
278
638
502
431
2464
-23%
24%
50%
-18%
8%
71%
16%
483
482
0
1671
0
2636
769
735
1152
2846
1060
4350
26%
31%
99
88
0
463
0
650
115
77
62
678
295
870
72%
129%
183
154
0
480
0
817
65
176
551
827
388
1068
463%
75%
Complications
Caesarean section
Group 2
Waingapu
Atambua
Ruteng
TC Hilliers
Group 2
Total
17%
21%
37%
49%
16%
53%
11.2.1 Conclusions
Initial indications from reporting over the first 6 months of 2015 suggest an increase in reported
maternal deaths, particularly from the AIPMNH supported districts, and those districts in the first group
of sister hospitals. While this trend may not continue, if it does, the annual reported maternal deaths
may be as much as 50% above those in 2014.
Analysis suggests that the majority of deaths are occurring in hospitals, and that an increase in the
case fatality rate from haemorrhage is the largest contributor to the increased deaths.
Further
investigation is suggested to identify whether the problem lies with late presentation at hospital, or
delays in obtaining and transfusing blood on arrival at hospital.
11.3 Contraceptive Uptake Constraints
The number of family planning-trained (CTU) and certified midwives is inadequate, only 5% of the
midwives in each district are trained in providing postnatal contraceptives (or KB pascasalin). Out of
85 Bikors, only 54% have attended CTU training – the midwives, however, have not been trained in
KB pascasalin. The National Health Insurance Scheme for package pregnancy stipulates inclusion of
39
post-natal contraceptive use. Without certification of CTU training, midwives cannot legally provide
long acting contraceptives. The training and certification are the responsibility of BKKBN and they are
aware of this constraint. In this years’ BKKBN budget there is provision for training in nine of the 10
districts and the priority will be the Bikors. More effort is clearly needed.
11.4 Fraud Case TTU District
In May 2015, a fraud case was identified and immediately reported to DFAT. The fraud consisted of
the TTU AIPMNH District Finance and Administrative Assistant (DFAA) failing to follow procedures by
re-depositing residual Activity funds back into the AIPMNH bank account.
The amount was
approximately Rp 93 million (AUD9,000) and this was returned in full by the perpetrator in August
2015 due to persistent and sustained action by AIPMNH.
Financial management procedures were immediately enacted to prevent such an occurrence in other
Districts. The DFAA’s contract was also immediately terminated and a replacement DFAA recruited.
The case was officially closed by DFAT on September 1, 2015.
40
ANNEX 1.
Output Progress by Component
41
Component 1.
Community Engagement and Service Delivery
Information on indicator achievement for Component 1 is in section 1 of the main text. This Annex is a
description of activities undertaken and constraints in this reporting period as well as future actions for
the next reporting period.
Output 1.1 Basic MNH care and first aid provided at all health facilities including ANC,
care for pregnancy and complications, the normal newborn and family planning
information
Progress in implementation
Activities are aimed at strengthening and supporting improvement in the capacity and quality of services
at the Puskesmas and include in this period:
1. Coordination meeting to improve ANC, INC and PNC.
2. Facilitative Supervision.
3. Comprehensive internship (magang) on Low Birth Weight (LBW)/asphyxia and kangaroo method
(PMK)
4. PONED (BEONC) Technical Assistance and Internship.
5. Clinical Training Skill/Clinical Instructors for midwife coordinators (BiKor).
1. Coordinating Workshop to Improve ANC, INC, and PNC.
The workshops were conducted in ten districts with the aim of improving the coverage of health
services and attended by all MNH/Family Planning personnel and midwives from Polindes.
Purpose: To obtain an overall picture on current services and identifying issues and solutions
Review MNH Standard Operating Procedures (SOPs) to ensure these are compliant with the
Puskesmas Accreditation requirements.
Results: The SOPs are not fully compliant with the principles written in the Puskesmas Accreditation
Documents.
Revision of the ANC, PNC, and NEO Flowcharts was conducted in March 2015. All inputs from the
districts for the revision of the flowchart have been included and it is expected that all parties will comply
with the new flowcharts.
Solutions: All Puskesmas need to revise their SOPs under the supervision of DHO.
Budget for each district: Rp. 10,000,000-Rp 15,000,000.
2. Facilitative Supervision
Facilitative supervisions were conducted in Puskesmas, Polindes and Pustu in ten districts.
Purpose: To identify issues at Puskesmas, Polindes and Pustu.
To assess the quality of services including ANC, post-partum, and other MNH health services.
To assess the role of midwife coordinators or Bikor as a supervisor in ten districts.
To ensure that all the inputs from previous period are implemented.
The Facilitative Supervision Team for 2015 January-June period consisted of staff from AT P2KS
Kupang, DHO, Head of MNH Section of DHO, DHO Bikor and clinical instructors from relevant
Puskesmas.
42
Scope of Supervision: DHO – the head of MNH section evaluated the administrative procedures of
MNH, family planning. The DHO Bikor and AT P2KS observed how Bikors supervise the midwives in
providing ANC, normal delivery care and post-partum management. The CIE on kangaroo method was
also observed. Simulation was conducted on phantoms.
Results: There have been improvements in the administrative aspect of MNH and family planning
services as well as compliance on SOPs of ANC, INC and PNC.
Laboratory Checks / Blood Tests; There has been improvement for the first trimester of pregnancy –
malaria check has been included. Treatment is provided immediately when a pregnant woman is
malaria-positive. Hb lab test (test of anaemia) is also conducted for all pregnant women.
Testing of Puskesmas Bikor: 40% of Bikors demonstrate good results. 40% of Bikors need some
improvement in procedures and 20% of Bikors require major improvements.
The positive aspect of the supervision is that 40% (34 bikors) conduct technical supervision in line with
standard procedure and also implement standard operational procedures (SOPs). However, another
40% were not fully conversant with the procedures and do not implement the SOPs correctly.
Unfortunately, 20% of bikors are neither familiar with the SOPs nor able to implement technical
supervision correctly.
Solutions: Specific tasks were assigned for participants to do in order to improve their competencies.
It is expected that their competencies will have been improved during the post-training assessment in
August and September 2015.
Budget for each district for this activity: Rp. 20,000,000-Rp 30,000,000.
3. Comprehensive Internship on Low Birth Weight/Asphyxia – Training on Low Birth
Weight Management with Kangaroo Method or PMK
Comprehensive internship was delivered in nine districts. The internship was conducted twice with the
budget for each internship amounting to Rp. 20,000,000.
The internship in Manggarai Barat was
conducted in Ruteng district hospital (only once) with a budget of Rp. 40,000,000.
The number of participants: 8-10 participants from Puskesmas for 6-8 days. The presenters included
clinical instructors, paediatricians and obgyns from the RSUD.
Results: Participants improved on pre-test scores and improved hands on technical skills.
Issue: The duration of training is not enough (6-8 days).
Solution: There is a need to continue comprehensive internship in the future using local, national or
other funding sources to improve health staff competencies. Comprehensive internship is also more
efficient than training. However, the duration of internship should be extended.
Management of Low Birth Weight with Kangaroo Method Workshop and Training
The workshop was conducted in Kupang for two days.
Resource persons: Dr. Erni (from MOH
Directorate of Child Health), the Head of the Provincial Health Office, P2KS staffs, paediatricians and
obgyns. Total number of participants: 40 people from ten districts including: division head of family
health, head of maternal and neonatal health, Bapelkes, midwifery and nursing schools, Poltekkes,
midwives association (IBI), PPNI, and P2KS Kupang. The purpose of this two-day activity is to develop
policies regarding management of low birth weight.
The topics on neonatal management were
proposed to be included in the curriculum.
The workshop was followed by training for Puskesmas facilitators (10 districts) with 2 participants from
each district: 1 Bikor and 1 GP from Puskesmas or district hospital. Three participants came from the
43
provincial level: one from Puskesmas Bakunase and the other two participants from Poltekkes. Total
number of participants: 21 people.
Participants from Sumba Barat district could not participate.
Resource persons: paediatrician, obgyn and P2KS Kupang. Duration of training: 3 days.
Result of activity: all participants qualified as facilitators for low birth weight management and kangaroo
method.
All participants received the following: CD, booklets, flipchart and kangaroo shirt.
Budget for the two activities: Rp. 190,000,000-Rp 200,000,000.
Socialisation of Low Birth Weight with Kangaroo Method at 10 districts
Implemented by district facilitators and supervised by staff from the province (2 days).
Participants: Puskesmas’ Bikor, midwives from Polindes, IBI, midwives from district hospital. Total
number of participants: 25-30 people.
Recommendations: all newborns should be provided the kangaroo method to stabilise body
temperature and to create emotional and physical bonds between the mother and the new baby. It was
proposed to use traditional woven cloth or ikat for kangaroo method. The PKK will be involved to
promote ikat at the posyandu’s monthly meeting.
All participants from Puskesmas received the followings: booklets, DVD on kangaroo method, flipcharts
and kangaroo shirt.
Budget for each district: Rp. 29,000,000-Rp 30,000,000.
Output 1.2 Services for the management of MNH complications are available at
Puskesmas and district hospitals: services include post-abortion care, care of LBW
neonate, care of obstetric complications, family planning and infection control
4. Improvement of Basic Emergency Obstetric and Neonatal Care (BEONC - PONED) Services
BEONC Technical Assistance
Obgyns and paediatricians in ten (10) districts provided technical assistance on BEONC with the budget
ranging between Rp. 20,000,000 to Rp. 40,000,000.
Training was provided for Puskesmas that did not have a complete PONED Team to improve the skills
in assessing the clinical case, providing basic treatment and implementing appropriate pre-referral
treatment.
Identified issues: The PONED Teams from some districts that do not have PONED coordinators were
invited to participate in PONED training conducted by the P2KS in Kupang. Those districts were TTS,
Kupang and Manggarai Barat.
5. Comprehensive Internship or magang PONED
The internship was conducted in the district hospitals in ten districts – Manggarai Barat joined with the
district hospital of Manggarai in Ruteng. The budget was about Rp. 40,000,000 for two cycles of
activities.
Participants included Puskesmas’ doctors, midwives, and nurses. The duration of activities: 8-10 days.
The number of participants: 8-10 people.
44
Trainers: paediatrician, obgyns and clinical instructors from the hospital.
Topics covered: normal
delivery care, obstructed labour, etc.
This kind of approach is more effective than other approaches as participants were able to analyse and
manage the cases.
Puskesmas have implemented the activities on infection control, however, lack of clean water is an
issue at some Puskesmas.
PONEK (District Hospital Services)
The report on District Hospital Service related activities is at ANNEX 3, which is the report on the Sister
Hospital program.
6. Family Planning
Cross-sectoral coordination meeting for quality contraceptive services
Coordinating Meetings on Integrated Family Planning Services were conducted in ten districts.
Participants included Bappeda staff, members of district council, chairperson of PKK, sub-district heads,
village heads, cadres, family planning field officers/PPLKB, district health offices, midwives
coordinators, and village midwives.
Issues: Lack of coordination between the midwives and the FP field officers
Low coverage of long-term contraceptive users
The number of family planning-trained (CTU) and certified midwives is inadequate, only 5% of the
midwives in each district are trained in providing postnatal contraceptives (or KB pascasalin). Out of 85
Bikors, 54% have attended CTU training – the midwives, however, have not been trained in KB
pascasalin.
The National Health Insurance Scheme for pregnancy stipulates that the insurance
package includes contraceptive use.
Budgets for photocopying the matrix-books are not available at Puskesmas. Matrix-books are used for
reporting family planning activities.
The field officers from BKKBN are expected to promote and
motivate the families in order to increase the coverage of contraceptive use when they visit Puskesmas,
Polindes or Posyandu.
Solutions: With regard to the training on contraceptive use after birth, the provincial BKKBN is
responsible to deliver the training. There are nine (9) training packages in nine districts. The midwife
coordinators at Puskesmas are the main targets of the training.
It is proposed to procure the report-forms through district BPPKB.
Blood Transfusion Services: The number of Districts with formal community groups established for
the purpose of increasing available blood supplies is now eleven. The intention is to have an ongoing
reliable supply rather than ‘campaign’ based or through personal contacts. The SH program is also
working with the RSUD to improve management and safety of the blood supply.
Output 1.3 Women and families have knowledge of appropriate practices and MNH
services
In this reporting period, the main activities implemented consisted of the Development Broadcasting
Unit (DBU), Interpersonal Communication (IPC) and developing a more effective IPC curriculum for
BKKBN.
45
Development Broadcasting Unit
Four districts implemented training in DBU; Sumba Timur (Waingapu: January 26-31), TTS (Soe:
February 23-28), Ngada (Bajawa: March 16-20) and Manggarai (Ruteng: April 6-11). The DBU training
involves three groups (1) Desa Siaga represented by the population we are working with, (2)
stakeholders at the district level, such as District Health Office, BPPKB (Stakeholder responsible for
Family Planning and Women’s Empowerment), PKK, CSOs; head of Desa Siaga and Religious leaders,
and (3) the radio represented by radio presenters and production managers.
DBU activities were implemented in the classroom, in the field (community) and radio station.
Classroom activities covered design of attractive and relevant radio programs, developing lists of
questions for key informants and collecting methodologies. Activities in the field consisted of collecting
information of the selected topics.
Topics selected were based on information from the heads of
villages participating in the meeting.
Radio station activities covered editing and broadcasting
techniques.
The focus of the DBU program is to identify relevant smart, health positive and family planning
behaviours in the community that have proven capable of facing identified challenges. These ‘model’
behaviours and challenges in the community are then packaged as attractive broadcasts to enable
learning by other segments of the population.
Advantages of DBU approach: (1) Solutions are being identified by the community themselves and
therefore the community’s skills in problem solving are improved, (2) The solutions have evidence of
effectiveness in solving the community’s problem (3) Minimise potential rejection of the idea or concept
by the community.
DBU training in the four districts has run well and produced some very interesting broadcasting
materials that are relevant to the local problems and local solutions.
Constraints
Despite success in conducting the DBU training in the four districts there are constraints, as follows;
Sufficient time is required to identify relevant health problems and solutions. The relevance is crucial if
we would like to obtain “unique” stories since some of these stories were “hidden” at a personal level
(for example: reason to quit smoking) or at the family level (for example: bringing up children and family
eating habits that impact on under five children)
Higher-level analytical skills are required to collect information for smart and effective health behaviours
at a personal and household level and then to develop effective communication mechanisms so that the
information is “interesting and effective” at the community level.
Inter Personal Communication/IPC
Two districts that had already had IPC training requested a further round of training, Manggarai and
Lembata.
Participants from previous IPC training considered that the training has improved their
communication skills in interacting with their clients particularly for midwives counselling family planning
clients. In Lembata District, the head of the BKKBN requested that family planning field staff participate
in the training so they can acquire better interpersonal communication skills since these skills are
crucial to enable them communicating effectively with the community. Therefore, four BKKBN field staff
participated in the training.
IPC training was conducted in Ruteng (March 9-14) and Lewoleba (April 20-25). Overall there were
117 participants (113 midwives and 4 family planning staff). The cumulative total of IPC participants
trained as of June 2015 is 541 (4 males from family planning and 537 female midwives).
46
Constraints
While there are no specific issues for the IPC training, there were requests to increase the training to
two days or more and others requested more role-play sessions.
BKKBN
The new head of Provincial BKKBN is Bapak Kres Saputra. Based on a series of meetings with Pak
Kres and senior provincial staff, it is clear that Pak Kres is very supportive of collaboration between
BKKBN and AIPMNH. Resulting from the discussions there are two relevant collaborative activities and
these are firstly revising the IPC curriculum to more focus on family planning and subsequently
conducting IPC training for 10 districts using the revised IPC training. The other activity is development
of media to provide crucial support to the IPC and counselling skills of BKKBN field staff. BKKBN has
responded positively to the proposed activities and will coordinate with Bappeda on development of the
TOR.
Future plans
Revising the IPC Curriculum with BKKBN from one day to two days IPC training.
Co-facilitating IPC training in 10 AIPMNH districts with BKKBN
Developing IPC materials with BKKBN
Output 1.4: Communities are involved in the provision and support of MNH services.
Output 1.4 responds to the high rate of home births by encouraging facility-based deliveries through the
Desa Siaga and revitalisation of Posyandu programs. These programs improve access to Puskesmas,
as well as increased levels of antenatal care (ANC). The Puskesmas reformasi program seeks to
encourage greater engagement, accountability and links between service providers and their
communities.
Progress against Output Indicator
(1) Number of villages with AIPMNH assisted Desa Siaga and Posyandu
Following 54 months of support, there are now 941 villages with AIPMNH supported Desa Siaga and
Posyandu operating. AIPMNH supported 343 of these while partners funded the remaining 598.
Some indication of the contribution of the Desa Siaga / Posyandu revitalisation program can be gained
from the reports from the heads of the Desa Siaga network in each village.
•
The proportion of pregnant women in the village attending Posyandu has increased from an
average of 52% before the AIPMNH intervention, to 93% currently (54 months after
commencement)
•
The proportion of children under five attending the Posyandu for regular weighing increased from
an average of 63% to 93%
•
The proportion of pregnant women delivering in the Puskesmas or hospital has increased from an
average of 67% before the AIPMNH intervention to 94% currently
•
Funds collected for supporting costs of delivery were accessed by 33% of pregnant women in the
Desa Siaga networks; while 59% of women accessed assistance from the transportation network
•
20% were accompanied during delivery by a potential blood donor, and 33% of women were
referred to hospital.
47
The average amount of funds collected in AIPMNH Desa Siaga villages for assistance to women at
delivery (Dasolin) now stands at Rp.1,087,000 per village.
Progress in Implementation:
(a) Posyandu revitalisation
AIPMNH is supporting partners to revitalise Posyandu through:
1.
Improving both the government and community’s capacity in managing Posyandu through
supporting the establishment of POKJANAL and POKJA (POKJANAL are inter-sectoral district and
Kecamatan level working groups that manage the functioning of Posyandu, POKJA are village level
working groups that support Posyandu through training of kader).
2.
Increasing participation of community leaders in the management of the Posyandu.
3.
Training of kader.
4.
Encouraging pro-MNH village planning and budgeting that supports Posyandu and kader.
District CE Mentors and Provincial Advisors continued with capacity building for District and Kecamatan
level POKJANAL and the village level POKJA (Posyandu Management Committees).
The Provincial POKJANAL for Desa Siaga and Posyandu is the responsibility of Provincial BPMD and
Dinas Kesehatan however the Secretariat is with BPMD.
For this year, 2015, AIPMNH support is only for POKJANAL monitoring and evaluation at province
level. There are no funds for any activities that are already covered by the district budget (APBD).
Problems Encountered
Nil and despite the reduction in CE mentors at District level, activities have been maintained and
expanded due to the previous good work with capacity building of the POKJANAL.
Future Action
Continue to work closely with partners to ensure that gains made in AIPMNH investment in Posyandu
are maintained.
Support generated for Posyandu through the pra-musrenbang process, such as
incentives for kader, also assist with maintenance of effective Posyandu.
(b) Desa Siaga
The GOI definition of ‘Desa Siaga’ refers to a range of interventions at the village level including health
infrastructure, the provision of midwives, and efforts to reduce malaria and improve disaster
preparedness (Keputusan Menteri Kesehatan No. 54/Menkes/SK/VII /2006, 2 August). AIPMNH’s
model of Desa Siaga is more limited focusing specifically on building community support to manage risk
factors for pregnancy and preparedness for women to deliver at health facilities through development of
five networks at the village level. These networks support 1) Notification/Antenatal care, 2). Financial &
other preparations, 3). Blood donors, 4) Transportation, and 5) Family planning.
Table 13 details APBDII funding for Desa Siaga / Posyandu by district 2013 to 2015 and as illustrated
there the Districts are continuing to fund establishment and maintenance of the programs. Funds from
ADD, BOK/JKN and PNPM are also being used for these purposes and are not included in this table
and the contribution from these sources has increased over the past year.
48
Table 13.
APBD Funding for Desa Siaga / Posyandu 2013, 2014 and 2015
no
AIPMNH Districts
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Kota Kupang
Kab. Kupang
TTS
TTU
Belu
Lembata
Flores Timur
Sikka
Ende
Ngada
Manggarai
Mangg.Barat
SumbaTimur
Sumba Barat
Totals
Desa Siaga / Posyandu (Rp.)
2013
2014
2015
40,000,000
600,000,000
92,710,000
140,985,600
30,000,000
349,520,000
115,787,500
697,615,750
306,000,000
410,950,000
313,000,000
332,689,600
207,750,000
632,755,500
112,610,997
4,342,376,961
867,500,000
212,339,000
607,862,100
134,570,000
259,828,000
125,116,400
241,542,000
62,500,000
996,477,000
205,000,000
235,500,000
295,000,000
260,000,000
247,910,200
4,751,146,715
77,000,000
292,000,000
403,605,000
127,762,000
193,860,000
128,000,000
106,740,000
827,911,000
137,388,000
206,283,000
427,766,000
137,498,000
3,065,813,000
At the village level, pro-MNH PERDES have been made to support village commitment and thus far,
there are a total of 298 (an increase of 78 from the previous period) as per Table 14. It is expected that
the total will increase by 40 in the July – December 2015 period.
Table 14.
Number of PERDES KIA by District as at June 2015
No.
Kabupaten
Total Perdes KIBBLA
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Kota Kupang
Kabupaten Kupang
TTS
TTU
Belu
Manggarai Barat
Manggarai
Ngada
Ende
Sikka
Flores Timur
Lembata
Sumba Timur
Sumba Barat
Total
(SK Lurah )
10
8
8
4
30
20
49
9
16
20
14
86
24
298
The Provincial BPMD is replicating Desa Siaga using the AIPMNH model and approach in non-AIPMNH
districts (Alor, Manggarai Timur, Nagakeo, Malaka and Rote) with all funding from Provincial APBD
budgets and limited TA support from AIPMNH.
Table 15 lists numbers of numbers of AIPMNH directly supported Desa Siaga and those replicated with
GOI funds (APBD, ADD, BOK and PNPM) as at the end of December 2014. AIPMNH will continue to
provide TA through the CE mentors and Advisers.
Table 15.
Number Desa Siaga by district, AIPMNH and Partner funded as at June 2015
No.
Districts
1
2
3
KOTA KUPANG
KAB KUPANG
TTS
AIPMNH-supported Desa
Siaga as of June 2015
15
10
13
Replicated Desa Siaga
supported by ADD/ APBD
& BOK as at June 2015
26
26
22
Totals as at end June 2015
41
36
35
49
No.
Districts
4
5
6
7
8
9
10
11
12
13
14
TTU
BELU
LEMBATA
FLORES TIMUR
SIKKA
ENDE
NGADA
MANGGARAI
MANGGARAI BARAT
SUMBA BARAT
SUMBA TIMUR
TOTALS
AIPMNH-supported Desa
Siaga as of June 2015
Replicated Desa Siaga
supported by ADD/ APBD
& BOK as at June 2015
15
12
15
26
18
50
30
37
43
25
34
343
52
93
30
36
71
16
32
71
52
6
65
598
Totals as at end June 2015
67
105
45
62
89
66
62
108
95
31
99
941
A handbook for Desa Siaga is now completed and was printed in August 2015. This is divided into
sections and provides sufficient and clear guidance for other programs and agencies to replicate the
program.
Blood donor groups based on various community organisations continue to be fostered by the CE
Mentors and it is hoped that these groups are pioneers for large-scale and reliable voluntary blood
donation in the districts. Districts now with active groups are. Sumba Timur, Sumba Barat, Ende,
Manggarai, TTS, Sikka, Belu Manggarai Barat, TTU, Ngada, Lembata
Nil
Future Action
Continue to provide technical support to the Province and Districts to maintain and expand Posyandu /
Desa Siaga.
Continue to focus on capacity building in the Districts and Province to sustain and expand the program.
(c) Reformasi Puskesmas. Improved transparency and reporting to clients of its operations by
Puskesmas involved in the Puskesmas Reformasi program.
The Community-based Puskesmas Reform or ‘Reformasi Puskesmas’ is a program that was first
implemented under AusAID’s LOGICA program in Aceh in 2007.
The original LOGICA Reformasi
Puskesmas program has been updated in line with national policy changes and adapted for AIPMNH’s
partnership model of implementation.
The program is based on the assumption that community
participation in the management of the Puskesmas improves the quality of service delivery. ‘Reformasi’
in this context means changing the mindset of Puskesmas staff to become more accountable to
complaints and input from the communities they serve and adopting transparent measures such as the
public display of Puskesmas budgets.
The Reformasi Puskesmas program is now operational in 92 Puskesmas in the 14 AIPMNH districts
(now operational in Sumba Timur) and an increase of 31 Puskesmas since the previous reporting
period.
Previously all Reformasi Puskesmas were AIPMNH PONED Puskesmas. However with
replication underway by partners many are both non-PONED and in non-AIPMNH geographical areas.
In early June 2015, the modules for Puskesmas Reformasi and Badan Peduli Kesehatan Masyarakat
(BPKM) and the Rumah Tunggu pocket booklets were distributed from the DFAT booth at the Jakarta
Jamboree for Bureaucratic Reforms.
50
The BPKM modules were reprinted in April 2015 continue to be used and in this reporting period the
mentors and district facilitators have continued to form new BPKM primarily to support sustainable
operation of the Rumah Tunggu. Districts most active are TTS, Sumba Timur and Ende. All modules
and guides are available on the Indonesian version of the website www.aipmnh.org.
During this reporting period, AIPD-Platform Papua invited the Adviser for Puskesmas Reformasi to
Papua and West Papua to assist in training facilitators for forming BPP. This will be implemented in 15
Puskesmas spread across in 5 districts in Papua and 17 Puskesmas in 5 districts in West Papua. The
AIPMNH modules on BKPM and Rumah Tunggu were used and distributed. The Adviser was also
invited by AIPHSS to facilitate refresher training for fourteen facilitators and mentors in TTU. The focus
of the training was on replicating the program in five new Puskesmas.
During this reporting period, BPMPD conducted workshops to support capacity building for subdistrict
heads (Camat), BPP, Heads of Puskesmas, BPMPD and the District Health Office. These workshops
were held in three districts; East Sumba, TTU and Ngada. This activity aims to encourage every health
facility to form a BPP.
In April 2105, a mentors meeting coordinated by BPMPD was held to compile documentation on the
community engagement program. This workshop produced a variety of multi-media products including
banners, Desa Siaga booklet, slide show, photo, display board, and a booklet profiling experiences of
mentors. This documentation is now the reference material for the Provincial BPMPD for socialization
and replication of the community engagement program. BPMD used these in there stand at the recent
Independence Day provincial exhibition (August 2015).
Table 16 demonstrates cumulative progress in the implementation of the Reformasi Puskesmas
program. Fifty-five Puskesmas are now in the final stages of the program compared to fifty-one in the
previous reporting period. Seven new Puskesmas are still in the socialisation stage are waiting for
APBD budget and BOK. Fifteen Puskesmas are already at the stage of preparation of the SOP and the
formation of BPP. Because of the limited budget (there is no specific line item in the district budgets for
the surveys), some Puskesmas did not complete the survey of complaints instead replacing this with
mini workshops for collecting complaints. Launching for most of the Puskesmas will be held on the
National Health Day in November.
Table 16.
Sta
ge
1.
2.
3.
4.
Progress status of Puskesmas Reformasi Program June 2015
Progress Implementation
Socialisation and Training of
Facilitators
Socialisation at the Sub-district level,
Complaints survey, internal meeting.
Commitment to vision and Mission of
Puskesmas, External meeting,
Improvement of SOPs, Formation of
BPP
Launching the “new face” of the
Puskesmas, M&E, BPP & intersectoral meetings
TOTAL
Number of Puskesmas Reformasi
Dec 2012
June 2013
Dec 2013
June 2014
Dec 2014
June 2015
0
0
0
0
0
7
7
7
7
1
1
15
2
14
3
18
9
15
20
21
36
42
51
55
29
42
46
61
61
92
Table 17 details progress of the Reformasi Puskesmas program against five selected indicators. In this
period most Puskesmas (68 out of 92) now display their financial plans of action for BOK.
This
represents a major shift in accountability to the public, as this has never happened before and it has
been observed that transparency positively affects Puskesmas staff performance. Puskesmas Pasir
Panjang in Kota Kupang and Aimere in Ngada, display not just plans of action (budgets) but also
51
expenditures of BOK and JKN funds. Over the past year most of the Puskesmas have commenced to
display public information related to the implementation of JKN. In Kota Kupang, Ende, Ngada and
Sumba Barat, Puskesmas are also displaying information on the distribution of JKN medical services
fees paid to staff.
Table 17.
Progress against Indicators (Reformasi Puskesmas) to June 2015
No
Indicator
1
Displays the vision and
mission statements
Displays the values and
services statements
Displays service
information
Displays BOK
information
Displays Jamkesmas /
JKN information
Total AIPMNH Reformasi
Puskesmas
2
3
4
5
June 2012
December
2012
June 2013
December
2013
June 2014
Dec 2014
June 2105
20
22
35
40
49
60
70
20
22
35
39
49
60
70
20
22
27
38
46
54
68
19
19
25
36
49
52
68
19
19
25
36
54
52
68
20
29
42
46
61
61
92
During this reporting period, TTS prioritised forming of BPP and operationalising Rumah Tunggu, which
increased from 5 to 9 Puskesmas. DHO TTS allocated budget funds amounting to 5 million for each
Rumah Tunggu to support operations by BPP. Until now, 9 of 28 Puskesmas participated in the reform
program with priority on aspects of community engagement.
TTU added a further 5 Puskesmas to participate in the program. Replication begins with training
facilitators and the head of the targeted Puskesmas. AIPHSS funds the training and involves the
AIPMNH Adviser as a facilitator. Implementation is funded by AIPHSS and mentoring by AIPMNH.
There are now 11 of the 26 Puskesmas participating in the reform program. In April 2015, Noemuti was
the first to commence accreditation assessment trial.
Sumba Timur has nine new Puskesmas participating in the reform program. Most have been formed
BPP to support the operation of Rumah Tunggu and to prepare service standards. Replication is done
with the support of the APBD and BOK funds. Until June 2015, 10 of 22 Puskesmas have participated
in the program. In Sumba Barat, all Puskesmas have participated in the reform program. During this
period, six Puskesmas printed service standards, vision, mission, values, service flow, and
transparency of public service levies.
In Ngada, four new Puskesmas are participating in the reform program. To support replication, DHO
used APBD funds to recruit one Mentor.
Puskesmas Waepana passed the basic accreditation
assessment by MoH. DHO Ngada has made it mandatory to participate in a mentoring program to
prepare for accreditation in 2016.
As at June 2015, 9 of 14 Puskesmas have participated in the
program reform. Like Ngada, the Bupati in Ende requires all Puskesmas to form a BPP and carry out
the reform program. In this period, 5 new BPP and 2 units of Rumah Tunggu became operational,
bringing to 11 BPP that have been formed in Ende. BPMPD facilitated BPP and community leaders to
form a Health Advisory Board (Badan Pertimbangan Kesehatan Daerah-BPKD) at district level. As at
June 2015, 11 of the 24 health centres have participated in the reform program.
DHO Lembata continued to replicate in Puskesmas Hadakewa.
Activity is still at the stage of
socialization. In Puskesmas Balaiuring BPP, sub-district chief and community leaders have worked
together to build a Rumah Tunggu. Until June 2015, 4 of the 9 Puskesmas have participated in the
reform program.
52
Puskesmas Oka in Flores Timur commenced so that there are now 5 of 20 Puskesmas participating in
the reform program. BPP, sub district chief and community leaders together performed campaign
safety of mothers and children (Pekan Keselamatan Ibu dan Anak-PKIA). This event drives people's
participation in the 2H2 centre program.
DHO Manggarai Barat with APBD funds continued to replicate in two new Puskesmas (Bari and
Werang). Activity is still at the stage of socialization. Up to June 2015, 6 of 15 Puskesmas have
participated in the reform program.
Belu, Sikka, Kabupaten Kupang and Kota Kupang, in this period continued support by mentors (and
concluded in June 2015). DHO Sikka with APBD funds replicated in two more Puskesmas, Magepanda
and Paga. In the other three districts, the focus was on strengthening BPP and finalizing standard
service displays.
Nagekeo and Manggarai Timur districts (non AIPMNH intervention), continue to replicate with Nagekeo
adding two Puskesmas (Maupanggo and Nanggaroro) and in Manggarai Timur Puskesmas Borong.
Replication is fully financed by APBD and receives technical assistance from the AIPMNH CE mentor.
Sustainability and Replication
Replication continues to increase with the use of GOI (APBD and BOK/JKN) funds.
During this
reporting period, eight Puskesmas in four districts underwent accreditation assessments. Results of the
evaluation showed that in Ngada and TTU Puskesmas Reformasi were better prepared for the
accreditation process as this emphasises internal service improvement and community engagement
(which is the basis of Puskesmas Reformasi).
As per the previous report, replication in the non-
AIPMNH districts is continuing well with funds allocated in the 2015 budgets as per Table 7.
(d) Rumah Tunggu
All Rumah Tunggu constructed under the project are being managed by communities (though
community boards or BPKM) and this is proving to be effective and sustainable. The Rumah Tunggu at
Ende RSUD is also being managed by the community with good success. Details on new Rumah
Tunggu are included in the previous section.
Lessons learned on BPKM management of Rumah Tunggu have been compiled into a set of modules
that will assist and guide operation of these facilities.
Some Puskesmas Reformasi being replicated with BOK or APBD have not run the full program as
designed.
For example, the complaint survey being replaced with satisfaction surveys and
establishment of the BKPM only through socialization and not followed by training on roles and
responsibilities. In addition, some display outputs are greatly simplified and therefore the program still
requires technical support by AIPMNH. In the APBD budgets, there is no ‘line item’ for complaint
surveys or for training of the BKPM.
Future Action
Support continued progress in implementing the Reformasi Puskesmas especially the replication
Puskesmas through the mentors supporting the District facilitators.
Dinkes to monitor and evaluate differences between Puskesmas Reformasi implemented by AIPMNH
those with APBD/BOK funds.
53
Continue to support the DHOs in Ende, Manggarai Barat, Sumba Timur in implementing an integrated
assistance package for Puskesmas. This strategy is a combination package of Puskesmas reformasi,
PML, and accreditation with intensive mentoring.
Mentors to continue support BPKM to manage Rumah Tunggu including advocating to the public and
government to replicate with a community-based approach.
Continue to provide support for implementation of the new Village Law to ensure that health (and in
particular MNH) is included in plans and budgets.
54
Component 2.
Health systems support
Output 2.1: Improved monitoring and reporting systems for finance and activities
Indicator: Improved timeliness and quality of HIS / HIMS-SIKDA data.
Progress in Implementation
This reporting period, continued to focus on standardisation of data elements and strengthening the
implementation of SIKDA NTT. The results of these efforts are set out in the regulation, SIKDA NTT
Uniform Minimum Basic Data Set MBDS Letter of Decree, Number: Dinkes.Sek.155/050/IV/2015 on the
1st of April 2015. Key elements of the Decree are;
•
The definition of Uniform Minimum Basic Data Set/UMBDS as a group of data set that shall be
recorded in the provision of health services at Puskesmas and its networks.
•
The word uniform implies that the data recording system follows certain agreed rules or criteria.
•
The word minimum implies any provision of the health services at Puskesmas and its networks will
generate a great amount of data, but only the data that is categorised as mandatory shall be
recorded.
•
The word basic data set implies a set of selected data that are required. The basic data consists of
selected data that are used for specific purposes or objectives.
•
The management of SIKDA NTT is based on the Uniform Minimum Basic Data Set and agreed
criteria.
In support of the regulation the following documents have been developed and printed;
•
SIKDA NTT Uniform Minimum Basic Data Set: Revised Edition (1 Book)
•
SIKDA NTT Guideline Book: Revised Edition (1 Book)
SIKDA NTT is also incorporated into the Provincial Planning and Budgeting systems and is now in
RPJMD/ Rencana Pembangunan Jangka Menengah Daerah Provinsi NTT Tahun 2013 – 2018 (MidTerm Development Plan) and Renstra Dinas Kesehatan Provinsi NTT Tahun 2013 – 2018 (PHO
Strategic Plan 2013 – 2018), in Mission 5, Improvement of Management, Information, and Health
Regulations.
There had been a previous agreement that AIPHSS would support development of a Peraturan Daerah
(PerDa) for SIKDA, unfortunately this has been cancelled. This will now be funded through APBD next
year.
SIKDA is now being implemented in all Puskesmas in all 22 NTT Districts. Improvements in both data
quality and timeliness are evident, for example decreasing data inconsistencies and as at early
September 2015, all districts have already submitted August 2015 data.
The is very strong support for SIKDA both provincially and at the district level as evidenced by the Rp.
1.7 billion GOI funding allocation for 2015. Apart from the 2015 investment funding, there has already
been very significant investment in the system, including for capacity building. To the present date,
there are 33 trainers of paper based and electronic application of SIKDA NTT and 1,448 trained
members of the SIKDA Team (male = 554; women = 894) across the 22 NTT Districts as per Table 18.
Table 18.
No
1
2
Numbers trained in SIKDA NTT by District to June 2015
DISTRICTS
Sumba Barat
Sumba Timur
PARTICIPANTS
Male
Female
Total
17
37
24
56
41
93
55
No
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
DISTRICTS
Kota Kupang
Kabupaten Kupang
TTS
TTU
Belu +Malaka
Lembata
Flores Timur
Sikka
Ende
Ngada
Manggarai
Manggarai Barat
Manggarai Timur
Nagekeo
Sumba Barat Daya
Sumba Tengah
Alor
Rote Ndao
Sabu Raijua
TOTAL
PARTICIPANTS
Male
Female
Total
14
37
41
41
47
16
22
20
27
16
62
26
52
15
11
16
10
14
13
554
43
47
74
62
80
20
56
72
67
53
64
36
26
21
19
30
11
16
17
894
57
84
115
103
127
36
78
92
94
69
126
62
78
36
30
46
21
30
30
1448
Issue SP2TP
As per the previous report, AIPHSS MOH has been revising an old Puskesmas reporting format called
SP2TP Revisi. Despite the SP2TP consultants reviewing SIKDA NTT and being very positive about it,
work continued to go ahead with SP2TP.
Note; MOH has been developing an electronic HIS (SIKDA Generic) over the past few years and the
purpose of reviving the SP2TP reporting was to provide a paper based system.
From the previous report: In late February 2015, a delegation from the PDE PHO and the AIPMNH
SIKDA adviser met with PusDatin of the MOH to discuss progress with SIKDA and the proposed revival
of SP2TP through HSS. SP2TP is a Puskesmas reporting system developed several decades ago and
is no longer used in NTT (or Java Timur) - being superseded by SIKDA / SP3. The HSS SP2TP
consultants, as part of their review of SP2TP actually reviewed SIKDA in Ngada and TTU with positive
findings. PusDatin, as a result of the meeting, confirmed their continuing support for SIKDA and have
th
declared NTT as a national laboratory for HIS. On 17 of March AIPMNH met with Prof Ascobat from
HSS in Kupang to discuss SIKDA and SP2TP and there is now a common understanding on both sides
that all items in the previous SP2TP are included in SIKDA, that SIKDA has greatly improved and
simplified data collection and reporting (reports from Puskesmas have more than halved) and SIKDA
has a ‘one-door’ approach. Pak Stef later joined the meeting and emphasised that SPT2P is no longer
in use and that SIKDA has resulted in a greatly improved data system and will continue to be used
throughout NTT.
Since the previous report, it is understood that Java Timur has declined to use the SP2TP as they
already have an electronic system (and testing SP2TP would be effectively using a parallel system).
NTT also declined to test the system and in late May there was an agreement that the SP2TP team and
relevant MOH officials would go to NTT to discuss how to reconcile these issues. As at September
2015 this meeting has not taken place.
56
Future Actions
Now that the Minimum Basic Data Set is finalised the electronic version will be revised, a training video
produced followed by installation and implementation.
The main programmer is from the FKM
University of Cendana who worked with the original SIKDA consultants. She is used to working with the
PHO and this should ensure sustainability of the system (note; the program software is open source).
SIKDA itself has been part of the curriculum of FKM undergraduates for the past two and half years.
Some graduates have now been hired by the districts for the specific purpose of managing SIKDA.
Output 2.2: Province and district governments develop and report on medium term and
annual plans and budgets with MNH performance targets
Indicator: number of DTPS MNCH recommendations on planned annual MNCH activities included in
the Annual District Health Work Plan (RKPD) in 2012 compared to baseline year (2009)
Increasing MNH APBD budget allocations is an AIPMNH supported strategy aimed at improving
maternal and neonatal health outcomes. Previous support provided, includes introduction, training and
use of District Team Problem Solving (DTPS), District Health Accounts (DHA) as well as funding for use
of these tools. The final tool, Integrated Health Planning and Gender Responsive (IHPB GR), was
produced in book form and officially launched at the May 2014 PCC in Surabaya. These tools aim to
improve planning and budgeting as well as being a source of information for advocacy for increased
funding allocations.
Unfortunately, continuation in the use of these tools has been found to be very poor (see Table 19) due
to (1) lack of budgets to support the process and (2) the loss of essential skills due to the high rates of
staff turnover (without handover of skills or further in-service training).
Table 19.
Use of Planning & Budgeting tools by Districts 2013 - 2015
No
Kabupaten
1
2
3
4
5
6
7
8
9
10
11
Ende
Sumba Timur
Ngada
Manggarai
Sumba Barat
Lembata
Manggarai Barat
TTS
TTU
Flores Timur
Province
Note
√
X
X*
2013
2014
2015
DTPS
IHPB
DHA
DTPS
IHPB
DHA
DTPS
IHPB
DHA
x
x
√
x
x
x
x
x
x
x
x
x*
x
x
x
x
√
√
x
√
x
√
x
x
√
x
x
√
x
x
x
x
√
x
x
x
√
x
x
x
√
x
x*
x
x
x
x
√
√
x
√
x
√
x
x
√
x
x
√
x
x
x
x
x
x
x
x
x
x
x
x
√
x
x*
x
x*
x
x
√
√
√
x
x
x
x
x
x
x
x
√
x
X
: confirmed there are replication
: confirmed there is no replication
: only allocated fund for mini lokakarya
The loss of skills is particularly important for the DHA, which also requires the staff from the local statics
office (BPS) to analyse the data, and now almost all of those trained have been transferred.
The PHO this year has budgets to train all the non-AIPMNH districts in DTPS and IHPB.
57
To counter these constraints in continuation of the processes, AIPMNH has supported development
and promulgation of a Governors Decree (PerGub IHPBRG No.12, 2015). The regulation will support
allocation of budget to implement the planning process and also make it a mandatory process.
A further strategy to increase budget allocations to health is development of a Governors Instruction
that will ensure integration between Village (Musrembang desa) and Puskesmas Annual Planning and
aims to maximise health allocations from the Dana Desa. The regulation was signed in August 2015.
Constraints
•
Limited number of competent planning officers at District Health Office which reflects the quality of
the planning process and documents
•
Limited budget allocation for planning and budgeting process
Future Actions
For the final six months, focus on strengthening capacity of the Puskesmas in data analysis to support
the Puskesmas Accreditation program.
Continue to advocate to Bappeda and the PHO to allocate adequate budgets for ongoing use of the
planning and budgeting tools.
Output 2.3: a) Health Workforce is distributed more equitably, performance is
monitored and refresher training provided more frequently
Indicator: proportion of AIPMNH-supported Puskesmas with beds in line with respective NTT
Rev-KIA staffing standards for doctors, midwives, nurses.
th
Full report comparing 2009 and 2014 data in previous progress report (12 ).
Progress in implementation Health Workforce Distribution
Indicator: 2 out of 3 partner districts (Sumba Timur, TTU and Flotim) have Bupati decrees on
workforce distribution (doctors, nurses, bidan at health facilities) in 2013
1.
Health Work Force Distribution
All three districts now have Health Workforce decrees (FloTim from DPRD and TTU and Sumba Timur
Bupati decrees). Monitoring of the decrees is by a team from DHO, Bappeda, RSUD and the Personnel
Unit (as per the Bupati SK).
2.
Human Resources Management Information System (SIMK)
The Human Resources Management Information System (SIMK) is now being implemented in four
districts (East Flores, East Sumba, TTU and Ende). Monitoring and evaluation is conducted six monthly
and results are as follows;
1. Coordination issues at the Provincial Health Office.
Staff responsible lack attention to the
importance of accurate staff mapping even though this is very important for the PHO. Besides that,
there is a serious communication problem in handing over after internal transfer.
2. Flores Timur has the best SIMK implementation due to high motivation of staff and full support from
the head of the DHO. In TTU low motivation, poor staff competency and lack of support from the
head of the DHO have resulted in the least progress. Sumba Timur results are better than TTU as
staff are motivated and competent but they are constrained by lack of funds and facilities.
3. Advocacy to the local government organization bureau and BKD is automatic as all related
institutions have been involved since the beginning.
58
4. Refresher training is conducted during the monitoring, as at least 30 – 40% of participants are new
staff and this has contributed to implementation being slower than planned.
5. Implementation of SIMK in Ende started in February 2015 and will be continued through Ende’s
learning centre. Several staff from the learning centre have been identified to implement SIMK.
The sustainability of SIMK in Ende will be assured from the beginning as there is a local
programmer and instructor as a trainer, which did not occur in other districts.
Strategic Opportunity for SIMK sustainability
AIPHSS supported the MOH BPPSDM Kesehatan in developing a staff planning system based on
workload analysis and projection. The computer application is still at the trial and finalization stage but
it only covers workload analysis and not information on the availability of staff in each institution, nor the
existing competency of staff. SIMK includes both of these and therefore SIMK can stand alone as it
covers all essential aspects including that in the AIPHSS application
SIMK is considered to be more sustainable as it includes complete data for health workforce monitoring
and policy development at each level of Government. It is therefore recommended that SIMK be
promoted by AIPHSS as a national program.
Problems encountered
•
Low commitment of TTU district in implementing SIMK.
•
The high turnover of Puskesmas staff with only 60 – 70% staff trained remaining in their position
between each monitoring round and no effective hand-over of knowledge to new staff.
•
Staff responsible for entering the SIMK data do this in their spare time which can result in delayed
entry of data.
•
Lack of awareness of Puskesmas and DHO staff in utilising the health workforce data for staff
planning.
•
Lack of equipment for SIMK implementation and some of the laptops are private ones.
•
Most participants do not have background in using and maintaining the usage of Laptop/ personal
computer.
Recommendations
To ensure the sustainability of SIMK implementation;
•
Refreshing training for staff who handle SIMK data.
•
Need to do a training on basic computer skills to ensure the staff can maintain and fix computer
•
Need to have a MoU for SIMK implementation with clear achievement targets.
•
Need to have a meeting between BPPSDMK, AIPMNH, AIPHSS and PHO to ensure clear function
and role of SIMK in districts and Province so that SIMK can be adopted as a standard tools for
recording, reporting and planning of health workforce.
•
Need to socialize SIMK to all districts in NTT so that SIMK can be implemented in all districts in
NTT which will ensure sustainability of SIMK implementation.
•
Provincial Health Office and 4 Districts need to discuss further with AIPHSS and MoH regarding
implementation of SIMK in 4 districts in NTT and how to integrate with WISN software from
AIPHSS.
59
Output 2.3: (b) Workforce training facilities provide high quality training & education to
MNH providers
As reported in previous progress reports, the approach of training and skills development has moved
from theoretical training into in-service or on-the-job training (magang) at RSUD and satellite
Puskesmas.
Output 2.4. Laws, policies & regulations which support MNH developed and approved
Indicators: Increased number of partner district parliaments that passed pro-MNCH decrees (Perda or
Peraturan Bupati). Increased percentage of villages with pro-MNCH decrees (Perdes)
From January 2013, AIPMNH has not provided further financial support to the districts in developing
pro-MNCH laws, policies and regulations. At the current time, 11 Districts have PERDA and three
districts PERBUP (Manggarai, Sikka and Kabupaten Kupang).
At the Provincial level, the current regulation is the PERGUB KIA 2009 and AIPMNH is supporting a
review and revision to the regulation and for this to become a PERDA.
The expanded and
strengthened regulation will be more comprehensive based on lessons learned and will support
increased funding for MNH.
Table 20.
No. districts pro-MNCH regulations by commencing group (as at June 2015)
District
Sikka
Ende
Sumba Timur
Ngada
Manggarai
Sumba Barat
Kota Kupang
Lembata
Manggarai Barat
Kabupaten Kupang
TTS
TTU
Belu
Flotim
Perda KIA
Not Yet (have PerBup)
Perda Nomor 5 Tahun 2015
Development of Health Data integration policy in Ngada
Progress and results
The objective of this activity is to develop a set of health related indictors that all sectors in the district
agree to, and use for monitoring, planning and reporting. These indicators also have precisely defined
definitions as well as defined sources of data.
Visibility study: The visibility study aimed to gather information regarding availability of data, policies
and the capacity of the district in implementing health data integration. The results of the visibility study
have been presented and discussed with all related sectors, led by BAPPEDA Ngada.
Agreement: All health related sectors in Ngada were brought together into one forum and asked about
their commitment to provide health data. The forum was established and led by Bappeda Ngada. The
60
name of the forum is Wadah Data Kesehatan Daerah (WDKD) Kabupaten Ngada. All the members
should contribute to the mechanism and the availability of health data in Ngada district.
The development of System Data Kesehatan Daerah: Need to establish one data system as the data
is sourced from many institutions.
The one data system needs to be placed in one electronic
application.
Working group and Policy development: The problem of cross-sectoral coordination needs
legitimisation from local government to establish a functional working group, which is in the Bupati
regulation. The Regulation has been developed and is now being processed through the Legal Section
of the Bupati’s office.
Strengthening of related institutions: All related institutions and members of the working group need
to be trained on data management and analysis.
These institutions are RSUD Bajawa, Dinas
Kesehatan, Bappeda and Family Planning.
Implementation: Implementation of the Health data integration system or Wadah Data Kesehatan
Daerah will be done based on the Regulation, and the piloting of data collection will use the MSS
indicators of district, province and national level.
Evaluation: to be conducted after 3 months of implementation
Problems encountered
•
Lack of time therefore not all activities can be accomplished.
•
High workload of related stakeholders – this is ‘extra work’.
•
Not all sectors have similar motivations towards accurate data collecting.
•
RSUD Bajwa do not have a good electronic recording and reporting system therefore it is difficult to
combine all data and data analysis of RSUD activities.
•
DHO have not yet implemented a one door policy for data system and still work semi manual,
•
The SIKDA officer has not yet been trained on data analysis and therefore lacks sufficient
therefore the process of data management takes time and high workload.
understanding of the benefits of SIKDA data.
Action plan and recommendations
•
Finalise the Bupati regulation on health data integration.
•
Development of data instrument, system implementation and data integration mechanism at district
level.
•
•
Conduct socialization of health data integration regulation for all related sectors.
Strengthening core institutions in district health data: DHO and RSUD Bajawa in using ICD 10 and
ICD 9 for hospitals and basic computer skills.
•
Support RSUD Bajawa in implementing Billing System
•
Develop tools for health data integration system.
•
Training on implementation of health data integration
•
Monitoring and evaluation
Note: Action plan No 1 and 2 will be supported by AIPMNH.
61
Output 2.5: Service delivery facilities have appropriate infrastructure, equipment and
supplies to deliver quality services
Audit and handover of PONED and PONEK Equipment and Buildings
All of the construction has been officially handed over to the districts with the Bupati signing the hand
over documents. The buildings are also part of the BAST process and documentation on this is now
complete. As at early August 2015, the BAST documents have been prepared, however these is still a
lack of clarity as to responsibility for approval and sign off from the GOI side. Further processing and
approval of the BAST will be mainly managed by the Jakarta Coffey office.
As part of the post construction and renovation follow up activities, the AIPMNH team developed a
building inspection checklist, and inspections based on the checklist were conducted at all 24 sites
between March and February 2015.
Findings were that in general, the physical condition of the
buildings and cleanliness were good. Exceptions to the general findings were that conditions of the
Oinlasi, Panite and Lurasik Health Centres were found to be not acceptable and care is lacking.
Instructions were given to health centre managers that maintenance and cleaning must be improved.
Procurement and Contracting
Procurement of goods and services, outside of the major sub-contracts, by the Procurement Services
Unit was very limited in this reporting period and consisted mainly of small items of equipment and
printing – see Table 21.
Table 21.
Procurement completed Jan – Jun 2015
District
Materials and services procured
Value (Rp)
AIPMNH Province
AIPMNH Province Mitra BPMPD Prov NTT
AIPMNH Province
AIPMNH Province
AIPMNH Province
Book: Risk Factors of Neonatal Death in NTT Province
BPKM Printing
Book: Mentor’s Field Notes
Printing of 2H2 Centre Module and Copying of DVDs
Book: Building Maintenance Manual Feb 2015
Printing of MNH Book
Multimedia Package
Printing of the Book: Improving the Participation of the PKK’s
Cadres and the Community
Printing the Forms: Neonatal Monitoring _PKK
Desa Siaga Booklet
Printing of the Book: Catechism on Pre-Marriage 1, The
Evangelical Church in Timor
Printing of the Book: Catechism on Pre-Wedding 2, The
Evangelical Church in Timor
Printing of the Book: Homilies on MNH
32,000,000
35,000,000
16,000,000
14,900,000
5,500,000
922,925,000
11,000,000
Book: Desa Siaga Profiles
Printing: Regional Health Information System (SIKDA) Manual
Book: Technical Guidelines on Reducing Neonatal Mortality
Family Planning & MNH Comics lay out, Sumba Barat
35,000,000
85,000,000
50,000,000
AIPMNH Province Mitra PKK NTT
AIPMNH Province Mitra PKK NTT
AIPMNH Province Mitra Sinode GMIT
AIPMNH Province Mitra Sinode GMIT
AIPMNH Province Mitra Promkes Dinkes Sumba
Timur
AIPMNH Province
AIPMNH Province Mitra KIA Dinkes Prov NTT
Barat
Barat
AIPMNH Province Mitra Paroki Ende
Family Planning & MNH Comics, Sumba Barat
Desa Siaga Guidelines Book
Catechism Module (Bajawa)
ANC-PNC-Neonatal
Purchasing Perinasia Products 1
Purchasing Perinasia Products 2
11,550,000
8,500,000
10,150,000
33,600,000
42,000,000
10,500,000
18,000,000
60,800,000
37,680,000
45,000,000
50,000,000
35,200,000
26,250,000
62
The status of new and ongoing major sub-contracts is as per the following table. Totals in the table for
SH are actual expenditure (not contract value).
Table 22.
No
1
2
3
4
5
6
7
8
9
10
Sub-contracts, Expiry Date and Value as at December 2014
Sub-Contractor
Expiry Date
Value (Rp.)
Area
Remarks
RS Panti Rapih
Yogyakarta
RSUP Dr. Sardjito
Yogyakarta
RSUP Dr. Kariadi
Semarang
30 Juni 2015
570,000,000
Sister Hospital in RSUD Ende District Ende
Completed
30 Juni 2015
744,440,000
Sister Hospital in RSUD Bajawa District Ngada Completed
30 Juni 2015
450,000,000
RSCM Jakarta
30 Juni 2015
420,790,000
RSAB Harapan Kita
Jakarta
RSU Dr. Soetomo
Surabaya
RSUD Dr. Saiful
Anwar Malang
RSUP Sanglah
Denpasar
RSUD Dr. Saiful
Anwar Malang
30 Juni 2015
407,570,000
30 Juni 2015
472,320,000
30 Juni 2015
645,500,000
30 Juni 2015
600,000,000
30 Juni 2015
573,800,000
30 Juni 2015
6,618,718,375
Sister Hospital in RSUD Umbu Rara Meha
District Sumba Timur
Sister Hospital in RSUD Ruteng District
Manggarai
Sister Hospital in RSUD Kefamenanu District
Timor Tengah Utara
Sister Hospital in RSUD Soe District Timor
Tengah Selatan
Sister Hospital in RSUD Lewoleba District
Lembata
Sister Hospital in RSUD Ekapata Waikabubak
District Sumba Barat
Sister Hospital in RSUD Larantuka District
Flores Timur
Coordination, Monitoring, Evaluation and
Verification Technical Support for Clinical
Outsourcing in NTT
UGM
Completed
Completed
Completed
Completed
Completed
Completed
Completed
Completed
Future Actions
Prepare and implement hand-over of all assets at District and Province level.
Output 2.6. Managers of services have skills and resources to provide good
management
Indicator: The percentage of Puskesmas that submit to DHO quarterly minilok reports that include
minutes
Progress in implementation – PML Puskesmas Program
The focus in this reporting period has been on finalization of all documentation in order to achieve
accreditation of the PML Puskesmas Program from central level (BPPSDM).
Preparation involved the Provincial Health Office, PKMK UGM and BPPSDMK in reviewing the
modules, process and result. All documentation is now complete and was submitted to BSDMK (MOH)
in late August.
Puskesmas accreditation
AIPMNH has supported Sumba Timur and Manggarai Barat in preparing for Puskesmas accreditation.
Sumba Timur commenced last year with assistance directly from Pusdiklat Aparatur while the
accreditation program was still in preparation.
Manggarai Barat District recently commenced implementation of Puskesmas accreditation and attended
training held by AIPHSS and the PHO. The PHO has included Puskesmas Manggarai Barat in the list
of those ready for accreditation in 2016.
To strengthen the capacity of the Puskesmas team in preparing for accreditation, AIPMNH supported
the placement of a mentor in both districts to provide day-to-day technical assistance. This was despite
63
there being three DHO staff trained by the PHO/AIPHSS to provide hands on support to the
Puskesmas. It has been reported support provided by the DHO was not as planned or budgeted for.
AIPHSS supported preparation for accreditation at two Puskesmas in four districts (TTU, FloTim, Ngada
and SBD). Assessments were conducted in February and results received in July. Only Puskesmas
Waepana passed and this was with a ‘basic rating’. The three Puskesmas in Sumba Timur are ready to
be assessed and await confirmation from the PHO.
As a continuation of this support, AIPMNH commenced an integrated approach for Puskesmas that
covers community engagement – good governance, management – leadership and clinical areas. This
approach will prepare Puskesmas for accreditation.
This commened in July 2015 and is being
undertaking in four districts; Ende, Sumba Timur, Manggarai Barat and Kota Kupang. A report on
monitoring results will be available in late November.
Note; The accreditation system is based largely on that used for hospitals and requires significant
inputs to assist the Puskesmas in the process. An accurate forecast of costs, time and resources is
needed to implement the current trial accreditation system in all of Indonesia to determine feasibility.
Badan layanan umum daerah (BLUD) –Puskesmas as a Public Enterprise
All Puskesmas in Kota Kupang have completed two out of the three required components to become
BLUD (Public Enterprise). Now they are finalizing the financial documents supported by provincial
BPK.
The Kota Kupang DHO found that preparing the financial component for BLUD is very
challenging, as most of the Puskesmas do not have staff with finance or accounting background.
However, the DHO is optimistic that this year the BLUD assessment will be conducted and at least
three Puskesmas will achieve BLUD status.
Future Action
•
Continue the Puskesmas Integrated packet approach in Ende, Sumba Timur, Manggarai Barat and
Kota Kupang– good governance (Puskesmas Reformasi), management – leadership and clinical for
attaining Puskesmas accreditation.
•
Support BLUD assessment of Puskesmas Kota Kupang.
Progress in implementation – PML RSUD
Billing system implementation
Four RSUD now are in the progress of implementing the billing system supported by PKMK UGM while
two RSUD are using proprietary software. All the RSUDs are now implementing the billing system in
out-patients and in-patients. Still there are some problems faced by the RSUDs especially where there
are no programmers at the RSUD and lack of IT staff who responsible for the implementation. Some
problems were also due to hardware and infrastructure which were solved by using APBD funds.
Although there are problems during implementation the motivation of the hospital teams is quite high
especially in Ende and Waingapu. Strong support from the directors and hospital management team
has also enabled effective implementation.
Performance Management and Leadership (PML)
After three years of PML Hospital implementation in the 11 RSUD improvements include;
Four out of six obligatory requirements 100% achieved; while there are 2 requirements still in progress
which are achieving BLUD status and finalizing physical asset management.
64
Three RSUDs now are in progress of achieving BLUD status. Two out of three RSUDs have already
prepared and finalized all the requirements to achieve BLUD status while one RSUD is still struggling.
The physical asset management is still in progress in all RSUD and difficult for them to complete due to
incomplete inventories and unusable items that cannot be deleted from the list.
Although all hospitals have already achieved the four obligatory requirements, ongoing issues include;
•
All hospitals need to be reaccredited in 2015 using the new accreditation system that is more
difficult compared to the previous version.
•
All RSUD have Class C classification due to placement of specialists through the SH program and
continuation of the classification is dependent on their presence and retention of returning newly
trained local specialists.
Progress of BLUD implementation – results from BLUD evaluation conducted in April 2015
A. Planning
•
Rencana Strategi Bisnis (Business Strategy Plan) consists of performance targets, annual program
and financial projections. However performance targets are not based on situational analysis and
forecasting. It is therefore difficult to compare between targets and performance achievements.
•
Most of the hospitals still develop RKA (the usual budgeting document) although they already have
a Business Budget Plan
•
Business Budget Plans have not yet been used as a basis for budgeting and expenditure.
B. Quality of services (implementation of Minimum Standard Services (MSS) or SPM)
•
One hospital has not yet monitored the achievement of SPM while the others already have a
monitoring team.
•
One hospital has only monitored the service units
•
Below are MSS standards which have not been achieved:
–
Human resources: quantity and skills (3 hospitals: Ende, Larantuka, Umbu Rara Meha)
–
Customer Satisfaction (Belu, Ende, Umbu Rara Meha)
–
Waiting time, responsiveness (Belu, Ende, Larantuka)
–
Post operation infection, nosocomial infection (Belu, Ende)
–
Death > 48 hours (Belu, Ende, Larantuka)
–
Section Caesarean (Belu, Ende, Larantuka)
–
Equipment, availability of beds (Ende, Larantuka)
–
Laboratory services, pharmacy, nutrition, morgue (Larantuka)
– Waste management (Ende, Larantuka)
C. Accountability System of Hospital (Tata Kelola/ governance and financial report)
•
Two hospitals have not yet developed Bupati regulations on financial management guidelines,
which are essential for implementation of BLUD.
•
One hospital has not yet developed an organizational structure based on PP 41/ 2007.
Financial Situation (Billion Rp)
RSUD
Income
Expenditure
Surplus/ Deficit
Remark
Bajawa
Ende
Larantuka
Ruteng
Umbu Rara Meha
Ekapata
12.6
24.8
11.2
26.8
18.5
8.8
33.2
35.1
34.9
43.2
29.5
16.7
(20.6)
(10.5)
(23.7)
(16.4)
(11)
(7.9)
All hospitals have
deficits and still need
subsidy from the
local government.
65
Having BLUD status does not mean that the hospitals no longer need to be subsidized, this needs to be
continued to support quality of services and patient safety.
Conclusion:
•
There are some constraints during the implementation of BLUD as follows:
o
o
o
o
o
Yearly planning (RBA vs RKA)
Regular monitoring of performance services (MSS, RSB, RBA)
Completion of MSS standards
The subsidy (financial support) from local governments tends to be reduced.
Although BLUD status is achieved, the RSUD are still using the rigid RKA mechanism.
Recommendations
1. Post AIPMNH support will be required to continue with Class C, maintain accreditation, quality of
services and improved performance.
2. Advocate for commitment and support from local government and central level.
3. Results of MSS monitoring can be used as a regional tool.
Output 2.7. Government and Non-Government organisations and donors with interests
or roles related to MNH provide effective support
Strengthening the Family Planning (FP) system in districts:
See full report under Output 1.2.
66
Component 3.
System reforms in performance and accountability
Output 3.1: Management of funds and resources satisfies good governance standards
Indicator: Increased expenditure of Jamkesmas funds by Puskesmas
Progress in implementation BOK, and BPJS / BKN
BOK
Support for the Mentor (BOK Pendamping) program ceased at the end of January 2014. As reported
previously several districts have contracted the mentors directly including TTS and Flores Timur. BOK
will continue in 2015, although greatly reduced (around 10% less) but will continue in 2016 as per the
2014 amounts.
Table 23.
Absorption of BOK funds by District 2012 - 2015
District
% expenditure in
2012
% expenditure in
2013
Amount Allocated
2014 Rp
% expenditure
2014
Amt allocated
2015 Rp.
KUPANG
BELU
TTU
TTS
SIKKA
FLOTIM
ENDE
NGADA
MANGGARAI
SUMBA TIMUR
SUMBA BARAT
LEMBATA
MANGGARAI BARAT
Kota KUPANG
Average / Total
100
100
100
100
98
90
97
100
97
95
58
73
96
100
93
100
94
100
100
90
100
92
100
99
98
97
100
100
100
98
6,890,130,250
4,243,120,450
7,654,048,000
7,478,165,000
6,062,199,253
5,380,214,700
6,478,916,560
2,769,000,000
5,739,710,000
5,959,700,000
1,927,991,500
2,409,454,500
4,075,545,100
2,700,810,000
69,769,005,313
98
50
99
98
97
99
99
100
100
99
99
97
99
98
93
683,343,000
449,343,000
663,343,000
787,343,000
605,343,000
527,343,000
631,343,000
371,343,000
553,343,000
579,343,000
189,343,000
241,343,000
397,343,000
267,343,000
6,946,802,000
National Health Insurance (BPJS / BKN)
Jamkesmas and Jampersal ceased at the beginning of 2014, being merged into BPJS (or JKN).
Districts are still operating JamKesDa to cover cases not covered by BPJS (principally for the RSUDs).
Major issues with the BPJS are that there remain considerable proportions of the population
unregistered; and also a tendency for those registered to discontinue payment of dues once treatment
is completed.
Constraints: Nil
Future action: Continue to monitor effect of BPJS.
Output 3.2: Provincial and district government agencies monitor and report on
performance to communities, government representatives and donors.
No further activities in this Output for the Transition Period
67
Output 3.4: Donors and regional governments agree to harmonise and develop a
sectoral approach for assistance in the health sector.
(a) Provincial Coordination Meeting (PCC)
The PCC was conducted in May in Denpasar and full details are reported under section 9.3 page 33.
(b) District Coordination Committee (DCC) meetings
Table 24 sets out dates for the DCC and District Technical Team meetings for the reporting period and
as indicated by the table commitment by the Districts remains strong. Apart from these formal meetings
day to day coordination with all District level partners continues.
Table 24.
District Coordination Meetings by District Jan – June 2015
District
DCC Meeting
Technical Team Meeting
TTS
TTU
Sumba Barat
Sumba Timur
Lembata
Flores Timur
Ende
Ngada
Manggarai
Manggarai Barat
31 January 2015
26 January 2015 & 20 May 2015
20 February 2015 & 25 June 2015
19-23 January 2015
22 May 2015
21 January 2015, 4 February 2015
23 December 2014 & 16 June 2015
13 January 2015 & 23 April 2015
7 February 2015 & 21 May 2015
3 July 2015
31 January 2015
23 January 2015 & 18 May 2015
19 February 2015 & 24 June 2015
9 June 2015
15 May 2015
19 January 2015
23 June 2015
9 January 2015 & 20 April 2015
n/a
18 June 2015
Constraints: No new constraints
Follow up: Continue to provide support for routine PCC and DCC meetings.
Partnership Management Units (Unit Pengelola Kemitraan / UPK)
AIPMNH continues to work through the UPK at Province and District level and with ongoing good effect.
Documentation on the UPKs in both Indonesian and English is published as a hard copy booklet and is
also available on www.aipmnh.org
68
ANNEX 2.
What causes a reduction in Maternal Mortality
69
Changes in maternal mortality with facility deliveries, 22 NTT districts
(2009-2014)
Previous reports have documented a substantial fall in reported maternal deaths in nearly all districts of
NTT over the period 2009 to 2014, both those supported by AIPMNH and those outside the program,
although with larger falls among AIPMNH supported districts. Over the same period, nearly all districts
have reported increases in coverage with facility deliveries.
This report addresses the question: has the increase in facility delivery coverage been responsible for
the fall in maternal mortality? If so, what is the timing and size of the relationship, that is, what level of
facility coverage is associated with what level of maternal mortality?
Method: Individual district comparisons
This analysis requires the calculation of an indicator of maternal deaths per population, in order to
enable comparison with other population based indicators (e.g. facility delivery coverage), and between
districts with different population numbers. While acknowledging that this is not an estimate of the
population maternal mortality ratio (due to under-reporting), the ratio of reported maternal deaths to
reported live births (maternal reported mortality ratio or MRMR) is used for the purpose of this analysis.
The yearly changes in facility delivery (FD) coverage, reported maternal deaths (measured as a ratio to
live births (MRMR), coverage of managed obstetric high risk (OHRMx), and ratio of coverage with 4
ANC visits to coverage with first ANC visit, are compared for each district in NTT, both AIPMNH
assisted and non-assisted. These indicators were selected to provide a comparison with changes in FD
coverage with other indicators of obstetric service coverage: ANC services, and high-risk case
management.
Comparisons are divided into three groups, each containing both AIPMNH supported and nonsupported districts: large districts (pregnancies over 8,000); medium districts (pregnancies between
4,000 and 8,000) and small districts (pregnancies less than 4,000).
Additional data to enable interpretation of differences between districts is also considered:
(a) Distribution of population by travel time distance from the referral hospital: < 2 hours average travel
time; 2 – 4 hours; more than 4 hours.
(b) Indicators of access to the referral hospital: proportion of estimated hospital catchment area
delivering in hospital, and proportion of deliveries in estimated hospital catchment by caesarean
section.
In most cases, the graphs of coverage and MRMR by years demonstrate a rise in FD and fall in MRMR,
which plateaus, mainly over the period 2012-2014.
To quantify the relationship between MRMR and FD, the ratio of the average FD over the period at
which FD coverage plateaus (in most cases 2011-2014, but in some cases 2012-2014), and the
average MRMR (reported maternal deaths to live births) over the same period, was calculated. This
ratio can be interpreted as estimating the extent to which the district health service was able to achieve
a reduced level of MRMR at a given level of FD coverage.
(1) Medium sized districts (4,000 – 8,000 deliveries)
(a) Facility delivery changes
Of the seven AIPMNH supported medium sized districts three (Sikka, Ende and Manggarai Barat)
demonstrate fairly high and stable FD coverage throughout the period, while the remaining four (Sumba
Timur, TTU, Flores Timur and Manggarai) demonstrate increases in FD coverage, mainly over the
70
period 2009 to 2012. Most then seem to plateau over the period 2012-2014 at coverages of between
70-80% (Figure 6).
The three non-AIP districts also show increases in FD coverage over the period 2010 – 2012, with a
tendency to plateau, but at much lower levels of between 45 and 60% coverage, than the AIPMNH
supported districts (Figure 7).
(b) Maternal mortality
Of those districts with stable FD coverage, only Ende demonstrates a fall in maternal mortality, while
there is little change in Sikka and Manggarai Barat. However, the level of maternal mortality (MRMR)
over the period 2012 to 2014 is higher in Ende (190/100,000) and Manggarai Barat (270/100,000)
compared to Sikka (100/100,000). Thus, the ratio of FD to MRMR is higher in Sikka (7.3) compared to
Ende (3.6) and Manggarai Barat (2.5).
Among the AIPMNH supported districts with rises in FD coverage, three (TTU, Manggarai and Flores
Timur) also show falls in MRMR, and one (Sumba Timur) has fluctuating MRMR with no clear trend.
The falls in MRMR were synchronous with the rise in FD coverage in the case of TTU and Flores Timur,
while, in the case of Manggarai, the fall in MRMR only occurred after FD coverage reached 70%. While
Manggarai and Flores Timur have FD:MRMR ratios of over 5, the ratio for TTU is 3.4, and for Sumba
Timur 3.0 (Figure 6).
Among the non AIPMNH supported districts, two, Alor and Manggarai Timur also demonstrate falls in
maternal mortality synchronous with the rise in facility delivery, while Sumba Barat Daya falls then rises
to demonstrate no change over the period. All have low ratios of FD:MRMR of, between 2.1 and 2.8
(Figure 7).
(c) Explanatory factors
Factors which might explain the differences in the relationship of FD and MRMR include: (i) the
geographic spread of the district, measured by the proportion of deliveries > 2 hours average travel time
from the referral hospital; (ii) coverage with ANC, measured by the ratio of coverage of ANC4 to
coverage of ANC 1; (iii) quality of FD services, measured by the coverage of OHRMx; and (iv) access to
referral level hospital services, measured by the coverage of caesarean section (C/S). See Table 25.
Districts with a higher proportion (>0.5) of deliveries occurring in Puskesmas catchment areas more
than 2 hours average travel time from the referral hospital tended to have lower FD:MRMR ratios. This
can be seen in the case of Ende, Sumba Timur, and TTU. Manggarai Barat is a special case, with the
district referral hospital in the adjacent district of Ruteng, so that all areas are more than 2 hours travel
from the referral hospital. However Flores Timur, despite 67% of deliveries in areas more than 2 hours
travel from the referral hospital, achieved a FD:MRMR of 5.5.
There does not appear to be much relationship between the ANC4/ANC1 ratio and either FD coverage
or FD:MRMR ratios. Ende and Sumba Timur have relatively low ANC4/ANC1 ratios (0.63 and 0.60),
but average FD coverage, although low FD:MRMR ratios. On the other hand Manggarai Barat with a
high ANC4/ANC 1 ratio has a lower FD coverage (65%) and a low FD:MRMR ratio; and Manggarai
Timur and Alor with high ANC4/ANC1 ratios have low FD coverage (50-60%) and low FD:MRMR ratios.
The extent of year on year fluctuation on OHRMx coverage makes it difficult to determine trends or
plateau levels. OHRMx coverage rose steeply in Ende and TTU to 80% coverage, but this doesn’t
seem to be associated with further reduction MRMR, as FD:MRMR is around 3.5 for both. Manggarai
Barat has also maintained a coverage level of 70% with OHRMx, without achieving further reduction in
MRMR, and with a FD:MRMR ratio of 2.5. Flores Timur and Sikka with declining and low coverage of
OHRMx achieved quite low MRMR, and high FD:MRMR ratios.
71
Access to a referral hospital does seem to play an important role, with poor access in Manggarai Barat,
and low C/S coverage in TTU, Ende, and Sumba Timur associated with lower FD:MRMR ratios.
Table 25.
District
Comparative indicators for medium sized districts (AIPMNH and non-AIPMNH)
FD
coverage
MRMR
/100,000
FD:MRMR
AIPMNH
Ende
67%
190
3.6
Sikka
72%
100
7.3
Sumba Timur
73%
250
3.0
Manggarai
72%
140
5.1
Mang. Barat
69%
270
2.5
Flores Timur
74%
130
5.9
TTU
79%
240
3.3
Non-AIPMNH
SBD
45%
210
2.1
Mang. Timur
48%
200
2.4
Alor
58%
210
2.8
FD & OHRMx Coverage estimated from average of period 2012-2014
C/S coverage for 2014 except Sikka (2013)
% deliveries > 2
hrs travel
ANC4/
ANC1
OHRMx
coverage
C/S
coverage
54%
34%
65%
45%
100%
67%
63%
0.71
0.76
0.62
0.85
0.90
0.76
0.71
67%
60%
35%
40%
72%
32%
66%
2.4%
7.6%
3.2%
6.5%
NA
NA
NA
0.47
0.82
0.80
12%
56%
19%
4.8%
1.2%
Figure 6. Medium size districts AIPMNH supported (2014 data)
Ende
Deliveries 6743
% del > 2 hrs 54%
Hospital= Ende
Deliveries = 21%
C/S proportion: 2.4%
FD : MRMR = 3.6
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ANC1
Ende MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
Sikka
Deliveries : 7624
% del > 2 hrs 34%
Hospital = TC Hilliers
Deliveries: 27% (2013)
C/S proportion : 7.6%
(2013)
FD: MRMR = 6.8
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ANC1
2010
2011
2012
2013
2014
Sikka MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
2010
2011
2012
2013
2014
72
Sumba Timur
Deliveries: 5746
% del > 2 hrs 65%
Hospital = Waingapu
Deliveries = 13%
C/S proportion=3.2%
FD: MRMR = 2.4
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ANC1
Sumba Timur MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
TTU
Deliveries: 5919
% del > 2 hrs 63%
Hospital = Kefa
Deliveries= 14%
C/S proportion=1.2%
FD: MRMR = 3.4
2010
2011
2012
2013
2014
TTU MRMR vs coverage indicators
0.90
0.80
0.70
0.60
0.50
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/
ANC1
0.40
0.30
0.20
0.10
0.00
2009
Manggarai
Deliveries: 8031
% del > 2 hrs 45%
Hospital = Ruteng
Deliveries = 22%
C/S proportion=6.5%
FD: MRMR = 5.1
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ANC1
2010
2011
2012
2013
2014
Manggarai MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
2010
2011
2012
2013
2014
73
Flores Timur
Deliveries: 5763
% del > 2 hrs 67%
Hospital = Larantuka
Delivers =23%
C/S proportion=4.8%
FD: MRMR = 5.5
Red= MRMR
Green = FD Blue =
OHRMx
Purple=ANC4/ANC1
Flores Timur MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
Manggarai Barat
Deliveries: 6370
% del > 2 hrs 100%
Hospital = Ruteng
(Manggarai)
2010
2011
2012
2013
2014
Manggarai Barat MRMR vs coverage
indicators
1.00
0.80
FD: MRMR = 2.6
0.60
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ANC1
0.40
0.20
0.00
2009
Figure 7.
2010
2011
2012
2013
2014
Medium size districts non-AIPMNH supported (2014 data)
Non AIP supported
Sumba Barat Daya
Deliveries: 7387
SBD MRMR vs coverage indicators
0.70
FD: MRMR = 2.1
0.60
0.50
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ ANC1
0.40
0.30
0.20
0.10
0.00
2009
2010
2011
2012
2013
2014
74
Alor
Deliveries: 4644
FD: MRMR = 2.3
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ ANC1
Alor MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
Manggarai Timur
Deliveries: 6578
FD: MRMR = 2.0
2010
2011
2012
2013
2014
Manggarai Timur MRMR vs coverage
indicators
0.90
0.80
0.70
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ ANC1
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
2010
2011
2012
2013
2014
(2) Smaller districts ≤ 4000 deliveries
Of the three AIPMNH supported smaller sized districts (<4000 deliveries in 2014), only Sumba Barat
demonstrates a clear increase in FD coverage, with a large rise in 2011, while Ngada and Lembata
show little change in reasonably high levels of coverage (around 70%) see Figure 8. Of the four nonAIP districts, two demonstrate sharp rises (Rote Ndao and Sumba Tengah), while Nagakeo has a fall
from 2009 to 2011, followed by a plateau, and Sabu Raijua, a large fall followed by a progressive rise
from low levels (Figure 9). FD coverage in Sumba Tengah and Nagakeo is similar to that in the
AIPMNH supported districts (around 70%), while coverage in Rote Ndao (58%) and Sabu Raijua (39%)
is well below the other districts.
Although there is little change in FD coverage, both Lembata and Ngada demonstrate falls in MRMR,
and have FD:MRMR ratios of over 5. MRMR in Sumba Barat changes little with the sudden rise in FD
coverage in 2011, but overall falls slightly over the period 2009 to 2014. All three AIPMNH supported
districts have FD:MRMR ratios that exceed 5.0 (Figure 8).
75
Of the non-AIPMNH districts, Rote Ndao and Sumba Tengah demonstrate falls in MRMR, both of which
are synchronous with rises in FD coverage. MRMR in Nagakeo and Sabu Raijua fluctuates from year
to year, so that no clear trend can be distinguished. This parallels the fairly steady FD coverage in
Nagakeo, and shows little change in Sabu Raijua despite an increase in FD coverage, although to low
levels (40%). The FD:MRMR ratio for Sumba Tengah is fairly high, at 5.7, while the ratios for Rote
Ndao and Nagakeo are low (2.2 and 3.6 respectively), and very low (0.5) for Sabu Raijua, where the
MRMR at 620/100,000 exceeds the FD coverage of 39%.(Figure 9)
Associations with the same explanatory factors were explored for these districts as for the medium
sized districts. See Table 26 and Figure 7.
Only Lembata had more than 50% of deliveries in areas further than 2 hours average travel from the
referral hospital, while both Sumba Barat and Ngada had only around one third of deliveries at that
distance. However, the ANC4/ANC1 ratio was quite high, and the FD:MRMR ratio also above 5.0.
Despite lower ANC4:ANC1 ratios, and FD coverage, Sumba Barat and Ngada were able to achieve
quite high FD:MRMR ratio, perhaps aided by the relatively closer population distribution. All of the
districts had quite high C/S coverage (well over 5%), while the low OHRMx coverage does not seem to
have prevented them achieving reasonably low MRMR.
Of the non-AIPMNH districts, Sumba Tengah is unusual in demonstrating a marked reduction in MRMR
associated with an increase in FD coverage, and being the only non-AIPMNH district to achieve a
FD:MRMR ratio over 5.0. While it does not have a district hospital of its own, it is quite close to the
district hospital in Waikabubak, Sumba Barat. The relatively low FD: MRMR ratio of 3.6 in Nagakeo,
despite a reasonable FD coverage level (67%), may reflect the low ANC4/ANC1 ratio (0.40), while the
low FD coverage in Rote Ndao and Sabu Raijua is the main factor in the low FD:MRMR ratios in both
these districts.
OHRMx coverage does not seem to have played much part in these smaller districts either, with low
levels of coverage associated with low MRMR in AIPMNH districts, and a higher coverage in Nagakeo
doing little to improve the FD:MRMR ratio. However, it may have contributed to the better performance
for Sumba Tengah.
Table 26.
District
Sumba Barat
Ngada
Lembata
Non AIPMNH
Rote Ndao
Sumba Tengah
Nagakeo
Sabu Raijua
FD
coverage
MRMR
/100,000
FD:MRMR
% deliveries > 2
hrs travel
ANC4/
ANC1
OHRMx
coverage
C/S
coverage
64%
75%
74%
100
130
140
6.5
5.9
5.3
38%
34%
55%
0.59
0.65
0.70
30%
34%
27%
6.8%
8.0%
11.7%
58%
70%
67%
39%
270
120
180
620
2.1
5.9
3.6
0.5
NA
NA
NA
NA
0.75
0.74
0.40
0.48
23%
60%
54%
18%
-
C/S coverage for 2014
76
Figure 8. Smaller Districts AIPMNH supported
AIPMNH districts
Sumba Barat
Deliveries: 2842
% del > 2 hrs 38%
Hospital = W’bubak
Deliveries=18%
C/S proportion=6.8%
FD: MRMR = 6.5
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ ANC1
Sumba Barat MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
Ngada
Deliveries: 3515
% del > 2 hrs 34%
Hospital = Bajawa
Deliveries = 28%
C/S proportion=8.0%
FD: MRMR = 5.4
R
ed= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ ANC1
2010
2011
2012
2013
2014
Ngada MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
Lembata
Deliveries: 2922
% del > 2 hrs 55%
Hospital = Lewoleba
Deliveres = 33%
C/S proportion=11.7%
FD: MRMR = 5.1
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/
ANC1
2010
2011
2012
2013
2014
Lembata MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
2010
2011
2012
2013
2014
77
Figure 9. Smaller Districts non-AIPMNH supported
Non AIP Supported
Rote Ndao
Deliveries: 3116
FD: MRMR = 2.2
Rote Ndao MRMR vs coverage indicators
0.90
0.80
0.70
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ ANC1
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
Nagakeo
Deliveries: 3382
FD: MRMR = 3.6
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ ANC1
2010
2011
2012
2013
2014
Nagakeo MRMR vs coverage indicators
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
Sumba Tengah
Deliveries: 1627
FD:MRMR=5.7
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ ANC1
2010
2011
2012
2013
2014
Sumba Tengah MRMR vs coverage indicators
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
2010
2011
2012
2013
2014
78
(3). Larger Districts (> 8,000 deliveries)
The four larger districts (more than 8000 deliveries in 2014) were all AIIPMNH assisted, although three
(Belu, Kota Kupang and Kab Kupang) graduated from direct support in 2014.
All four districts
demonstrate a similar pattern of an increase in FD coverage over the period 2009 to 2012, and then a
plateau to 2014, although Kab Kupang continued a small increase from 2012 to 2014 (Figure 10).
Three of the districts (TTS, Belu and Kab Kupang) also experienced reductions in MRMR over the
same period as the increase in FD coverage, although Belu experienced an initial increase in MRMR
between 2009 and 2010. Kota Kupang reported a sharp fall in MRMR between 2009 and 2010, prior to
any increase in FD coverage, although even in 2009 FD coverage had already reached 70%. Following
these falls in MRMR, MRMR has tended to plateau in all four districts over the period 2012 to 2014,
although at different levels.
FD coverage in TTS plateaued at a fairly low level of just over 50%, and MRMR plateaued at a high
level, resulting in a low FD:MRMR ratio (1.6). In contrast, FD coverage in Belu-Malaka and Kota
Kupang plateaued at high levels (over 80%), and MRMR plateaued at low levels (below 100/100,000)
resulting in high FD:MRMR ratios of over 10. Kab Kupang occupied an intermediate position, and
achieved a FD:MRMR ratio of 5.7.
Associations with the same explanatory factors were explored for these districts as for the medium
sized districts. See Table 27 and Figure 8
Three of the districts are geographically quite dispersed, with significant proportions of their populations,
and consequently deliveries, in areas more than 2 hours average travel time to the referral district
hospital. TTS and Belu-Malaka have very similar proportions of deliveries (just over 50%) living in
areas more than 2 hours travel time, yet very different MRMR and FD:MRMR ratios. A major difference
is the much lower FD coverage in TTS (53%) compared to 84% in Belu-Malaka.
Another key difference is in access to referral services, with much lower C/S coverage in TTS than in
Belu. The higher ANC4/ANC1 ratio, and the higher OHRMx coverage in TTS do not appear to have
enabled it to overcome the impact of the lower FD coverage and access to referral hospital, with the
result of a higher MRMR and lower FD:MRMR ratio.
Kab Kupang and Kota Kupang both access referral hospitals in the provincial capital city of Kupang. No
residents of Kota Kupang are more than 2 hours travel time from a referral hospital, but a large
proportion (61%) live more than 2 hours travel time in Kab Kupang. Despite this, Kab Kupang reports a
high level of ANC4/ANC1 and OHRMx coverage, and has achieved a good FD:MRMR ratio of 5.7. The
C/S coverage data is not available for Kab Kupang or Kota Kupang.
Kota Kupang has the advantage of good access to referral hospitals, and has achieved high FD
coverage and ANC4/ANC1 ratios, although the OHRMx coverage remains relatively low. Despite this,
Kota Kupang reports the lowest MRMR, and the highest FD:MRMR ratio of all NTT districts.
Table 27.
District
TTS
Belu + Malaka
Kab Kupang
Kota Kupang
FD
coverage
MRMR
/100,000
FD:MRMR
53%
84%
65%
89%
340
80
110
70
1.6
10.0
5.7
11.8
% deliveries > 2
hrs travel
ANC4/
ANC1
OHRMx
coverage
C/S
coverage
53%
52%
61%
0%
0.88
0.67
0.91
0.86
46%
40%
69%
56%
2.4%
8.0%
NA
NA
79
C/S coverage for 2014 (TTS), 2013 (Belu), not available for Kab Kupang and Kota Kupang
Figure 10.
Larger AIPMNH supported Districts
TTS
Deliveries: 10914
% del > 2 hrs 53%
Hospital = Soe
Deliveries=9% C/S
proportion=2.4%
FD: MRMR = 1.6
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ ANC1
TTS MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
Belu / Malaka
Deliveries: 8772
%del > 2hrs 52%
Hospital=Atambua
Deliveries = 19%
(2013)
C/S prop = 8.0%
(2013)
FD: MRMR = 10.0
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/
ANC1
Red= MRMR
Green = FD
Blue = OHRMx
Purple=ANC4/ ANC1
2011
2012
2013
2014
Belu MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
Kab Kupang
Deliveries: 7746
% Del > 2 hrs 61%
Hospital = Kota Kupang
Data NA
FD: MRMR = 5.7
2010
2010
2011
2012
2013
2014
Kab Kupang MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
2010
2011
2012
2013
2014
80
Kota Kupang
Deliveries: 9378
% Del > 2 hrs = 0
Hospital = Kota Kupang,
data NA
FD: MRMR = 11.8
Red= MMR
Green = FD
Blue = OHRMx
Purple=ANC4/ ANC1
Kota Kupang MRMR vs coverage indicators
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
2009
2010
2011
2012
2013
2014
Comparison across district groups and conclusions
This analysis focuses on the relationship between FD coverage and maternal mortality MRMR, in
particular the association between changes in coverage and MRMR over the period 2009 to 2014 in
both AIPMNH supported and non-supported districts.
Two common patterns emerge:
(1) A rise in FD coverage over the period 2009-2012 to a plateau over 2012–2014, associated with a
simultaneous fall in MRMR and a plateau at a lower level.
This pattern can be seen in the four large districts (TTS, Belu-Malaka, Kab Kupang and Kota Kupang);
two of the non AIPMNH supported smaller districts (Sumba Tengah and Rote Ndao); two of the
AIPMNH medium sized districts (TTU and Flores Timur), and two of the non AIPMNH medium districts
(Alor and Manggarai Timur). Manggarai, another AIPMNH supported medium district demonstrates an
association that is similar to this, although the fall in MRMR only occurred after the FD coverage
plateaued.
(2) The second most common pattern was a relatively steadily maintained moderate to high level of FD
coverage, associated with a modest fall in MRMR. This pattern is seen among two of the medium
AIPMNH supported districts (Ende and Sikka), and two of the AIPMNH supported smaller districts
(Ngada and Lembata).
Most districts with these two patterns achieved reductions in MRMR over the period of the program,
although the extent of the reductions, particularly in comparison to the level of FD coverage, varied.
There were also a small number of districts that did not demonstrate identifiable trends in MRMR, either
due to large fluctuations, or to later changes that reversed earlier changes and left no change overall.
These included:
Sumba Timur (fluctuating MRMR, despite a clear rise in FD coverage); Manggarai Barat (little change in
either FD coverage or MRMR) among AIPMNH supported districts; and Sumba Barat Daya (SBD) (a
fall followed by a rise in MRMR, despite a rise in FD coverage), Nagakeo (fluctuating MRMR despite a
steady and high FD coverage) and Sabu Raijua (a high and rising MRMR, despite some increase in low
levels of FD coverage).
81
While in most cases the changes in FD coverage and MRMR occurred simultaneously, suggesting the
likelihood of a causative association, the levels of FD coverage and MRMR at the plateau situation
varied considerably. The ratio of FD coverage: MRMR provides a convenient way to group the districts
into three groups:
Table 28.
Districts of NTT grouped by FD:MRMR ratio
FD: MRMR ratio
Districts AIPMNH supported
High (> 10.0)
Moderate (5 – 10)
Kota Kupang, Belu-Malaka
Kab Kupang, Sikka, Ngada, Lembata, Sumba Barat,
Manggarai, Flores Timur
Ende, Sumba Timur, Manggarai Barat, TTU, TTS
Low (Below 5)
Districts non AIPMNH supported
Sumba Tengah
Nagakeo, SBD, Manggarai Timur, Alor, Rote
Ndao, Sabu Raijua
A number of potential explanatory factors were examined in order to determine what might be
responsible for the differences in changes in MRMR in response to increases in FD coverage.
1. Access to referral hospital for emergency obstetric services.
Most of the districts with low
FD:MRMR ratios and low levels of FD coverage had 50% or more of their deliveries from mothers
living in Puskesmas catchment areas two hours travel time or more from the referral hospital.
However, it is notable that some districts were still able to achieve high FD:MRMR ratios despite
this constraint (notably Belu-Malaka, Kab Kupang, and Flores Timur).
2. Low levels of use of emergency obstetric services as measured by coverage of caesarean section
below 5% was also associated with low FD:MRMR ratios, notably in Ende, Sumba Timur, TTU and
TTS; while Manggarai Barat can only access emergency obstetric services from the neighbouring
district with minimum travel times of 4 hours. This is likely to be a significant problem for most of
the non-AIPMNH supported districts, as, except for Alor, none has a referral hospital in their district.
3. The ratio of ANC4 coverage/ANC1 coverage was used as a measure of the quality of ANC
services; while the coverage of OHRMx was used as a measure of the quality of FD services.
However, neither of these measures are robust measures, and the OHRMx coverage in particular
showed a lot of year to year fluctuation which made it difficult to identify trends. Those districts with
the highest FD:MRMR ratio (and lowest MRMR) tended to have high levels of ANC4/ANC1 ratio,
and of OHRMx coverage (e.g. Kota Kupang, Belu-Malaka). However, for districts with problems of
access to emergency obstetric services, high levels of ANC4/ANC1 or OHRMx coverage were not
sufficient to achieve reduced MRMR and higher FD:MRMR ratios (e.g. TTS, Manggarai Barat and
Ende).
4. AIPMNH support. Nine of the 14 AIPMNH supported districts have achieved reductions in MRMR
with moderate to high FD:MRMR ratios, while only one of the non-supported districts achieved this.
This suggests that AIPMNH support has contributed to improved performance, although it has not
been able to overcome some of the geographic barriers described above in the remaining 5
districts.
This analysis demonstrates that in many cases there is a clear relationship between an increase in FD
coverage and reduction in MRMR, although the extent of the association varies; but that in some cases
the relationship was not seen, either when FD coverage changed little, or when despite increases in or
high FD coverage, MRMR did not fall. Further study is needed to explore in more depth the potential
factors influencing this relationship, which may be related to the quality of FD services, and barriers in
the referral system for high-risk cases or those experiencing complications.
82
ANNEX 3.
83
NTT’s strategy to reduce maternal, neonatal and child mortality and morbidity includes provision of
comprehensive emergency obstetric and neonatal clinical (CEONC) services. In 2010, only two of 17
district hospitals had an obstetrician, paediatrician and an anaesthetist. AIPMNH facilitated outsourcing
the essential clinical providers from national referral hospitals as a short-term measure while the longerterm solution of selection and training of district doctors in specialist training was in process.
The goal of the Sister Hospital Program is to achieve 24 hour provision of CEONC services at district
hospitals in NTT. The objectives are: 1) to provide quality 24 hour CEONC services at selected district
hospitals, 2) Strengthen 24-hour comprehensive emergency obstetric and neonatal service system, 3)
Improve knowledge, attitude, and skills of the personnel in District hospitals and Puskesmas
responsible for the provision of MNH health services, 4) Improve the quality of the referral system, and
5) Facilitate the selection and training of general doctors in relevant speciality areas.
The sister hospital program commenced in the 4th quarter of 2010 through twinning six large teaching
hospitals in central Indonesia with six district hospitals in NTT (Group 1). Six months implementation
demonstrated significant changes in reducing maternal mortality and neonatal mortality and the
program expanded to the remaining five RSUD (Group 2) with an increase in twinning sister hospitals to
nine. Group 2 hospitals differed from Group 1 in that these hospitals had some existing CEONC
capacity.
Starting in October 2011, the Sister Hospital program expanded to include hospital management
through a Performance Management and Leadership (PML) program, as without such improvement
provision of clinical services was unable to be optimised.
Since July 2014, AIPMNH has only supported ten districts with four districts being graduated, including
Belu and Sikka and therefore RSUD Atambua in Belu and RSUD T.C. Hillers in Sikka are no longer
supported. In line with the phasing out of AIPMNH since March 2015, all costs for incentives and
mobilisation have been absorbed by local government (with the exception of Lembata, which was
supported until the end of June 2015).
In this period, AIPMNH support has focused on improving the quality of care through monitoring and
clinical supervision by partnering hospitals, capacity building of staff and improving hospital
management.
An operational study on identification and management of obstetric and neonatal
complications through a retrospective facility audit in four districts was conducted to provide better
understanding of how investment in BEONC and CEONC has affected management of complications.
This report provides a descriptive analysis of the program activities over the period January to June
2015, an analysis of program’s performance indicators for each hospital, results of periodic monitoring
and evaluation visits, and a summary of findings from the complications study.
A. Summary Activities in the Reporting Period
Clinical Services
1. Provision of 24-hour CEONC by sending residents on rotation from partner hospitals to nine district
hospitals was continued by the district governments.
2. Continuation of improvements in the CEONC system, through quality improvement activities
focused on clinical audits, infection control, patient safety, and equipment maintenance and
management
3. Continuation of capacity building for hospital and Puskesmas staff through training and regular
supervision by the sister hospital partners.
Teleconference has been mainly used for
84
4.
5.
6.
communication between the district hospital and its partnering hospital in capacity building,
consultation and coordination of activities.
Facilitation of improvement in the quality of referrals, through supervision to PONED Puskesmas by
sister Hospital partners.
A study of the management of complications in four districts of Ende, Flores Timur, Sumba Timur
and TTS.
Activities conducted by PKMK-FK UGM as monitoring evaluation coordinator of the sister hospital
program:
a. Coordination of the external monitoring evaluation in April 2015.
b. Conduct training in Clinical Pathway for nine RSUD, and monitoring of the follow up
implementation in each hospital through Skype or teleconference.
c. Conduct an evaluation meeting with the partnering hospitals, district hospitals and their
stakeholders, Provincial and District Health Office and AIPMNH, in May 2015
d. Conduct three studies in collaboration with P2K3 UNDANA:
(1) Penelitian Pembayaran Bidan dan Pelaksanaan Rujukan Maternal Neonatal / Midwife
payments and referral,
(2) Kajian Penentuan besaran Unit Cost, penyerapan klaim INA-CBG, dan Kebijakan
pemanfaatan dana sisa dalam monitoring penyelenggaraan program Jaminan Kesehatan
Nasional (JKN) di Provinsi NTT / Service unit costs, uptake of JKN and policy implications
of residual funds, and
(3) Penelitian Remunerasi Dokter di NTT / Remuneration of doctors in NTT.
e. Continuation of capacity building of P2K3 UNDANA including through the studies as coresearchers and in monitoring management aspects of the sister hospital program.
f. Facilitation of implementation of maternal perinatal audits (AMP) in the three districts of
NTT with the highest maternal mortality cases in 2014 (TTS, Sumba Timur and Manggarai
Barat).
Executive Summary; Identification and Management of Obstetric and Neonatal Complications in
NTT, Indonesia: A Retrospective Facility Audit in Four Districts”
AIPMNH has invested in improving basic (PONED) and emergency (PONEK) obstetric and neonatal
care since 2009. A facility audit of government district hospitals (RSUD) and selected sub-district
health centres (Puskesmas) was conducted in the four districts of Ende, Flores Timur, Sumba Timur
and TTS to understand the extent to which obstetric and neonatal complications are being managed at
the Puskesmas and RSUD level and where the remaining gaps are for future programs.
A total sample of 445 maternal complication cases and 272 neonatal complication cases were audited
across the four districts for the period September 2014 to May 2015. A medical team assessed the
data collected on complications managed to determine whether the management was according to
established standards of care.
Overall, the patterns of obstetric and neonatal complications detected and managed across the four
districts
were
similar.
The
most
commonly
reported
obstetric
complications
were
preeclampsia/eclampsia (20%); post-partum and ante-partum haemorrhage (15%); premature rupture
of membranes (12.6%); and abortion related complications (8.5%).
The most commonly reported
neonatal complications were asphyxia (38%), low birth weight/pre-term (36%) and infections (13%).
The RSUD are managing most obstetric and neonatal complication cases according to standards of
care. However, the audit did find a relatively large number (10 out of 34) of the neonatal deaths were of
normal birth weight babies delivered in the RSUD, suggesting improved management of neonatal
complication cases is needed.
The audit found that PONED Puskesmas had managed 36% of obstetric complications with 64%
referred; and 60% of neonatal complications, with 40% referred. More detailed analysis found that for
85
the most part, mild complications were being managed at the Puskesmas level, with more severe cases
being referred.
In PONED Puskesmas 70% of obstetric complication cases were managed appropriately to standard,
and over 50% provided appropriate pre-referral treatment.
Similarly, 79% of managed neonatal
complication cases were provided treatment according to standard and 53% were provided appropriate
pre-referral treatment.
Non-PONED Puskesmas were managing very few obstetric complications (only 2%) and fewer
neonatal complications (36%). Appropriateness to standards of care was also lower, with >50% of the
obstetric cases and almost 75% of the neonatal cases referred without proper pre-referral treatment.
Most complications in non-PONED Puskesmas are being directly referred to the RSUDs.
The study found the need to continue investment in building PONED and PONEK capacity in NTT.
There is a need to improve pre-referral treatment and stabilization for mothers and babies at both the
PONED and non-PONED Puskesmas.
In terms of management of obstetric complications, more
attention needs to be given to the management of preeclampsia, premature rupture of membranes and
prolonged labour as these conditions were more likely to lead to adverse outcomes of the pregnancy
(as found in this audit). There is an ongoing need to address guaranteed availability of essential drugs,
equipment and oxygen at the Puskesmas level; and to ensure ongoing availability of complete PONED
and PONEK teams at these facilities.
B. Analysis of Sister Hospital Program Indicators 2011 - 2014
As in previous reports, maternal and neonatal indicators are analysed in two groups of district hospitals,
Group 1 or Group 2 RSUD, based on their date of commencement in the program (Group 1
commenced in 2010, and Group 2 in 2012). Since in this period, data is only available from January to
June 2015, the analysis will be done on a six monthly basis from 2011 - 2015. In the Group 1 analysis,
data from the first SH period (October 2010 – Feb 2011) is considered as data from first and second
quarter of 2011. Given that the data covers only the first 6 months of the year, some caution is needed
in interpreting trends as quite large fluctuations in indicators have been found in previous years
between the first and second six-month periods of a year.
Group 1 RSUD
Maternal Health Indicators
1. In hospital deliveries
Table 29 shows the number of in-hospital deliveries, which have continued to increase in three
hospitals (Ende, Bajawa and Waikabubak) almost 1.5 times higher than the figure in 2011. However, in
the other three hospitals (Soe, Lewoleba, and Larantuka), the number of in hospital deliveries increased
from 2011, but then commenced decreasing from 2014. Lewoleba has the fewest number of in-hospital
deliveries in this period.
Table 29.
Districts Hospitals
TTS
Lembata
Flotim
Ende
Sumba
Barat
Soe
Lewoleba
Larantuka
Ende
Ekapata
Group 1 RSUD deliveries as % of estimated deliveries in catchment area
Pre
Q4 2010- Q3-4 2011 Q1-2 2012 Q3-4 2012 Q1-2 2013 Q3-4 2013 Q1-2 2014 Q3-4 2014 Q1-2 2015
Q1 2011
206
399
789
657
283
371
384
545
601
389
525
527
692
720
766
611
670
957
827
610
543
740
782
698
674
613
648
934
881
697
612
492
630
710
555
543
565
793
883
729
541
398
550
857
628
471
337
764
928
719
86
Districts Hospitals
Ngada
Bajawa
Total Group 1
Pre
Q4 2010- Q3-4 2011 Q1-2 2012 Q3-4 2012 Q1-2 2013 Q3-4 2013 Q1-2 2014 Q3-4 2014 Q1-2 2015
Q1 2011
458
2792
663
2953
628
3858
686
4361
529
3966
693
4466
773
3772
747
4260
783
3757
904
4123
The number of hospital deliveries as percentage of estimated deliveries in the hospital catchment area
in Group 1 Sister Hospitals has remained around 20% from 2012-2015, after increasing from 2011
(Table 30). Four hospitals (RSUD Bajawa, Larantuka, Ende, and Lewoleba) have a percentage more
than 20%, with RSUD Bajawa having the highest increase in percentage (34%). RSUD Ekapata also
has increased its percentage to 19%. Two hospitals have decreased their percentage of deliveries,
with RSUD Soe having the lowest percentage of estimated deliveries in this group at 8%.
Table 30.
Group 1. In-hospital deliveries as % of total catchment estimated deliveries
District
Hospitals
Pre
Q4 2010- Q3-4
Q1 2011 2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
TTS
RSUD Soe
4%
7%
9%
12%
10%
11%
11%
9%
9%
8%
12%
21%
37%
22%
18%
14%
35%
23%
17%
45%
33%
20%
50%
27%
17%
43%
33%
21%
33%
22%
17%
39%
28%
22%
27%
19%
21%
23%
27%
23%
6%
11%
21%
17%
18%
19%
15%
20%
17%
19%
17%
13%
25%
14%
24%
19%
26%
22%
20%
20%
27%
22%
30%
19%
28%
21%
29%
18%
34%
20%
Lembata RSUD Lewoleba
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
2. In hospital mortality rate
In-hospital maternal mortality, both from all causes and from direct obstetric causes, began increasing
from mid-2014 (Table 31). Five hospitals show increasing proportions of deaths, with only RSUD
Larantuka showing decreasing mortality. Besides the increase of in-hospital deliveries in RSUD Ende,
Bajawa and Waikabubak, these three hospitals plus RSUD Lewoleba have also had a significant
increase in total complications treated (Table 33). The increased number of complications managed
may contribute to the increased mortality.
The decrease in maternal mortality reported by RSUD
Larantuka, which also had a decrease in the number of complications treated despite an increase of inhospital deliveries, tends to confirm this hypothesis. However, this pattern was not observed with
RSUD Soe, which had decreased complications treated and a reduction of in-hospital deliveries, but
also an increased maternal mortality.
Table 31.
Group 1 in-hospital maternal mortality as % of hospital deliveries – all causes
District
Hospitals
Pre
Q4 2010- Q3-4
Q1 2011 2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
TTS
RSUD Soe
0.49%
0.81%
0.38%
0.00%
0.74%
1.47%
0.16%
0.00%
1.66%
2.55%
0.50%
0.13%
0.61%
0.00%
0.00%
0.18%
0.17%
0.00%
0.38%
0.00%
0.42%
0.00%
0.30%
0.00%
0.73%
0.33%
0.27%
0.51%
1.15%
0.59%
0.00%
0.43%
0.91%
0.57%
0.41%
0.32%
0.28%
1.08%
0.00%
0.38%
0.00%
0.14%
0.00%
0.91%
0.12%
0.32%
0.89%
0.52%
0.54%
1.11%
1.31%
13%
0.15%
0.50%
0.16%
0.20%
0.00%
0.21%
0.00%
0.23%
0.43%
0.55%
0.39%
0.63%
0.40%
0.42%
0.26%
0.16%
0.44%
0.51%
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
As Table 32 demonstrates, the same pattern is seen with direct obstetric causes of maternal death,
indicating that the changes in maternal mortality is not the result of changes in indirect causes of death
only.
87
Table 32.
Group 1 in-hospital maternal deaths direct obstetric causes as % of hospital
deliveries
District
Hospitals
TTS
RSUD Soe
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
0.49%
0.81%
0.38%
0.00%
0.37%
1.47%
0.16%
0.00%
1.11%
2.34%
0.50%
0.13%
0.61%
0.00%
0.00%
0.18%
0.17%
0.00%
0.19%
0.00%
0.28%
0.00%
0.00%
0.00%
0.36%
0.33%
0.14%
0.38%
0.86%
0.15%
0.00%
0.32%
0.23%
0.43%
0.20%
0.32%
0.14%
1.08%
0.00%
0.38%
0.00%
0.00%
0.00%
0.73%
0.00%
0.32%
0.89%
0.39%
0.43%
0.70%
1.31%
0.15%
0.50%
0.00%
0.20%
0.00%
0.13%
0.00%
0.11%
0.29%
0.33%
0.39%
0.43%
0.40%
0.37%
0.13%
0.14%
0.22%
0.35%
3. Complications and Case Fatality Rate (CFR)
Overall, total obstetric complications managed increased constantly since 2011, and have reached the
target of more than 20% of in-hospital deliveries (Table 32). Three hospitals (Ende, Lembata and
Bajawa) have achieved the target, while the achievement of Soe, Larantuka, and Waikabubak is less
than 20%.
Compared to the previous period, Lembata shows an almost ten times increase in
complications managed, while TTS and Larantuka show reductions of around 50%.
Ende’s reported managed complications outnumber in-hospital deliveries, which could indicate a high
number of referrals or could reflect different application of definitions and recording of complications.
The hospital data validation and complication studies revealed large variations between hospitals in
operational definitions of complications, as well as in recording formats. RSUD Ende for example,
record complications by cases, thus 1 patient having 2 complications will be counted as 2 in the number
of complications. This may also contribute to the high number of complications treated in Ende of more
than 100% of hospital deliveries.
Table 33.
Group 1 total obstetric complications treated as % of in-hospital deliveries
District
Hospitals
TTS
RSUD Soe
Flotim
RSUD Larantuka
Ende
RSUD Ende
Ngada
RSUD Bajawa
Sumba
RSUD Ekapata
Barat
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
30.6%
8.6%
30.5%
30.1%
23.4%
10.9%
14.1%
22.8%
21.8%
12.5%
4.3%
7.5%
12.5%
28.7%
7.2%
17.2%
4.4%
27.3%
31.6%
22.5%
11.4%
14.0%
24.4%
20.1%
18.8%
10.6%
2.9%
10.0%
31.6%
14.4%
10.4%
15.6%
56.7%
26.7%
7.8%
5.6%
5.8%
69.2%
18.8%
12.8%
9.6%
10.2%
73.2%
16.7%
6.7%
5.7%
11.9%
74.9%
30.3%
21.6%
2.8%
29.1%
75.4%
25.5%
10.7%
26.7%
13.0%
131%
30.9%
19.4%
12.1%
18.9%
19.8%
15.0%
23.8%
22.1%
22.9%
30.4%
31.4%
45.2%
Table 34 shows that the overall number of direct obstetric complications treated in hospital as a
percentage of estimated district complications has increased to 17.3% in mid-2015. RSUD Lembata
and RSUD Bajawa treated more than 20% of estimated direct obstetric complications arising from
deliveries in the district catchment area. Waikabubak has also increased the percentage of direct
obstetric complications treated to almost 20%. However, Ende, Soe and Larantuka have decreased the
percentage of direct obstetric complications treated, with reductions of almost 50% in Soe and
Larantuka from the previous period.
Table 34.
Group 1 total direct obstetric complications treated as % of in-hospital deliveries
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
RSUD Soe
30.6%
8.6%
28.6%
27.3%
23.4%
10.1%
14.1%
22.8%
21.8%
12.5%
RSUD Lewoleba
RSUD Larantuka
RSUD Ende
4.3%
7.5%
12.8%
17.2%
4.4%
27.2%
10.1%
14.0%
19.4%
8.2%
2.9%
9.3%
10.0%
15.1%
14.2%
4.3%
5.8%
8.1%
9.4%
9.7%
10.7%
5.3%
11.2%
10.2%
2.8%
21.1%
16.7%
24.3%
11.4%
13.9%
District
Hospitals
TTS
Lembata
Flotim
Ende
88
District
Hospitals
Ngada
RSUD Bajawa
Sumba
RSUD Ekapata
Barat
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
28.6%
7.2%
31.6%
22.5%
19.5%
16.2%
29.0%
13.0%
23.0%
7.8%
18.5%
12.1%
14.6%
6.3%
27.9%
20.0%
20.5%
10.5%
25.3%
19.3%
12.1%
18.9%
17.9%
13.6%
15.5%
9.6%
10.6%
16.1%
15.9%
17.3%
The indicator related to the outcome of complications managed is Case Fatality Rate (CFR), which is
calculated as the number of direct maternal deaths as a proportion of direct complications treated.
Overall, the CFR for direct obstetric complications shows much variation over different periods and is
closely related to the number of direct complications treated in hospitals. Compared to the previous
period, the CFR increased to 3.9%, but is still below the baseline of 4.2%.
Four hospitals have
increased CFR (RSUD Soe, Lewoleba, Ende, and Ekapata with the most significant increase in RSUD
Soe (18.6%). The increased CFR in Lewoleba and Ekapata was associated with an increase in the
number of direct obstetric complications treated, in Ende with an increase in total obstetric
complications treated, and the increase in CFR at Soe occurred despite a decrease in the number of
complications treated. (Table 35)
Table 35.
Group 1 Case Fatality Rate for Direct Obstetric Complications
District
Hospitals
TTS
RSUD Soe
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
1.6%
9.4%
1.3%
0.0%
1.6%
14.5%
1.2%
0.0%
5.1%
18.6%
11.8%
1.7%
4.8%
0.0%
0.0%
4.2%
0.6%
0.0%
1.9%
0.0%
1.4%
0.0%
0.0%
0.0%
3.9%
1.1%
1.4%
2.5%
6.1%
0.6%
0.0%
5.6%
2.8%
2.3%
2.2%
3.3%
1.3%
7.4%
0.0%
3.4%
0.0%
0.0%
0.0%
3.4%
0.0%
1.6%
3.7%
3.4%
3.1%
2.7%
18.2%
4.2%
0.7%
1.1%
0.0%
0.7%
0.0%
0.8%
0.0%
2.1%
2.4%
4.4%
6.1%
3.5%
2.0%
0.9%
1.2%
2.2%
1.1%
3.9%
Referrals
One of the target indicators of providing CEONC is that the number of referred women as a percentage
of estimated district deliveries is >10%.
This target was achieved in 2012, and has continued to
increase and now stands at 12%, although two hospitals (Soe and Sumba Timur) still report <10%.
Compared to the baseline figure, all hospitals have an increased proportion of referral cases, with
Lewoleba achieving an increase of 4.5 times baseline (Table 36).
Table 36.
Group 1 Obstetric referrals as % of estimated district deliveries
District
Hospitals
TTS
RSUD Soe
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
2.3%
5.0%
6.0%
5.1%
6.3%
7.1%
4.8%
7.2%
8.1%
5.7%
3.4%
6.5%
7.9%
1.2%
8.6%
9.1%
3.2%
2.1%
10.2%
12.0%
5.5%
3.2%
9.6%
11.5%
9.8%
6.4%
25.6%
13.8%
9.3%
3.7%
10.6%
13.8%
12.3%
6.3%
8.5%
11.2%
10.5%
5.3%
12.2%
11.1%
10.9%
6.6%
10.5%
10.1%
11.1%
4.4%
15.3%
14.9%
13.0%
4.6%
15.7%
5.0%
25.5%
7.6%
26.7%
9.3%
27.2%
10.5%
26.1%
11.5%
27.9%
11.9%
18.2%
8.9%
21.3%
10.6%
28.7%
11.2%
29.0%
12.0%
4. Caesarean Section
The proportion of women delivering by caesarean section indicates access and utility of emergency
obstetric services. As a proportion of hospital deliveries, caesarean section has remained around 30%
since 2011, with a slight increase to 34.6% in this period. The highest rate was in RSUD Lewoleba
(62.6%), followed by Bajawa (40.7%) and Ekapata (37.8%). The results among the Group 1 hospitals
suggest that too low a rate of caesarean section may lead to increased maternal mortality, but also that
89
too high a rate can be associated with higher maternal mortality, perhaps due to increased workload.
Soe, which had the highest CFR (18.6%) and the lowest rate of caesarean section (22.3%) also has the
highest in hospital maternal mortality rate.
Lewoleba reported an increase in CFR and maternal
mortality, despite a very high CS rate. Again, a thorough analysis of the indications, process and
outcomes of caesarean sections is needed to determine the appropriateness of the procedure for each
patient (Table 37).
Table 37.
Group 1 Caesarean sections as percentage of hospital deliveries
District
Hospitals
TTS
RSUD Soe
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
0.0%
25.3%
29.1%
26.0%
33.5%
35.9%
17.5%
30.9%
19.6%
22.3%
33.4%
15.3%
38.3%
47.0%
35.4%
17.2%
28.3%
45.5%
34.3%
26.9%
33.9%
41.4%
26.6%
27.0%
39.5%
46.7%
32.2%
21.2%
39.4%
37.4%
24.8%
18.0%
35.4%
31.9%
28.0%
17.1%
37.5%
37.3%
30.6%
20.2%
37.7%
39.6%
42.2%
21.5%
35.6%
33.9%
62.6%
27.2%
28.2%
37.8%
20.1%
26.2%
28.7%
29.2%
26.9%
32.4%
14.0%
29.9%
21.7%
31.0%
22.7%
27.8%
25.7%
27.2%
28.0%
31.3%
28.4%
30.1%
40.7%
34.6%
Overall, the caesarean section rate as a proportion of estimated district deliveries has remained 5.1%
and 6.9% for each six-month period between 2011 and 2015. Only RSUD Soe has a CS rate below the
recommended minimum of 5%, much lower than the other hospitals. This suggests that efforts to
improve access to CEONC in this district is needed including involvement of other sectors (Table 38).
Table 38.
Group 1 Caesarean Sections as percentage of estimated district deliveries
District
Hospitals
TTS
RSUD Soe
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
0.0%
1.7%
2.7%
3.1%
3.4%
4.0%
1.9%
2.9%
1.8%
1.8%
4.0%
3.3%
14.0%
2.7%
7.7%
3.1%
4.1%
4.8%
12.0%
6.2%
5.8%
8.6%
12.0%
8.8%
8.0%
7.8%
16.0%
5.7%
6.7%
6.9%
10.8%
5.9%
7.5%
6.1%
9.2%
3.8%
6.4%
5.7%
11.8%
5.6%
8.1%
7.8%
11.5%
4.1%
7.4%
5.8%
14.4%
7.2%
6.4%
7.4%
3.4%
3.3%
7.1%
4.1%
6.3%
6.0%
3.7%
6.6%
4.4%
6.1%
6.1%
6.1%
7.7%
5.1%
7.8%
6.5%
8.2%
5.5%
13.6%
6.9%
Neonatal Health Indicators
1. In-hospital neonatal mortality
Neonatal in-hospital mortality has declined since 2013, and remains the same as the 2014 figure in this
period (2.2%), and below the baseline figure (3.7%).
Soe, Lewoleba and Ende have decreased
neonatal mortality, while three other hospitals (Larantuka, Ekapata and Bajawa) have increased
mortality compared to the 2014 figure but still below the baseline figure (Table 39). Table 40 shows an
increase in the number of neonates treated in hospital, with the highest number in Ende (938).
Table 39.
Group 1 In-hospital neonatal mortality
District
Hospitals
TTS
RSUD Soe
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
4.4%
1.9%
3.9%
4.9%
4.8%
3.6%
4.0%
2.7%
3.0%
2.0%
1.3%
4.1%
3.8%
3.5%
2.3%
0.7%
2.5%
3.6%
1.8%
1.9%
1.8%
1.3%
3.0%
1.2%
3.3%
3.6%
3.0%
2.1%
4.7%
4.7%
2.8%
1.8%
3.1%
2.6%
4.2%
4.2%
2.4%
2.1%
3.1%
3.6%
2.4%
1.6%
2.3%
2.1%
3.0%
0.9%
1.4%
3.6%
1.9%
2.1%
5.0%
3.7%
2.0%
2.1%
3.5%
2.3%
2.7%
2.9%
3.5%
3.7%
3.1%
2.8%
2.6%
3.1%
1.8%
2.4%
1.7%
2.2%
2.1%
2.2%
90
Table 40.
Group 1 total neonates treated in hospitals
District
Hospitals
TTS
RSUD Soe
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
206
371
562
587
579
725
718
414
465
501
399
789
657
283
384
545
601
389
493
624
725
769
696
940
828
576
736
751
724
613
472
966
930
625
236
689
707
579
393
526
884
766
299
422
892
658
370
647
938
761
458
2792
663
2953
626
3799
783
4410
689
4092
740
4458
887
3816
779
3762
864
3600
827
4044
2. Complications and CFR
Neonatal complications treated both as a percentage of total hospital neonates and as a percentage of
estimated district complications, show significant increases from 2014 and from baseline figures (Table
41 and Table 42.
The most significant increase occurred in Ende.
However, as with obstetric
complications, Ende recorded neonatal complication treated by type, thus, a baby with more than 1
complication will be counted as 2 or more neonatal complications treated. RSUD Ekapata still has not
achieved the target of more than 20% neonatal complications treated as a percentage of total hospital
neonates, although the number of neonates treated in hospital has increased.
Table 41.
Group 1 neonatal complications treated as % of total hospital neonates
District
Hospitals
TTS
RSUD Soe
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
18.0%
22.9%
25.1%
19.6%
29.4%
33.7%
30.4%
51.2%
28.0%
37.3%
4.8%
1.1%
51.7%
44.5%
42.7%
11.7%
81.4%
31.1%
14.8%
37.5%
62.9%
19.2%
17.5%
13.0%
27.4%
33.2%
17.7%
19.6%
37.4%
26.3%
48.7%
18.0%
35.2%
25.9%
50.8%
25.3%
47.1%
3.3%
31.0%
34.2%
50.1%
11.1%
34.4%
49.8%
46.9%
19.5%
22.2%
43.9%
116.5%
19.3%
65.3%
29.7%
26.4%
37.2%
41.1%
34.5%
53.3%
27.1%
18.4%
24.6%
24.9%
29.6%
33.3%
30.4%
44.4%
36.9%
36.5%
36.2%
36.5%
51.8%
Compared to baseline figures, significant increases have occurred in the number of neonatal
complications treated as a percentage of estimated complications arising from district deliveries. The
highest increases occurred in Ende, followed by Larantuka, Soe and Ekapata. A decrease in the
proportion of neonatal complications treated occurred in Lewoleba and Bajawa (Table 42).
Table 42.
Group 1 Neonatal complications treated as % of estimated district complications
District
Hospitals
TTS
RSUD Soe
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
4.3%
10.0%
16.6%
15.0%
21.1%
29.3%
26.2%
24.7%
15.1%
21.8%
3.9%
1.6%
126.4%
16.9%
61.9%
14.3%
77.9%
21.8%
32.2%
52.2%
72.6%
26.7%
54.8%
27.8%
36.9%
34.9%
58.4%
33.4%
44.0%
29.4%
102.7%
40.4%
52.3%
29.9%
53.6%
40.4%
53.3%
3.5%
55.7%
41.7%
72.0%
15.3%
47.0%
48.6%
67.9%
23.1%
37.4%
65.7%
177.7%
26.5%
73.6%
24.9%
43.8%
34.9%
64.3%
42.1%
106.4%
40.0%
32.4%
33.3%
47.7%
43.5%
76.5%
38.1%
85.5%
45.0%
77.9%
42.3%
74.7%
67.9%
The neonatal Case Fatality Rate (CFR) measures the outcome of complications managed, as the
number of neonatal deaths as a proportion of neonatal complications treated. Although the neonatal
CFR varied between 2011 and 2013, it declined to three times lower than the baseline figure in this
period. Three hospitals (Ende, Soe and Lewoleba) decreased neonatal CFR, with Ende having the
lowest figure (1.6%).
Larantuka, Ekapata and Bajawa reported increased neonatal CFR, with the
highest CFR reported from Ekapata (Table 43).
91
Table 43.
Group 1 Neonatal Case Fertility (CFR) for neonatal complications
District
Hospitals
TTS
RSUD Soe
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
24.3%
8.2%
15.6%
25.2%
16.5%
10.7%
13.3%
5.2%
10.8%
5.3%
26.3%
355.6%
7.4%
7.9%
5.5%
6.3%
3.1%
11.6%
12.3%
5.1%
2.9%
6.8%
17.2%
9.0%
11.9%
11.0%
16.9%
10.9%
12.5%
18.0%
5.7%
9.8%
8.9%
9.9%
8.3%
16.7%
5.1%
63.2%
9.8%
10.6%
4.7%
14.1%
6.8%
4.3%
6.5%
4.7%
6.1%
8.1%
1.6%
10.9%
7.7%
12.5%
7.4%
5.6%
8.6%
6.7%
5.0%
10.9%
18.9%
15.2%
12.5%
9.4%
7.8%
10.4%
4.0%
6.4%
4.8%
6.0%
5.6%
4.2%
3. Referrals
The number of neonatal referrals has not changed much during implementation of the sister hospital
program and referrals as a percentage of estimated catchment live births remains between 0.5 and
2.7% (Table 44). However, the increase in maternal referrals noted in the analysis of obstetric services
will also entail an increase in neonatal referrals, although these are not recorded as such.
Table 44.
Group 1 Neonatal referrals as % of est. catchment live births
District
Hospitals
TTS
RSUD Soe
Flotim
RSUD Larantuka
Ende
RSUD Ende
Sumba
RSUD Ekapata
Barat
Ngada
RSUD Bajawa
Total Group 1
Pre
Q4 2010Q1 2011
Q3-4
2011
Q1-2
2012
Q3-4
2012
Q1-2
2013
Q3-4
2013
Q1-2
2014
Q3-4
2014
Q1-2
2015
2.1%
2.4%
0.9%
0.5%
0.8%
0.9%
2.4%
0.6%
0.5%
1.1%
0.9%
2.1%
16.0%
4.1%
12.3%
1.8%
10.2%
2.4%
1.4%
0.7%
0.7%
0.3%
0.9%
0.8%
0.7%
1.0%
2.4%
0.8%
0.9%
0.4%
2.1%
3.6%
1.5%
0.7%
1.1%
0.6%
0.6%
0.4%
1.6%
1.6%
0.6%
0.5%
1.6%
0.7%
0.7%
0.6%
2.4%
1.8%
0.4%
0.5%
5.8%
3.9%
9.0%
5.6%
2.1%
0.9%
2.4%
0.9%
2.4%
1.1%
2.7%
1.7%
2.4%
1.3%
3.2%
1.1%
2.3%
0.9%
2.7%
1.2%
Group 2 RSUD
This group has a longer history of having at least some emergency obstetric services, prior to
commencement of the SH program. This group commenced in the SH program in 2012, with regular
reporting from mid-2012, so the hospital data is only available for six-months of 2012, and the whole of
2013 and 2014. However, since July 2014, AIPMNH ceased support for four districts including Belu
and Sikka, thus RSUD Atambua and RSUD T.C Hillers are no longer supported. This section reports
on the analysis of the three hospitals in Group 2 which remain in the program to June 2015, i.e. RSUD
Kefamenanu (TTU), RSUD Ruteng (Manggarai) and RSUD Umbu Rara Meha (:Sumba Timur).
Maternal Health Indicators
1. In hospital deliveries
In Group 2, the number of in-hospital deliveries has increased, as has the proportion of estimated
district deliveries. All three hospitals have slightly increased numbers of deliveries for the first half of
2015 compared to 2014.
Ruteng has the highest figure since this hospital must also provide
comprehensive MNH services for both Manggarai Barat and Manggarai Timur districts (Table 45).
Table 45.
Group 2 in-hospital deliveries as a % estimated deliveries in catchment area
Number of in-hospital deliveries
In-hospital deliveries as % district deliveries
Districts Hospitals
Jul-Dec Jan-Jun Jul-Dec Jan-Jun Jul-Dec Jan-Jun Jul-Dec Jan-Jun Jul-Dec Jan-Jun Jul-Dec Jan2012
2013
2013
2014
2014
2015
2012
2013
2013
2014
2014
June
2015
TTU
Mangg-
514
1165
RSUD Kefa
RSUD
502
1465
540
1091
401
1381
368
1465
483
1671
17%
17%
17%
22%
18%
19%
16%
20%
12%
25%
16%
29%
92
Number of in-hospital deliveries
In-hospital deliveries as % district deliveries
2013
2013
2014
2014
2015
2012
2013
2013
2014
2014
June
2015
Districts Hospitals
arai
Ruteng
Sumba RSUD Umbu 413
Timur
Rara Meha
Total Group 2
2092
463
431
338
397
482
12%
14%
13%
12%
15%
18%
2430
2062
2120
2230
2636
19%
21%
19%
24%
19%
23%
2. In-hospital mortality rate
In this period, hospital maternal mortality from all causes increased in RSUD Ruteng and Umbu Rara
Meha, while no deaths were reported from RSUD Kefamenanu. However, the maternal deaths at
RSUD Umbu Rara Meha were all from indirect causes, so the rate of deaths from direct causes fell
overall (Error! Reference source not found.).
Table 46.
Group 2 in-hospital maternal mortality – all causes & direct obstetric causes
All causes maternal deaths as % in-hospital
deliveries
Direct maternal deaths as % of in-hospital deliveries
Districts Hospitals
2013
2013
2014
2014
2015
2012
2013
2013
2014
2014
June
2015
TTU
RSUD Kefa
Manggara RSUD
i
Ruteng
Sumba RSUD Umbu
Timur
Rara Meha
Total Group 2
0.97%
0.52%
0.60%
0.20%
0.37%
0.46%
1.00%
0.22%
0.27%
0.20%
0.00%
0.36%
0.39%
0.52%
0.20%
0.30%
0.37%
0.27%
0.75%
0.07%
0.27%
0.14%
0.00%
0.24%
0.24%
0.65%
0.93%
0.89%
0.25%
0.41%
0.24%
0.00%
0.46%
0.89%
0.25%
0.00%
0.57%
0.37%
0.53%
0.47%
0.22%
0.30%
0.43%
0.16%
0.39%
0.33%
0.18%
0.15%
3. Complications and Case Fatality Rate
Overall, total obstetric complications treated in hospital have increased, both absolutely and as a
percentage of in-hospital deliveries. In this period, the three hospitals (RSUD Ruteng, Umbu Rara
Meha and Kefa) have achieved the target of managing 20% of the estimated maternal complications in
the catchment area, with the highest percentage in RSUD Ruteng (> 50%) (Table 47). The majority of
reported complications are direct obstetric complications (99%).
Table 47.
Group 2 Total obstetric complications & % estimated catchment complications
Total obstetric complication cases treated
Total obstetric complications as % of estimated
catchment complications
Districts Hospitals
2013
2013
2014
2014
2015
2012
2013
2013
2014
2014
June
2015
TTU
RSUD Kefa
Manggara RSUD
i
Ruteng
Sumba RSUD Umbu
Timur
Rara Meha
Total Group 2
338
335
168
500
26
314
75
377
42
311
100
466
67.3%
33.0%
33.9%
48.5%
5.1%
36.4%
19.5%
35.4%
9.4%
35.2%
22.1%
53.0%
62
123
71
69
19
88
11.6%
19.2%
12.9%
14.9%
3.9%
21.5%
735
791
411
521
372
654
35.3%
37.7%
22.0%
27.6%
21.1%
37.5%
The Case Fatality Rate (CFR) for obstetric complications in group 2 has continued to decrease since
2013, and has reached the target of > 1% in all three hospitals. Kefa and Umbu Rara Meha had no
maternal deaths in this six-month period.
93
Table 48.
Districts
Group 2 Case Fatality Rate for direct obstetric complications
Case Fatality Rate (CFR)
Hospitals
TTU
RSUD Kefa
Manggarai RSUD Ruteng
Sumba
RSUD Umbu
Timur
Rara Meha
Total Group 2
Jul-Dec 2012
Jan-Jun 2013
Jul-Dec 2013
Jan-June 2014 Jul-Dec 2014
Jan-Jun 2015
0.7%
1.8%
1.7%
0.7%
0.6%
0.00%
8.7%
1.3%
3.1%
4.1%
0.3%
4.9%
2.4%
0.7%
6.3%
0.0%
0.9%
0.0%
1.3%
0.5%
2.0%
1.4%
1.1%
0.6%
4. Referrals
Overall, obstetric referrals as a proportion of estimated district deliveries have increased since 2014
although still below the 2012 figure. The proportion increased in RSUD Umbu Rara Meha, and RSUD
Ruteng, with both achieving the target of 10% coverage.
However, the proportion in RSUD Kefa
decreased compared to the previous period, although similar to the same period in 2014 (Table 49).
Table 49.
Districts
Group 2 Obstetric referrals as a percentage of estimated district deliveries
Case Fatality Rate (CFR)
Hospitals
TTU
RSUD Kefa
Manggarai RSUD Ruteng
Sumba
RSUD Umbu
Timur
Rara Meha
Total Group 2
Jul-Dec 2012
Jan-Jun 2013
Jul-Dec 2013
Jan-Jun 2015
24.4%
17.3%
8.5%
19.2%
18.4%
5.7%
22.8%
13.1%
3.0%
8.9%
12.0%
4.0%
16.0%
12.5%
3.4%
9.2%
13.7%
13.5%
16.6%
15.4%
13.0%
9.6%
11.2%
12.5%
5. Caesarean Section
There is an increase in reported Caesarean Sections from all three hospitals, both as a proportion of inhospital deliveries and as a proportion of estimated district deliveries (CS-rate). All three hospitals have
achieved the target of CS-rate between 5-15%, suggesting that access and use of emergency obstetric
services has improved. RSUD Kefa has recently developed a collaboration with Brawidjaya Medical
Faculty for resident doctors on rotation, thus enabling a significant increase in CS-rate (Table 50).
Table 50.
Group 2 Caesarean sections total and as % of estimated catchment deliveries
% in-hospital deliveries by Caesarean section
Caesarean section as % of estimated district
deliveries
Districts Hospitals
2013
2013
2014
2014
2015
2012
2013
2013
2014
2014
June
2015
TTU
RSUD Kefa
Manggara RSUD
i
Ruteng
Sumba RSUD Umbu
Timur
Rara Meha
Total Group 2
13.2%
32.3%
12.9%
29.4%
17.0%
32.3%
10.2%
25.4%
6.5%
32.5%
37.9%
28.7%
2.3%
5.6%
2.2%
6.3%
3.1%
6.2%
1.6%
5.0%
0.8%
8.2%
6.1%
8.2%
27.1%
32.5%
23.7%
26.9%
21.4%
32.0%
3.2%
4.5%
3.1%
3.3%
3.1%
5.6%
28.3%
29.1%
31.1%
32.8%
26.2%
31.0%
4.2%
4.9%
4.6%
4.0%
5.1%
7.1%
Neonatal Health Indicators
1. In hospital neonatal mortality
In Group 2 hospitals, overall neonatal mortality has declined below the 2012 figure, after increasing in
2013. Sumba Timur (RSUD Umbu Rara Meha) reduced mortality by a half in this period. RSUD Kefa
also has a significant reduction and only RSUD Ruteng has a slight increase in neonatal mortality
(Table 51).
94
Table 51.
Districts
Group 2 in-hospital neonatal mortality
Neonatal deaths as % of neonates in-hospital
Hospitals
TTU
RSUD Kefa
Mangga-rai RSUD Ruteng
Sumba
RSUD Umbu
Timur
Rara Meha
Total Group 2
Jul-Dec 2012
Jan-Jun 2013
Jul-Dec 2013
Jan-Jun 2015
11.6%
3.3%
4.3%
6.7%
3.7%
5.3%
9.2%
5.1%
8.6%
12.7%
4.0%
11.2%
12.3%
3.5%
8.8%
6.4%
3.7%
4.0%
4.3%
4.4%
6.7%
6.3%
5.1%
4.2%
2. Neonatal Complications and CFR
The number of neonatal complications treated in these three hospitals has increased, both as a
percentage of total hospital neonates and as a percentage of estimated complications arising from
district deliveries.
Similar to RSUD Ende, RSUD Kefa also records more than one complication
occurring in the same neonate, thus resulting in much higher numbers of neonatal complications treated
(Table 52).
Table 52.
Group 2 Neonatal complications treated in hospitals
Neonatal complications treated as % of total hospital Neonatal complications treated as % of estimated
neonates
district complications
Districts Hospitals
2013
2013
2014
2014
2015
2012
2013
2013
2014
2014
June
2015
TTU
RSUD Kefa
Manggara RSUD
i
Ruteng
Sumba RSUD Umbu
Timur
Rara Meha
Total Group 2
98.8%
11.0%
75.6%
52.1%
100.7% 72.0%
20.9% 12.1%
94.7%
13.4%
97.8%
14.4%
37.5%
13.7%
37.6%
78.0%
65.3%
25.2%
45.5%
16.3%
36.1%
22.1%
70.1%
23.6%
34.1%
35.4%
23.6%
24.4%
31.1%
26.8%
29.2%
37.5%
22.2%
21.2%
22.4%
33.9%
24.6%
50.6%
34.7%
21.3%
23.4%
29.0%
23.2%
58.5%
34.4%
23.4%
25.8%
38.1%
The Neonatal Case Fatality Rate has continued to decrease since 2014, achieving 14.4% in this period
for the group as a whole. Significant decreases occurred in RSUD Kefa and RSUD Umbu Rara Meha,
but only RSUD Kefa has a CFR <10% (Table 53).
Table 53.
Districts
Group 2 Neonatal Case Fatality Rate – neonatal complications
Hospitals
TTU
RSUD Kefa
Sumba
RSUD Umbu
Timur
Rara Meha
Total Group 2
Case Fatality Rate (CFR) for neonatal complications
Jul-Dec 2012
Jan-Jun 2013
Jul-Dec 2013
Jan-Jun 2015
11.8%
29.9%
12.6%
8.8%
7.0%
15.1%
9.2%
24.3%
36.4%
17.6%
33.3%
46.0%
13.0%
25.9%
28.3%
6.7%
25.7%
15.1%
17.5%
8.6%
19.2%
29.7%
21.7%
14.4%
3. Neonatal Referrals
In this period, the referral rates for neonates are similar to Group1 with levels of between 1 and 2%
estimated catchment live births. This reflects that most referrals occur in utero, and the hospital only
records neonates born outside of the hospital and referred to hospital as ‘referral cases’.
Table 54.
Districts
Group 2 Neonatal referrals as a % of estimated district live births
Hospitals
TTU
RSUD Kefa
Sumba
RSUD Umbu
Timur
Rara Meha
Total Group 2
Neonatal referrals as % of estimated district live births
Jul-Dec 2012
Jan-Jun 2013
Jul-Dec 2013
Jan-Jun 2015
2.3%
1.2%
1.8%
1.9%
1.4%
2.1%
1.9%
1.1%
1.7%
2.3%
0.7%
2.8%
1.7%
0.8%
2.2%
1.8%
0.7%
1.9%
1.6%
1.7%
1.4%
1.5%
1.4%
1.2%
95
Summary
In this period, Group 1 hospitals reported a significant increase in maternal mortality, and consequent
increase in maternal CFR. Only 1 of the Group 2 hospitals reported maternal deaths. Three of the five
Group 1 hospitals reporting increased maternal mortality also reported large increases in the number of
hospital deliveries, obstetric complications treated and Caesarean Sections conducted. However, two
hospitals, Soe and Larantuka reported reductions in complications; and Soe and Ende also reported
reductions in the proportion of caesarean sections. Maternal referral has also increased to more than
10% of estimated district deliveries. Starting in 2014, almost all Group1 hospitals already have their
local SpOG working in the hospitals except RSUD Ekapata (Sumba Barat). This results in a single
specialist doctor rather than a rotating team providing specialist services and could lead to work
overloads and subsequent reduction in quality of care.
However, it is not an explanation for the
increased mortality in Soe, which occurred despite reductions in deliveries and complications managed,
and was accompanied by a reduction in caesarean sections conducted.
RSUD Ruteng and RSUD Umbu Rara Meha (Sumba Timur) also have local SpOG working in the
hospitals, but they continue to receive support from their partnering hospitals in sending residents
Obgyn using APBD funds. Thus, even though these hospitals also have increased hospital deliveries,
complications treated and high numbers of Caesarean Sections, they still manage to have lower
maternal mortality and CFR (less than 1%) compared to the Group1 hospitals. This condition supports
the above assumption that persistently high workloads could compromise quality of care.
Neonatal care, on the contrary, has improved in both groups. Despite increases in the number of
neonates treated in hospital, and in the number of complications managed, the neonatal mortality and
CFR has decreased in both groups of hospitals. Only 3 hospitals (Kefa, Lembata and Waikabubak)
already have a local Paediatrician. Comprehensive emergency neonatal care can also be provided by
the PONEK team and trained nurses; thus providing support for the Paediatric units to deliver quality
neonatal care, which has resulted in the decrease of neonatal mortality and neonatal CFR.
C. External Monitoring Results:
An external monitoring evaluation conducted in April 2015 monitored specific aspects of clinical and
managerial performance. Qualitative aspects were excluded, based on the assumption that not much
has changed in the 5 months since the last evaluation in November 2014.
1. Clinical monitoring of results in obstetric and neonatal care
In this period, the Kupang Obstetrician and Gynaecologist Association (POGI) and Kupang Paediatric
Specialists Association (IDAI) conducted clinical monitoring both in obstetric and neonatal care. Thus,
the NTT team is ready to take over monitoring clinical aspects of Sister Hospital.
Obstetric Care
As in the previous periods, clinical aspects were evaluated using the National PONEK standards, which
consist of standards for input, management and hospital performance in maternal and perinatal care.
Six hospitals have been categorized as good in input standard (score >75%), except Larantuka and
Waikabubak which are categorized as moderate (score 73% and 69%). Lewoleba has improved its
input standard to 76% (in the latest monitoring on Nov 2014 it was categorized as poor / score 47%).
In terms of management standards, four hospitals (Ende, Bajawa, Waingapu & Ruteng) have been
categorized as good performance (score >75%), and the other five hospitals were categorized as
moderate performance. The two hospitals (Kefa and Larantuka) which were categorized as poor in the
previous monitoring in November 2014, have managed to improve their management standards and
scored more than 60%.
96
Assessment of hospital performance in maternal perinatal care for the three components of input,
process and output was conducted. Assessment results was scored and categorized as good (score
>27), moderate (score between 21-26), and poor (score <21). Seven hospitals (Ende, Ruteng, Bajawa,
Waikabubak, Larantuka, Soe and Kefa) were categorized as having a moderate performance, one
hospital (Waingapu) had a good performance (score = 27), and one hospital (Lewoleba) had a poor
performance with score = 19.
To improve clinical care, the monitoring team suggested establishment of a ‘PONEK corner’ in the
emergency department, designated specific room for preeclampsia/ eclampsia, standardized hand
washing and infection precaution area, ensure proper storage of emergency drugs and maintenance of
equipment, and improve recording and reporting.
Neonatal Care
Neonatal care was evaluated using the National PONEK standards, consisting of management
performance and clinical performance.
The management performance includes input and process
assessment. Clinical performance was done using a checklist, to measure compliance to specific
clinical procedures, retrospectively or concurrently.
Assessment of the standards for inputs for neonatal care showed that all district hospitals had high
scores of more than 70%, with Waingapu having the highest score (93%), followed by Bajawa (91%),
Ende (89%) and Ruteng (84%). Only two hospitals (Soe and Waikabubak) have lower scores than the
previous period, although still above 70%.
Assessment of the standards for process show that only Ende and Bajawa have scores of more than
70%, and Waikabubak still has the lowest score due to the absence of both maintenance and quality
management (scored 30%).
Clinical performance assessment was done concurrently and retrospectively.
In concurrent
assessment, Ende, Bajawa, and Lewoleba had higher scores than the previous period (> 80%), and
Soe had the lowest score <50%. In retrospective assessment, 4 hospitals (Ende, Bajawa, Ruteng,
Waikabubak) have higher score than before (>80%) but Lewoleba and Waingapu have the lowest score
(60%).
Clinical monitoring also identified the three major causes of neonatal death were; Low Birth Weight,
Asphyxia and Sepsis.
Follow up suggested by the clinical team include; improve clinical services through infection control
programs, transfer of knowledge, capacity building, maintenance of equipment, improved referral
system and quality of clinical audits (AMP).
2. Management Monitoring Results
In this period, The Provincial Health Office and P2K3 FK UNDANA conducted field monitoring and
evaluation of managerial aspects on their own, with the role of PKMK FK UGM mainly in the preparation
(if monitoring forms needed to be revised) and the reporting process. Overall, there was improvement
in managerial aspects compared to the previous period; however, some issues still need to be
considered, namely:
•
In terms of facility, equipment and drugs: not all hospitals have specific rooms designated as
PONEK, some equipment has not been utilized, and not all hospitals had electro medical staff
which resulted in inability to repair equipment and health staff cannot work optimally.
•
Not all hospitals had blood bank, ambulance and accommodation for women awaiting delivery;
lack of transport and waiting accommodation had caused late referral in some cases.
97
•
Implementation of Clinical pathway and quality improvement need strong back up from hospital
directors, currently only 11% clinical pathway and 27% quality improvement program had been
implemented across the hospitals.
•
Capacity building activities had been conducted in hospitals (82%), involving also Puskesmas staff.
Bedside teaching, on-the-job training and distance learning through teleconference were mostly
used in this period.
•
Most hospitals have reviewed their standard procedures; however, compliance to the standard
procedure was still low and needed close monitoring.
•
Finance administration: almost all district hospitals except Lewoleba paid incentives on time to the
partnering hospitals. All district hospitals have provided housing and vehicles to the partnering
hospital's team.
•
CEONC Management: most hospitals have 1 functioning PONEK team, only Larantuka currently
did not have a complete team (no doctor) and Waikabubak just has a new PONEK team replacing
the previous one from which most of the members had already been transferred.
•
Performance of CEONC management: CEONC teams have managed to work 24/7 through
appropriate rostering of nurses and midwives, although the residents are still on call. The response
time in emergency department is between 5-15 minutes, while response time in Caesarean Section
is 30-60 minutes. The long response time in CS is usually due to the long decision making process
made by the family.
•
Sustainability: advocacy to relevant stakeholders has been conducted by all district hospitals,
informally and formally through Musrenbang or other inter-sectoral meeting forums.
This has
resulted in budget allocations for the Sister Hospital program in district APBD 2015
Suggestions to improve managerial aspects are: improving and managing infra-structure in hospitals,
monitoring and maintenance of electro medic equipment, develop and implement clinical pathways,
develop evaluation plan for QI program and compliance to SOP and drug formulary, and improving
coordination with other sectors to ensure implementation of AMP' recommendation.
3. Qualitative monitoring results
As in the previous periods, the external consultant of PKMK FK UGM conducted monitoring of the
qualitative aspects. The methods used were interview and focus group discussion (FGD). Summary
results are as follows:
•
Referral manual has been implemented except for referral from neighbouring districts.
•
PONEK corner was built as recommended in the previous monitoring evaluation results.
•
Many items of medical equipment had broken, but hospitals did not have electromedic staff to
repair the equipment
•
In terms of working culture: (1) use of finger printing to document arrival and departure from work,
and cutting salary for absences, can discipline the staff, (2) need to refresh knowledge or skills in
teamwork by outbound team exercises, (3) the lack of transparency on the division and allocation of
medical service/ capitation fees among staff, because no direction (SK) has been issued by the
bupati's office, could decrease staff's working ethos, and (4) there is still no clear system for
determining levels of remuneration, but hospitals continue to use the point or percentage system.
•
In terms of exit strategy: (1) most RSUD will continue the clinical contracting with their partnering
hospitals until the trainee specialists have finished their training and returned to work in their
districts of origin, (2) independent monitoring and evaluation was considered high cost and of
limited value.
•
Skills of hospital directors had improved, especially in advocacy and communication with
stakeholders, resulting in increases in approved budget.
98
•
The workload on specialists returning to the hospitals after training is high, preventing them from
having time to conduct capacity building; clearer task distribution can minimize conflicts between
specialists and existing general doctors, and in some hospitals there was still discussion on
whether the PONEK team should be dismissed or continue functioning.
•
According to some hospitals, BPJS administration system is difficult; and also the reimbursement of
claims is usually late, thus the medical service fee is not paid on time.
•
RSUD Atambua & T.C. Hillers Maumere, two hospitals that ceased involvement in the sister
hospital program since 2014, state that they currently face difficulties in finding equipment and
training needed without the support of the partnering hospitals
•
Conclusion: (1) all community elements have felt the benefit of the sister hospital program, (2)
hospital managers and staff show improvement in their confidence, skills, discipline, and
communication skills, (3) BPJS has contributed to the late distribution of medical service fees, (4)
the number of candidate specialist doctors has increased, (5) districts want to continue the sister
hospital program until RSUD have all needed specialists.
•
Recommendation from the monitoring evaluation team: (1) district government need to support
hospital to improve or at least maintain what has been achieved to date, (2) need to find a solution
to distribute the medical service fees on time to improve the working ethos, (3) continuous capacity
building is still needed even after the sister hospital program has ceased, (4) collaboration between
hospital directors and the stakeholders has to be continued and strengthened.
D. Training of local Specialists
In the beginning of the Sister Hospital program, districts allocated scholarships for training local
specialists especially to provide PONEK services.
However, along with the development of
collaboration with the partnering hospitals, most districts have broadened the scope of scholarships
involving other area of specialties such as surgery, internist, radiologist and clinical pathologist. By
having four basic specialties (SpOG, SpA, surgery, and internist) hospitals can apply for registration as
a class C hospital.
Currently, there are 39 local doctors who are undertaking specialist training at several medical faculties
and most of them will return to the district hospitals by 2018. 31 specialists, of which 10 specialists are
related to PONEK services (7 SpOG and 3 SpA), are working in the 9 district hospitals.
However, it seems that the returning specialists need strong support so they can provide quality
CEONC service in district hospitals. Therefore the sister hospital program could be further developed
to address this issue and to come up with possible solutions.
E. Exit strategy and sustainability
As stated in the previous report, the local government has allocated budgets to support the funding of
sister hospital activities especially to continue providing specialists for CEONC services.
Since
AIPMNH will cease in December 2015, all costs related to mobilization and fee for residents has been
funded through local APBD since March 2015. Funding from AIPMNH was mainly for monitoring and
clinical supervisory visits, certain capacity building activities focused on improving service quality and
some activities for strengthening implementation of BLUD.
99
F. Constraints and challenges
In this period, key issues identified include the following:
1) The transition from rotating teams of specialists from the mitra A, to the return of the local specialist,
and resumption of responsibility for specialist functions by the local specialist. This is particularly an
issue for the SpOG, who becomes the sole specialist on call 24 hours a day for all obstetric
emergencies. This has resulted in delays in emergency surgery, and potentially contributed to a
rise in in-hospital maternal mortality. In some cases, there are general doctors who have been
trained to undertake surgery, but the newly qualified SpOG has been reluctant to delegate
responsibility to the general doctors. Where the local government have recognized the need for
continuing support from rotating teams of residents from the mitra A hospital, hospital mortality
rates have been lower (eg Ruteng, Waingapu).
2) The relatively low reimbursement rates for procedures undertaken in C-class hospitals under the
BPJS scheme compromises the financial viability of hospitals in NTT. Almost all hospitals in NTT
still have C-class status (except the NTT Provincial Hospital), and therefore reimbursement is
based on the lowest package of INA-CBG, with no consideration of actual costs. In hospitals that
have no specialists and where care has is provided by general doctors, BPJS reimbursement will
be even lower. This condition, if it continues, will force the hospitals to cut costs and potentially
compromise the quality of service.
3) Persistent issues with the recording and reporting of data on maternal and neonatal cases,
particularly the identification of complications, which results in high levels of variability between
hospitals, or within the same hospital over different time periods, and difficulties in interpreting case
fatality rates (which are based on complications).
4) Problems with infrastructure and maintenance of equipment, with some equipment requiring repair
remaining idle due to lack of budget for maintenance.
5) Shortages or stock-outs of essential supplies and drugs that affect quality of care.
6) Issues with some local governments accepting their ongoing financial responsibilities for hospitals
that attain BLUD status. As noted above BPJS reimbursements cannot cover all the costs of
hospitals, and allocation of budgets from local government is still required. However, some local
governments regard the BLUD status as no longer requiring budget support. .
7) Sustainability of external Monev and willingness of local government to cover costs. The regular
monitoring visits by teams of external specialists are important to assess and maintain quality of
care and performance. They have been funded by AIPMNH up to now, but ongoing funding by
district or provincial governments is yet to be secured.
8) Maintaining capacity of PONED /non-PONED Puskesmas to provide basic emergency care and
stabilize before referral. Failure to provide initial stabilization will result in patients arriving at the
district hospital in poor condition, and compromise efforts to save lives.
However, transfer of
trained PONED staff, particularly doctors has resulted in loss of PONED capacity in some
previously trained Puskesmas.
G. Recommendations and Future Actions
The AIPMNH program will finish in December 2015, but all SH activities will cease in October 2015.
Focus of support will be to facilitate the hospitals to address the identified constraints so quality PONEK
100
services can be provided and contribute to the reduction of maternal and neonatal mortality. These
include:
1) Develop PONEK teams in district hospitals, equipping the existing general doctors for this purpose
through specific training needed and providing them with clinical privileges in task shifting.
2) Facilitate district hospitals in NTT to calculate actual unit costs for medical services, as a basis for
further discussion and negotiation of the BPJS scheme at national level and advocacy to increase
reimbursement rates.
3) Improving reporting and recording systems in hospitals and Puskesmas, and strengthening district’s
AMP teams capacity to make use of the MNH data for the audit process.
4) PHO to take a more active role in oversight and building collaboration with professional
organizations and or universities to provide external monev for the SH program to ensure the
quality of PONEK services. The PHO to contribute to funding of external MONEV e.g. though
Dekon
5) RSUD should maintain the relationship with the partnering hospitals to ensure continuity of capacity
building and ongoing support where needed for clinical capacity gaps.
6) RSUD to ensure budget allocation for maintenance of infrastructure and equipment, as well as for
continuous availability of essential drugs and supplies.
7) Strengthen collaboration between DHO and RSUD for providing regular on-the-job training
(magang) for Puskesmas midwives and nurses to maintain knowledge and skills of basic
emergency care (PONED).
8) For districts without hospitals, there is a need to develop referral collaboration with neighbouring
districts in clinical and managerial aspects including funding mechanisms.
DFAT to consider providing funding to ensure collection and compilation of the data for the final six
month period of 2015 (July to December) to enable assessment of whether the increases in maternal
mortality noted in this period persist throughout the year. Data will only be available in early 2016, after
completion of the current program.
101
ANNEX 4.
Sister Hospital by year of intervention
102
Table 55.
Sister hospital partners and RSUD by year of intervention
st
As from 1 July 2014 the RSUD in Sikka and Belu left the program as these Districts were amongst the four that were graduated.
District
Name of
District
Name of
Partner or
Hospital
Sister
TTS
RSU D Soe
RSU D Dr.
Soetomo (1
Sumba
Barat
RSU D
Ekapata,
RSU P
Sanglah ( 9
Waikabubak
Ags - 8 Feb)
RSU D
Bajaw a
RS Bethesda,
Yogy akarta
Group
2011
7
8
9
10
11
2012
12
1
2
3
4
5
6
7
8
9
10
11
Jan – June
2014
2013
12
1
2
3
4
5
6
7
8
9
10
11
July – Dec
2014
Jan-June
2015
July-Dec
2015
12
Ags -31 Jan)
N gada *
(16 Ags - 15
Feb)
RSU D
Bajaw a
RSU P
Sardjito,
Yogy akarta
Ende
RSU D Ende
Group 1
RS Panti
Rapih,
Yogy akarta (1
Sept - 28
Feb)
Flores Timur RSU D
Larantuka
RSU P
Wahidin
Soedirohusod
o (19 Jul- 18
Jan)
Larantuka
Saiful Anw ar
(from1st Jan
RSU D
Lew oleba
RSU D Saiful
Anw ar ( 1
2015)
Lembata
Sept - 28
Feb)
TTU
RSAB
H arapan Kita
Kefa
Saiful Anw ar
Belu
RSU D
Atambua
RSU D Saiful
Anw ar
Sumba
Timur
RSU D U mbu RSU P
Rara Meha,
Kariadi
Group 2
*
RSU D Kefa
Waingapu
Manggarai
RSU D
Ruteng
RSU P C ipto
Mangunkusu
mo
Sikka
RSU D TC
RSU D Dr.
H illers,
Maumere
Soetomo
untuk Ngada, RS Mitra berganti dari Bethesda ke Sardjito.
periode dimana kontrak tahap pertama (6 bln) berakhir dan sebelum kontrak tahap 2 (periode Jul11-Jun12) dimulai, dalam tahap ini kegiatan pengiriman
spesialis masih dilaksanakan dengan bridging fund (mekanisme TOR) sehingga pelaporan data tidak berkesinambungan.
tidak ada pengiriman spesialis (program berhenti sementara)
103
ANNEX 5.
Partnership with Religious Organisations
104
OVERVIEW OF AIPMNH PARTNERSHIP WITH RELIGIOUS ORGANISATIONS
BACKGROUND
Religious leaders are role models for the communities that they live in and are potentially very
influential in changing attitudes and behaviours in their communities including improving maternal and
neonatal health. In many areas in NTT, they have greater influence and reach than that of either the
health services or other government agencies.
CHRONOLOGY
In 2011, AIPMNH in collaboration with the District BPMPD of Ngada and Ende invited the Catholic
1
Vicariates in 2011 to discuss improving community participation and awareness in the area of
maternal and neonatal health. The invitation was well received by the Church as it aligned with the
church’s focus on marginalised and poor people. Seven Catholic Parishes in Ngada district were then
established as Paroki Siaga (Alert Parish). Two important and influential people behind this initiative
were Fr. Sil Betu, Pr (Laja Parish) and Fr. Fery Dhae, Pr (from the Pastoral Centre of the Ende
Archdiocese).
Establishment of Paroki Siaga was followed by development of community guidelines by the Health
and Pastoral Commissions of both Vicariates. These were developed in collaboration with BPMPD,
and took the form of Modul Panduan Katekese Paroki Siaga (The Catechism Modules – a Guide for
Alert Parish). These modules are now formally integrated into the policy and approach of the
Archdiocese of Ende.
The Paroki Siaga initiative and the development of the modules become the model for collaborating
with other religious organisations in NTT.
Internal discussions in AIPMNH continued as to an effective approach to wider involvement with
religious organisations in order to extend the reach of MNH programs. This included a visit to a local
church in early 2013, for what was effectively a Focus Group Discussion, and from this it was realised;
the depth of lack of knowledge, the very strong desire for evidence based information, and the strong
aspirations by the church leaders to provide practical help to their congregations.
In August 2014, an AIPMNH team member negotiated involvement in a large meeting (Konven
Pendeta) of the Evangelical Church in Timor (GMIT) in TTS district. As part of this meeting, AIPMNH
technical advisers presented on the current MNH situation, issues and potential solutions.
Resolutions from this meeting included initiating activities to improve maternal and neonatal health
and reduce the high maternal and neonatal mortality rates in the district. The TTS initiative was then
brought to the Synod Meeting by the Rev. Imanuel Sinae, S.Th and the Rev. Bernadetha Tafui
Tapatab, S.Th. The Synod in turn resolved to address MNH issues through their church and this
included the need to develop sound information for the pastors in the form of a book.
Development of the book was very much led by the Church and took over six months to finalise
(September 2014 to March 2015). Development also involved the AIPMNH technical advisers to
ensure inclusion of both sound and up to date information. The book is titled Buku Katekisasi
Pranikah Membangun Generasi Kristen Sehat dan Cerdas Melalui 1000 Hari Kehidupan (Pre-Marital
1 A form of territorial jurisdiction of the Roman Catholic Church, headed by a Vicar (priest) and under the authority of an Archbishop.
105
Catechism to Develop a Healthy and Intelligent Christian Generation in First 1000 Days after birth).
The book is available on the Indonesian side of the website www.aipmnh.org
Apart from book, the church is implementing a variety of other activities to support improved MNH.
Other churches in NTT commenced to replicate the GMIT approach and as at September 2015, also
includes other faiths; Muslim and Hindu.
METHODOLOGY
The development of activities in collaboration with religious leaders is both sustainable and efficient.
As an overriding approach, it is more effective to work through energetic and innovative local religious
leaders rather than directly through the ‘hierarchy’. It is then, these local religious leaders, which bring
the initiative to the hierarchy.
Step I: Workshop I – MNH current situation, issues and solutions.
Workshops are attended by religious leaders and incorporate a final session where recommendations
and plans for further action are developed.
Step II: Identification and Supervision
This workshop to identifies religious leaders who can be ‘pioneers’ and are willing to work and
implement MNH activities in their areas. They need to be energetic and prepared to be innovative.
Step III: Sharing and Publication
Supervising and facilitating the sharing process as well as publicising the services.
Step IV: Institutionalisation
MNH activities and initiatives are institutionalised into the religious organisations structure and
policies..
Summary of Activities
Year
District
Activities
Results
2011
Ngada, Ende
Agreement to support MNH. The Archdiocese of Ende establishes
seven alert parishes/ paroki siaga.
Catechism Modules for Paroki Siaga printed
February 2013
Sumba, Flores,
Timor
Workshop For Religious
Leaders on MNH, presented
by BPMPD and the Health
Office
Workshop for Religious
Leaders for the regions of
Flores, Sumba and Timor
with Paroki Siaga approach.
Catechism modules of paroki
siaga as a model.
2013 - 2014
MaBar,
Manggarai,
Ngada, Ende,
Sikka, Flores
Timur, Lembata,
Kabupaten
Kupang, TTS,
TTU, Belu,
Sumba Timur,
Sumba Barat.
District-level coordinating
meeting, District-level
monitoring and evaluation.
Religious leaders agreed to support MNH program.
Since 2013, there have been many activities implemented by
religious leaders such as collecting MNH-related data, assisting
pregnant women, providing support for pregnant women to give
birth at the health facility, supporting Posyandu activities, special
prayers devoted to pregnant women in the Mass, advising the
couples to participate in FP, taking part as desa siaga personnel,
BPKM’s personnel, including MCH as the church’s official program
(catholic and protestant).
Activities are more varied and based on the local situation and
needs.
Collecting data, assisting pregnant women, providing support for
pregnant women to give birth at the health facility, supporting
Posyandu activities, special prayers devoted to pregnant women in
the Mass, advising couples to participate in FP, taking part as desa
siaga personnel, BPKM’s personnel, including MCH as the church’s
official program (catholic and protestant).
Religious leaders ensure the availability of blood-supplies through
KRDD or the volunteer blood donor groups.
Keuskupan Ruteng : Surat Komisi Keluarga Keuskupan Ruteng
tentang Gerakan Peduli Kesehatan Ibu dan Bayi Baru Lahir
(KIBBLA) melalui Penyediaan Rumah Tunggu Persalinan Berbasis
Komunitas Basis Gerejawi (KBG) di Keuskupan Ruteng (Waiting
106
Year
2015
District
Province,
Mabar,
Manggarai,
Sumba Timur
Activities
Preparing guidelines for
religious leaders’
involvement in supporting
MNH.
Results
Houses for pregnant women)
Modul KIBBLA, HIV/AIDS dan Gender sebagai Gerakan untuk
Menyelamatkan Ibu Hamil dan Ibu Melahirkan (Movement for safe
Pregnant Women and Children)
Catholic Church (The Archdiocese of Ende): Catechism Modules the first 1000 days of the newborn as the basis.
Protestant Church (GMIT): Pre-Marital Modules – Developing
Healthy and Smart Christian Generation with the first 1000 days of
the newborn as the basis.
Muslim (MUI): Counselling books for pre-marital course – the first
1000 days of the newborn.
Hindu (PHDI): Family guide to develop excellent generation in the
first 1000 days after birth.
Catholic Church of Manggarai Barat Vicariate: Pocket Family Book
on MNH Sumba Timur: Compilation of Homilies on MNH – Christian
Church in Sumba / GKS.
107
ANNEX 6.
DFAT Feedback 12th Progress Report
108
AIPMNH Progress Report July-December 2014
Attachment – Feedback
Overall comments
The progress report of July-December 2014 overall is well written and accommodates DFAT’s
previous feedback. DFAT values the extra detail and comprehensive information provided in the
report, but some parts are too lengthy.
Noting that DFAT recently has released a new format of Investment Development Reports (IDR) such
as Aid Quality Check (ADR) and Aggregate Development Results (ADR), the next progress report
should align with those reporting requirements.
DFAT requests a presentation on any future PRs or whatever milestone document we agree for the
next extension.
Assessment & Rating
The Performance and Quality section of DFAT Jakarta requires all progress reports to be assessed
against the criteria below. DFAT applies ratings of either ‘Met’ ‘Partially Met’ or ‘Not Met’.
No
Feature of progress report
AusAID
Rating
AusAID Feedback
AIPMNH Response
3.1
There is an executive
summary that
communicates the key
information required for
QAI reporting
Partially met
Executive Summary kept as short
and concise as possible in 13th
Report.
Cross Cutting Issues retained but
Innovation and Private Sector
included in Exec Summary (as
exisiting cross cutting topics not
appropriate under heading of
Innovation and Private Sector)
3.2
The relevant aspects of
the context are adequately
described
There is a reflection on
the continuing relevance
of the expected end-ofprogram outcomes
An assessment of the
adequacy of progress
toward sustained end-ofprogram outcome is
described
Met
The executive summary provided most of
required indicators for Investment
Development Report (IDR)/AQC and
concluded from all activities that related to
the components. However need some
improvement on some parts:
The main area that needs to be
strengthened is to shorten the executive
summary and should come up with
different narrative with previous report
(but same structure). eg. On relevance
and purpose – noted that it’s similar with
as previous report.
For the next reporting - On Cross cutting
issues, it would be good if we can change
the heading to Innovation and Private
Sector, in line with new reporting
requirements for the AQCs
On the progress, it should be describe in
the dot points (matrix of changes before
and after). Currently the information
scattered and is not focus.
The report covers all context, though
some description need to be shortened
The quality, reach and
Partially met
3.3
3.4
3.5
Met
Yes, we think this is clear in the report.
Met
The report showed the progress of
analysing the comparison of non-AIP
district data. The report has identified
problem and challenges which includes
the concrete future actions are required to
take.
The next report should provide analysis
relating innovation and private sector.
The report presented so many data but
Kept as concise as possible.
Included in 13th Report
The main AIPMNH indicators do not
109
No
AusAID
Rating
coverage of key outputs or
deliverables for the
reporting period are
described
AusAID Feedback
AIPMNH Response
limited information on quality of the output
explicitly contain information on
quality. However, there is extensive
reporting on quality in sections of
Annex 1 and in the SH Annex. A
number of the studies completed
also report on quality.
Due to the currently observed
reversal of achievements, a short
survey is currently being conducted
in an attempt to better understand
the reasons for this.
3.6
The adequacy of progress
implementing the annual
plan is described
Partially met
3.7
An assessment of the
likely adequacy of planned
inputs to meet the
expected end-of-program
outcomes is provided
Met
3.8
The adequacy of progress
against budget is
assessed
Met
3.9
The efficiency and
effectiveness of key
management or
implementation systems is
assessed or demonstrated
Partially met
3.10
The report provides
balanced and fair
reporting of positive and
negative issues,
achievements and
challenges
For claims of achievement
or barriers to
achievement, credible
supportive evidence is
provided
Data or findings are
presented in formats that
effectively and efficiently
communicate important
information
Met
As mentioned in the previous PR
feedback, the report has not been
providing analysis how the program dealt
with the decreased numbers of activities
for the transition year (eg. advocacy and
coordination with local government
towards end of program). It would be
good if there is some comparison analysis
between before and after transition
phase.
The report provides a well-supported
argument to the progress of
implementation. For example, in the
report has described how the program
anticipate issues and challenges and
solution has taken (Annex 2)
The budget breakdown and work plan
expenditure for district and province level
is provided. However, from my last
participation in DPCs meeting, I reckoned
some activities were having difficulties to
absorb the budget (eg. BCC activities). It
would be good if the report covers some
challenges on budget absorption.
As mentioned in the previous PR
feedback, this report hasn’t provided
analysis of mentor in each district. Based
on mini PCC in Denpasar, we agreed that
the quantity of mentor of each district
remains the same. This issue should be
reflected in this report.
Met
Met
Data and findings are presented
effectively though need more analysis
how the program could communicate
effectively eg. Presenting to Government
on progress of the program; National level
engagement
3.13
The frequency of reporting
is suitable for effective
initiative management
Met
3.14
The report includes
Met
The six-monthly progress report is
suitable for effective monitoring
documentation and supporting document
for DFAT’s report. Although, the program
always stand by for any ad hoc requested
relating information and data.
The report has provided lessons learn
3.11
3.12
The issue of absorption of the BCC
activities was resolved.
For this reporting period there has
been just one Mentor in each
Districts, although some districts
have directly contracted ex-mentors
Booklets on each of the major
activities have now been produced
and widely distributed at events and
meetings as well as being available
on the web-site. As per Table 4 in
this report there has been very
extensive participation in and
presentation at numerous national
level meetings and events.
110
No
3.15
lessons learn from
implementation that have
potentially important
implications more broadly
Previous and/or proposed
management response or
recommendation are
summarized
AusAID
Rating
Met
AusAID Feedback
AIPMNH Response
from implementation based on
component. This report also included
Sumba Timur analysis as requested in the
previous feedback.
The previous feedback included in this
report and very useful for DFAT
reference.
111
ANNEX 7.
District and Puskesmas by year of Intervention
112
The following tables include 2008, although it should be noted that this was the interim phase with the
st
AIPMNH project officially commencing in 2009. As from July 1 2014 only limited supported was
provided to Sikka, Belu, Kota Kupang and Kabupaten Kupang (these are the four graduated Districts).
Table 56.
Districts by year of intervention 2008 – June 2015
No
District
Years AIP Intervention
1
Ende
2008
2009
2010
2011
2012
2013
2014
2
Sikka
2008
2009
2010
2011
2012
2013
2014
3
Sumba Timur
2008
2009
2010
2011
2012
2013
2014
4
Kota Kupang
2009
2010
2011
2012
2013
2014
5
Lembata
2009
2010
2011
2012
2013
2014
2015
6
Ngada
2009
2010
2011
2012
2013
2014
2015
7
Manggarai
2009
2010
2011
2012
2013
2014
2015
8
Manggarai Barat
2009
2010
2011
2012
2013
2014
2015
9
Sumba Barat
2009
2010
2011
2012
2013
2014
2015
10
Kab. Kupang
2010
2011
2012
2013
2014
11
TTS
2010
2011
2012
2013
2014
2015
12
TTU
2010
2011
2012
2013
2014
2015
13
Bellu
2010
2011
2012
2013
2014
14
Flotim
2010
2011
2012
2013
2014
2015
14
14
14
14
14
10
District AIP
Table 57.
3
9
2015
2015
District Puskesmas by year of intervention 2008 – June2015
The following table with the list of Puskesmas covered by AIPMNH includes only the ten remaining
Districts. In 2012 the total number of Districts in the Province increased to 22 with the splitting of Belu
into a further District, Malaka. It should also be noted that over the AIPMNH time period the Districts
have commissioned additional Puskesmas.
Districts
Ende
Puskesmas
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
24
Sumba
Timur
Nangapanda
Welamosa
Kelimutu
Ndetundora
Riaraja
Detusoko
Maurole
Kotabaru
Wolowaru
Kotaratu
Rukun Lima
Kota Ende
Watuneso
Maukaro
Peibenga
Year of AIPMNH Intervention
2008
2008
2008
2009
2009
2009
2009
2009
2010
2010
2010
2010
2010
2010
2010
2010
2010
2010
2010
2011
2011
2011
2011
2011
2011
2011
2011
2011
2011
2011
2011
2011
2011
2012
2012
2012
2012
2012
2012
2012
2012
2012
2012
2012
2012
2012
2012
2013
2013
2013
2013
2013
2013
2013
2013
2013
2013
2013
2013
2013
2013
2013
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
Total Puskesmas, % Puskesmas AIPMNH Intervention: 63%
1
Kawangu
2008
2009
2010
2011
2012
2013
2014
2015
2
3
4
Mangili
Tanarara
Malahar
2008
2008
2008
2009
2009
2009
2010
2010
2010
2011
2011
2011
2012
2012
2012
2013
2013
2013
2014
2014
2014
2015
2015
2015
113
Districts
Puskesmas
5
6
7
8
9
10
22
Lembata
1
2
3
4
5
9
Manggarai
1
2
3
4
5
6
7
8
9
10
2009
2009
2009
2009
2009
2009
2010
2010
2010
2010
2010
2010
2011
2011
2011
2011
2011
2011
2012
2012
2012
2012
2012
2012
2013
2013
2013
2013
2013
2013
2014
2014
2014
2014
2014
2014
2015
2015
2015
2015
2015
2015
2012
2012
2012
2012
2012
2013
2013
2013
2013
2013
2014
2014
2014
2014
2014
2015
2015
2015
2015
2015
2012
2012
2012
2012
2012
2012
2012
2013
2013
2013
2013
2013
2013
2013
2013
2013
2013
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
Wairiang
Balauring
Loang
Lewoleba
Wulandoni
2009
2009
2009
2010
2010
2010
2010
2010
2011
2011
2011
2011
2011
Wangko
Wae Codi
Waekajong
Narang
Ketang
Watu Alo
Beamese
Bangkakenda
Loce
Dintor
2009
2009
2009
2009
2010
2010
2010
2010
2010
2010
2010
2011
2011
2011
2011
2011
2011
2011
Labuan Bajo
2009
2010
2011
2012
2013
2014
2015
2
3
4
5
6
7
Wae Nakang
Golo Welu
Pacar
Terang
Rekas
Orong
2009
2009
2009
2010
2010
2010
2011
2011
2011
2011
2011
2011
2012
2012
2012
2012
2012
2012
2013
2013
2013
2013
2013
2013
2014
2014
2014
2014
2014
2014
2015
2015
2015
2015
2015
2015
2012
2012
2012
2012
2012
2012
2013
2013
2013
2013
2013
2013
2013
2013
2013
2014
2014
2014
2014
2014
2014
2014
2014
2014
2015
2015
2015
2015
2015
2015
2015
2015
2015
1
2
3
4
5
6
7
8
9
13
Sumba
Barat
2008
2008
2008
1
15
Ngada
21
Manggarai
Barat
Nggoa
Lewa
Rambangaru
Kombapari
Tanaraing
Nggongi
Waepana
Koeloda
Maronggela
Aimere
Watumanu
Riung
Mangulewa
Laja
Inerie
2009
2009
2009
2010
2010
2010
2010
2010
2010
2011
2011
2011
2011
2011
2011
1
Tanarara
2009
2010
2011
2012
2013
2014
2015
2
3
4
5
6
7
8
Lahihuruk
Malata
Puuweri
Kabukarudi
Gaura
Pededewatu
Weekarou
2009
2009
2010
2010
2011
2011
2011
2011
2011
2012
2012
2012
2012
2012
2012
2013
2013
2013
2013
2013
2013
2013
2014
2014
2014
2014
2014
2014
2014
2015
2015
2015
2015
2015
2015
2015
114
Districts
Puskesmas
9
Flores Timur
1
2
3
4
5
6
20
TTS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
33
TTU
1
2
3
4
5
6
7
8
9
10
26
*Data end
2014 for 10
Districts
Waiklibang
Waiwadan
Ritaebang
Boru
Waiwerang
Witihama
2010
2010
2010
2011
2011
2011
2011
2011
2011
2012
2012
2012
2012
2012
2012
2013
2013
2013
2013
2013
2013
2014
2014
2014
2014
2014
2014
2015
2015
2015
2015
2015
2015
2012
2012
2012
2012
2013
2013
2013
2013
2013
2013
2013
2013
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
2012
2012
2012
2012
2012
2012
2013
2013
2013
2013
2013
2013
2013
2014
2014
2014
2014
2014
2014
2014
2014
2014
2014
2015
2015
2015
2015
2015
2015
2015
2015
2015
2015
Oinlasi
Panite
Kapan
Niki-niki
Hoibeti
Kuanfatu
Boking
Kota
Siso
Nule
Oenino
Noemuke
Kualin
Polen
Ayotupas
Kolbano
2010
2010
2010
2011
2011
2011
2011
Noemuti
Wini
Lurasik
Eban
Napan
Oeolo
Manufui
Tublopo
Nunpene
Sasi/Kota
2010
2010
2010
2011
2011
2011
2011
Total Districts
Intervention
(N=21)*
Total
Puskesmas
Intervention
from N=193*
Percentage
Puskesmas
Intervention
3
9
14
14
14
14
10
10
13
43
79
97
100
114
96
96
5%
15%
28%
35%
36%
41%
34%
50%
115
ANNEX 8.
Training Data January – June 2015
116
1.1. Integrated Management
1.1 Normal Delivery Care (APN)
1.1. Basic First Aid for Maternal and Newborn
1.1. Contraceptive Technique Update Family
of Illness of Children
(PPGDON)
Planning (CTU KB)
Under-Five (MTBS)
1.1. Interpersonal /Counselling Communication for Family
Planning (KIPK-KB)
1.1 IUD Kit
KABUPATEN/KOTA
Training
F
On the Job-Training
M
F
Post-Training Evaluation
M
F
M
On-the Job Training
F
Post-training Evaluation
M
F
On-the Job Training
F
M
M
F
M
Training
F
Training
M
F
Training
M
F
Total
F
M
M
F
M
Sumba Timur
0
0
Ende
0
0
Sumba Barat
Manggarai Barat
5
Manggarai
Ngada
0
9
2
16
0
57
19
0
0
Lembata
114
10
0
0
5
0
66
2
35
0
114
10
Flores Timur
0
0
TTS
0
0
TTU
25
0
Province
Total
0
0
55
2
0
0
0
0
0
0
0
0
19
0
0
0
0
0
171
10
0
0
25
0
0
0
245
12
257
95%
1.1 PMCT (Prevention of
Mother to Child
1.1 Integrated ANC / PNC 1.2 PONED Basic Emergency Obstetric Neonatal
Transmission) / VCT
Care/BEONC
(SOP)
1.1 HIV/AIDS
Consellor
1.2 Integrated
PONED/PPGDON/BBLR/
Asfiksia
1.2. PONEK (Comprehensive Emergency Obstetric Neonatal Care/CEONC)
5%
1.3 BCC (Behaviour Change
Coomunication)
1.2. PICU NICU Training
KABUPATEN/KOTA
Training
F
Orintation/ Training
F
M
M
Meetings /Workshop
F
M
Technical Guidance / PostTraining Evaluation
F
M
On-job-Training
F
M
On-job-Training
F
M
Technical Guidance / PostTraining Evaluation
Procedure Standard (SOP)
F
M
F
M
On-job-Training
F
M
Training
F
Media / Orientation
F
M
M
Total
F
M
Sumba Timur
20
0
96
17
116
17
Ende
19
1
156
25
175
26
Sumba Barat
15
18
15
18
12
25
5
68
Manggarai
16
8
16
8
Ngada
64
11
64
11
159
60
Manggarai Barat
43
7
Lembata
17
6
Flores Timur
27
2
TTS
24
6
20
5
131
26
28
15
0
2
TTU
Province
Total
0
0
0
0
97
21
38
2
67
7
94
9
34
2
73
10
73
10
73
10
569
87
38
0
0
38
26
26
38
0
0
38
26
26
0
0
0
0
20
5
873
186
1059
82%
18%
117
1.1 Birth Preparedness 1.2 Management of Asphyxia and Low Birth Weight
KABUPATEN/KOTA
Program (P4K)
(BBLR)
Meetings
F
On the-Job Training
M
1.3. MCH and Family
Planning Promotion
1.2 Sister Hospital Program
F
Post-Training Evaluation
M
F
M
Clinical Management /
Capacity building
Meeting
F
M
F
MONEV
M
F
Meeting
M
F
Sumba Timur
Ende
79
Sumba Barat
6
0
150
1.2. 2H2 / FP Center
18
1.1 MCH Book
Training
M
1.3. Breastfeeding
1.3 Motarlity Reduction
Counsellor (ASI)
Guidelines
Orientation
F
M
F
Training/Refreshing
M
F
78
25
15
114
33
156
101
101
164
6
94
46
52
13
261
124
63
21
265
400
51
12
0
4
0
300
6
463
84
TTS
20
TTU
Province
0
0
0
0
32
20
32
600
871
240
79
18
1455
479
20
1043
12
20
12
43
7
43
7
59
21
297
119
897
485
21
41
26
20
M
35
Lembata
Flores Timur
F
23
59
133
Total
M
25
Ngada
Total
F
23
Manggarai Barat
Manggarai
Meeting/Workshop
M
59
21
94
46
353
149
348
453
55
12
364
297
707
310
364
297
3103
1754
4857
64%
1.3 Development Broadcasting Unit (DBU)
1.3 Mother Friendly
Movement (GSI)
1.3 FP Service
36%
1.4. AMP (Review of Maternal Perinatal Deaths)
KABUPATEN/KOTA
Meetings/Workshop
F
M
Sumba Timur
Training
F
MONEV
M
Meeting
M
F
MONEV
M
F
Meetings
M
F
Meeting/Workshop
F
M
M
MONEV
F
13
14
4
10
23
15
44
31
Manggarai
6
6
9
9
Ngada
4
6
23
24
Lembata
66
20
Flores Timur
13
4
44
27
16
14
19
234
9
138
Ende
Sumba Barat
37
F
28
31
Manggarai Barat
TTS
51
2
34
25
8
TTU
Province
Total
52
59
37
28
0
0
0
0
34
25
0
0
20
32
20
9
35
40
Total
Operational Support
F
M
M
41
F
19
38
10
M
81
61
4
10
67
46
51
38
15
15
81
87
101
30
33
13
46
35
85
41
101
55
9
211
8
116
28
608
17
407
1015
60%
40%
118
1.4 INTERVENTION PACKAGE FOR DESA SIAGA
KABUPATEN/KOTA
Sumba Timur
Ende
Sumba Barat
Manggarai Barat
Orientation
Refreshing Desa Siaga
/Meetings/Workshop
F
M
Facilitators
F
32
56
8
61
20
60
IEC / PERDES
M
F
Formation of Desa Siaga
M
F
13
81
165
91
69
81
Ngada
1
5
Lembata
25
79
Flores Timur
72
48
TTS
20
46
TTU
47
71
28
101
307
631
Total
Self-Assessment Survey &
Technical
Operationalisation
Community Consultation
Guidance/MONEV
F
M
26
F
24
M
25
F
M
F
CE Mentor Meeting
M
F
Total
M
F
64
97
5
Province
Support for
TBA and Kader
70
62
49
Manggarai
M
Partnership for Midwives,
84
4
8
216
351
0
0
70
24
127
144
70
158
100
127
120
187
70
65
156
243
118
172
115
140
110
141
25
79
38
68
110
116
46
130
47
71
84
26
M
373
434
0
0
0
0
0
0
32
109
992
1524
2516
39%
1.4 INTERVENTION PACKAGE FOR REVITALISATION OF POSYANDU
KABUPATEN/KOTA
Sumba Timur
Orientation/Meeting of
Posyandu Working Group
F
M
54
Training
F
1.4 INTERVENTION PACKAGE FOR WAITING HOUSE (RUMAH TUNGGU)
MONEV
M
1.4 BLOOD GROUP
EXAMINATION
F
Meeting
M
F
Operational Support
F
M
M
26
125
Training
F
IEC/Workshop
F
M
M
222
23
MONEV
F
Training
M
F
Total
M
F
80
Manggarai Barat
Manggarai
45
64
M
202
105
Ende
Sumba Barat
61%
2.3 Workload Indicator for 2.3 CLINICAL
Staffing Need (WISN)
INSTRUCTOR (CI/CTS)
297
353
0
0
80
297
8
12
8
12
43
49
88
113
Ngada
10
49
17
23
27
72
Lembata
3
20
4
15
7
35
61
109
Flores Timur
18
TTS
44
27
84
TTU
18
25
36
52
50
19
155
212
9
15
9
15
252
560
Province
Total
54
26
0
0
0
0
74
178
214
370
18
27
0
0
67
0
67
0
67
0
679
1161
1840
37%
63%
119
KABUPATEN/KOTA
1.4 INTERVENTION PACKAGE FOR PUSKESMAS REFORMASI
Operational Support
F
M
Training
F
Sumba Timur
19
7
Ende
54
27
7
7
Manggarai Barat
28
19
Manggarai
29
9
Ngada
10
Lembata
172
Sumba Barat
2.1 SIKDA (Provincial/District Health Information System)
Customer Complaints
Survey
F
M
Workshop/Meeting
F
M
M
2.2 IHPB (Integrated
Health Planning and
Budgeting)
MONEV
F
Meeting
M
F
MONEV / Technical
guidance
F
M
Training/Refreshing
F
M
M
Technical Guidance
F
M
20
19
36
3
Total
F
M
32
4
39
39
76
67
7
7
50
53
31
81
29
9
65
32
8
42
73
160
59
121
Flores Timur
14
15
245
296
161
39
161
39
TTS
0
0
TTU
0
0
Province
Total
2
2
321
296
0
0
11
30
174
226
0
0
0
0
117
90
292
144
0
0
3
4
20
32
130
122
810
702
1512
54%
KABUPATEN/KOTA
2.2 DTPS KIBBLA
(District Team Problem 2.2 PHA/DHA (District
Solving)
Health Account)
2.1 PWS KIA (Local Area
Monitoring System)
2.1 F1-F8 Data Verification/ Mortality data
Meeting
F
Meeting / verifikasi
M
F
Sumba Timur
MONEV/STUDY
M
F
Workshop
M
F
Workshop/ Training
M
F
2.3 SIMK Electronic
(Workforce Management
Information System)
2.2 Assistensi SKPD
Mitra/Planning meeting
Orientation
M
F
2.6 BLUD (Local Public Service Agency)
Orientation/ MONEV
M
F
Assesment/Training
M
F
2
16
10
Ende
13
0
34
41
Sumba Barat
14
1
Manggarai Barat
15
0
Manggarai
10
2
20
Ngada
18
0
119
Lembata
10
1
7
0
22
11
TTS
TTU
18
28
0
37
6
52
10
46
13
18
18
Total
37
6
196
27
46
13
18
18
0
0
10
14
73
51
83
65
9
77
F
M
35
225
141
Total
M
F
M
11
0
281
142
26
0
195
200
79
15
114
29
27
0
42
0
44
10
0
40
46
56
58
14
195
70
73
0
83
1
282
0
307
6
33
3
151
94
10
1
63
24
21
12
21
13
101
147
55
45
153
60
452
254
23
80
Facilitative Supervision
F
6
41
Province
106
Training / Workshop
M
7
Flores Timur
184
F
2.6 Facilitative
Supervision
2.6 Learning Center
Technical Guidence
M
46%
101
147
609
33
57
38
379
158
1844
784
2628
70%
30%
120
2.7 IEC/-Recording &
2.8 Village Meetings to prepare pro-MNCH agenda for
Reporting for Family
KABUPATEN/KOTA
2.6 PML (Performance Management & Leadership)
2.6 Minilok Puskesmas
Meeting / operasional
Training
F
F
Sumba Timur
Customer Satisfaction
/MONEV
Survey
Workshop
support
M
Technical Guidance
M
16
F
10
M
22
F
16
M
217
F
113
2.6 Referral System
Meetings/
Meeting/ Workshop
M
107
Village Development Work Plan / MUSRENBANG
Planning
F
Meeting
M
F
MONEV
M
F
76
Meeting/Training
M
37
F
Establishing Regulation
Workshop/trainings
M
F
(PERDES)
M
F
Total
M
F
Ende
Sumba Barat
Manggarai Barat
2
1
35
15
82
11
Manggarai
30
11
83
50
Ngada
264
18
2
52
31
TTS
TTU
65
18
216
56
38
22
13
0
33
7
44
37
169
78
19
0
35
31
168
54
21
17
104
67
19
16
283
68
58
58
83
58
30
15
138
70
42
27
76
28
140
117
84
29
0
21
1
Province
Total
2
1
187
108
481
165
107
76
0
0
0
26
25
Flores Timur
225
0
90
52
Lembata
M
399
10
192
37
0
2
47
44
2
7
49
53
249
203
47
44
2
7
1609
818
2427
66%
34%
3.4 DCC/PCC (District
3.2 Performance Report of Coordinating
KABUPATEN/KOTA
2.8 RPJMDes (Medium
3.1 INTERVENTION PACKAGE FOR BOK/JAMKESMAS/JAMPERSAL (see
Term Development Plan) abbreviation section in body of report)
Training/Review
F
Techinal Guidance
M
F
Training
M
F
Meetings/ workshop
M
F
M
2.6 Medical Equipment
Maintanance
3.1 Regulation (UU) BPJS
2011
Meeting/ Workshop
Meeting / socialisation
workshop
F
M
F
3.2 E-Procurement
(Electronic-Procurement)
Website Training
M
F
Government Institution
(LAKIP)
3.2 Partnership Management Unit (UPK)
Evaluation
M
F
Meetings
M
F
Committee/Provincial
Coordinating Committee)
Meetings
M
F
Meetings
M
F
Total
M
F
M
7
17
7
17
Ende
18
31
18
31
Sumba Barat
26
26
26
26
6
23
6
23
19
31
19
31
18
51
55
63
12
Sumba Timur
Manggarai Barat
Manggarai
Ngada
37
12
Lembata
Flores Timur
TTS
TTU
42
92
Province
Total
42
92
0
0
0
0
0
0
37
12
0
0
0
0
0
0
0
0
0
0
7
12
7
12
15
12
15
7
13
7
13
113
9
21
51
56
70
56
70
185
310
264
414
39%
61%
678
121
Table 58.
Training Codes and Abbreviations
Code and Title
Indonesian
English
1.1 APN
1.1. PPGDON
Asuhan Persalinan Normal
Pertolongan Pertama Gawat Darurat Obstetri dan Neonatal
1.1. CTU KB
1.1. MTBS
1.1. KIP/K KB
1.1 PAKET P4K
1.2 MANAJEMEN ASFIKSIA & BBLR
1.2 PONED
1.2. PONEK
1.3 GSI
1.3. KONSELOR ASI
1.3 GENDER
KSGP
PUG
1.4. AMP
1.4 PAKET DESA/KELURAHAN/PAROKI SIAGA
SMD
MMD
2.1 SIKDA
2.1 PPWS KIA
IPHB Responsive Gender
PML
2.2 DTPS KIBBLA
2.2 DHA
2.6
2.7 KIE/R-R bagi PPKBD/Sub PPKBD
2.7 LDU bagi Petugas KB
2.8 PRA-MUSRENBANG PRO KIBBLA
2.8 RPJMDes
3.1 PAKET BOK/JAMKESMAS/JAMPERSAL
Contraceptive Technique Update Keluarga Berencana
Manajemen Terpadu Balita Sakit
Komunikasi Inter Personal / Kebidanan
Perencanaan Pertolongan Persalinan dan Penanganan Komplikasi
Berat Badan Lahir Rendah
Penanganan Obstetrik Neonatal Emergency Dasar
Penanganan Obstetrik Neonatal Emergency Komprehensif
Gerakan Sayang Ibu
Air Susu Ibu
Normal Delivery Care
Basic First Aid for Emergency Obstetric and Neonatal/ Basic First Aid for
Maternal and Neonatal
Contraceptive Technique Update for Family Planning
Integrated Management of Childhood Illness
Interpersonal Communication/Midwifery
Birth Preparedness and Emergency Readiness Program
Management of Asphyxia and Low Birth Weight
Basic Emergency Obstetric and Neonatal Care (BEONC)
Comprehensive Emergency Obstetric and Neonatal Care (CEONC)
Mother Friendly Movement
Breastfeeding Counsellor
Kajian Sosial Gender Partisipatif
Pengarustamaan Gender
Audit Maternal Perinatal
Participatory Gender Audit
Gender Mainstreaming
Perinatal Maternal Audit
Survey Mawas Diri
Musyawarah Masyarakat Desa
Sistem Informasi Kesehatan Daerah
Penelusuran Pemantauan Wilayah Setempat Kesehatan Ibu dan Anak
Integrated Health Planning and Budgeting
Peformance Management & Leadership
District Team Problem Solving
District Health Account
Referral System
Komunikasi Informasi dan Edukasi / Recording and Reporting
Latihan Dasar Umum
Pra - Musyarawah Perencanaan Pembangunan
Rencana Pembangunan Jangka Menengah Desa
Biaya Operasional Kesehatan/Jaminan Kesehatan Masyarakat/Jaminan
Persalinan
Electronic-Procurement
Laporan Akuntabilitas Kinerja Instansi Pemerintah
District Coordinating Committee/Provincial Coordinating Committee
Self-Reflection Survey
Village Community Forum
Regional Health Information System
Local Area Monitoring and Tracking on Maternal and Child Health
3.2 E-Procurement
3.2 LAKIP
3.4 DCC/PCC
Basic Training for Family Planning Staff/Officers
Pre-Meeting of Participatory Development Planning
Village Medium-Term Development Planning
Health Operational Funds/Community Health Insurance/Birthing Services
Insurance
Government Agencies Performance Accountability Report
Normal Delivery Care
122
ANNEX 9.
Operational and AAIF Expenditure Jan – June 2015
123
Table 59.
Operational Account Expenditure January – June 2015 (AUD)
Budget Line
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Total
%
Milestone
Personnel
Program Support Unit
District &Provincial Coordinators
Program Administration &
Equipment
Total
0
15,401
34,977
72,600
0
18,690
35,132
72,657
0
25,589
34,911
72,657
0
17,062
35,132
70,796
324,604
22,103
34,899
71,885
649,208
26,675
35,132
72,657
973,812
125,521
210,182
433,251
49.17%
6.34%
10.61%
21.88%
52,292
32,331
43,400
33,689
35,917
40,000
237,628
12.00%
175,271
158,809
176,557
156,678
489,407
823,671
1,980,394
100.00%
Expenditure from AAIF funds all district and Provincial Work Plans and a number of locally engaged
advisors (Partner Hired Advisers).
Table 60.
AAIF Account Expenditure January – June 2015 (AUD)
Budget Line
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Total
Approved Activity Cost
261,709
816,746
430,200
498,451
214,001
482,070
2,703,177
Finance Cost
2,805
8,754
7,114
2,839
2,294
6,013
29,818
Total
264,514
825,500
437,314
501,290
216,295
488,082
2,732,995
Table 61.
Total Monthly Expenditure January – June 2015 (AUD)
Budget Line
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Total
Total
439,785
984,309
613,871
657,967
705,702
1,311,754
4,713,389
124
ANNEX 10. Personnel Movement & Schedule Jan – June 2015
125
Table 62.
No.
Personnel Movement January – June 2015
Staff Name
AIPMNH Position in the JulyDec 2014 Reporting Period
AIPMNH Position in the Jan-Jun
2015 Reporting Period
PSU STAFF
Erens Nenobesi
Building Maintenance Manual
Building Maintenance Manual
Writer/Trainer
Writer/Trainer
DISTRICT AND PROVINCIAL COORDINATORS & ADMINISTRATIVE SUPPORT STAFF
Welly Dortya Lai
DFAA TTU
DFAA TTU
AAIF FUNDED STAFF
Ferderika Rambu
Ngana
Rinawati Sirait
Programmer for Health
Information System
Health Information System Expert
Programmer for Health Information
System
Health Information System
Facilitator
Health Information System
Facilitator
-
Magdalena E Tukan
CE Mentor in Sumba Barat
(Posyandu)
-
Yanti M Ralo
Alfons
-
Tadeus Andreas
CE MENTORS
Vincentious Imau
CE Mentor in Sumba Barat
(Posyandu)
CE Mentor in Belu
CE Mentor in Kabupaten Kupang
Remarks
Contract expired in the 5th of
January 2015
Contract was terminated 8th June
2015
Engaged in April 2015 for one
month only
month only
month only
Contract Expired end of December
2014
Recruited in January 2015
Recruited in February 2015
Recruited in February 2015
126
Table 63.
Adviser staff
NAME
POSITION
Program Director
Transition Manager
Operations Manager
Research Adviser
Construction Monitor
Louise Simpson
Ignatius Henyo Kerong
Hamsya Mappa
Asnaw i Abdullah
Philip Wilson
Table 64.
Maradata Kale
Adriana Ludoni
Helena Maria L Seran
Monitor Krisbrianto Rubino
Liemardheo TH. O Tatengkeng
Erens Nenobesi
Ester Kana
Edel Mary Quien Mole
Yohannes Sebastianus
John Thomas Ire
Hadi Wibaw a
Wiw in Damayanti
Maria Oktaviani Dua Bunga
Ria Pah
Siprianus Woka Ritan
Yulius Gae Lomi
Endi Alfa Edison Kuman
Michael Djami
Stefanus Riw u
Feb-15
Mar-15
Apr-15
May-15
Jun-15
District, Provincial Staff
Yuli Butu
Teldiana H.A. Bunga
Yane Ngaddi
Mamnun Halma
Nugroho
Slamet Riyadi
Saprijal
Marcelinus Levi
Yublina Pandarangga
Ferderika Tadu Hungu
Yoakim Asy
Onesimus Yohanes Markus Lauata
Stefanus Bere
Simon Tondeng
Dyah Sih Winedar
Selviana Ivony Taboy
Rosalin Nggadas
Irmina Dew iaty
Maria Dince
Rambu Kadi
Irma Nababan
Fransiska Lamury
Green Nilla Naw a
Welly Dortya Lay
Sebastianus Mboja
Petrus Ola
Kornelis N Aw a
Paul Samador da Cunha
Melkianus Fallo
Rafael Min (Rafael)
Octovianus Wempy (Octo)
Mesak Tefbana
Bathasar Dini
Jonathan Alex Manuleu
Pristo Ridho
Tarsisius Lobo
Richardo Suharto Angi
Agustinus N Wedjo
Table 65.
Jan-15
ADVISERS
Deputy Provincial Ccordinator
Provincial Liaison Officer
Provincial Admininstration and Finance Assistant
District Program Coordinator - Ende
District Program Coordinator - Kota Kupang
District Program Coordinator - Manggarai
District Program Coordinator - Manggarai Barat
District Program Coordinator - Ngada
District Program Coordinator - Sumba Barat
District Program Coordinator - Sumba Timur
District Program Coordinator - Kabupaten Kupang
District Program Coordinator - TTS
District Program Coordinator - TTU
District Program Coordinator - Flores Timur
DFAA - Lembata
DFAA - Ngada
DFAA-Manggarai Barat
DFAA - Manggarai
DFAA - Ende
DFAA - Sumba Barat
DFAA - Sumba Timur
DFAA - Flores Timur
DFAA - TTU
DFAA - TTS
Driver - Ende
Driver - Lembata
Driver - Manggarai Barat
Driver - Ngada
Driver - Kupang
Driver - Sumba Barat
Driver - Manggarai
Driver - Sikka
Driver - Kabupaten Kupang
Driver - TTS
Driver - Sumba Timur
Driver - TTU
Driver - Belu
Driver - Flores Timur
Program Support Unit staff (PSU)
Finance Manager
Finance Officer
Assistant Finance Officer
IT Manager
IT Assistant
Site Engineer & QC
M&E Data Manager
Public Relations / Translator Coordinator
Translator/ Interpreter
CE Desa Siaga P4K Technical Adviser
CE Puskesmas Reform Adviser
Liaison Officer, KemKes
Office Manager
Assistant Office Manager
Assistant Administrationn Officer
Driver PSU
Driver PSU
Office Assistant/Storeman
Aula Office Assistant/ Storeman
127
Table 66.
AAIF Funded Staff
Elizabeth Umpenaw any
Dr. Yvonne Paula Tibuludji
Dr. Yustina Yudha Nita
Dr. Idaw ati Trisno Koamesah
Ferderika Rambu Ngana
Rinaw ati Sirait
Teodeus Andreas
Teguh Budiyono
Clinical Adviser Training and Education
Monitoring & Evaluation Program Coordinator
Health Planning and Budgeting
Clinical Services Adviser
Programmer
Health Information System Facilitator
Behavioural Change Specialist
Leonis Herman
Stefanus R. Paso
Angelinus N Alberto
Juniarty Araujo
Charles R. Bria
Berty Sola Dima
Arni Djaw a
Magdalena E. Tukan
Alex Sadipun
Abel Y. Dasi
Elis Winfried Kitu
Alex Kono
Damasus Badur
Alfridus S. Dhedo
Yos Kia Waton
Chris Triana
Gerardus Rangga
Donatus Meak
Maria Goreti Bulor S.E
Yeremias Pande Gany
Egidius Halemura
Frans Pito
Thomas Dolaradho
Rita Kefi
Marselina Sedo
Simon Semana
Yanti M Ralo
Alfons Seran
Iki Lobo
Puskesmas Reformasi
Desa Siaga - Revitalisasi Posyandu (Desi-Posy)
Puskesmas Reformasi
Puskesmas Reformasi
Puskesmas Reformasi
Musrenbang & Puskesmas Reformasi
Reformasi Puskesmas/Pramusrenbang
Desa Siaga
Puskesmas Reformasi
Pusref
Desa Siaga
Puskesmas Reformasi
Puskesmas Reformasi
Puskesmas Reformasi
Puskesmas Reformasi Belu
Puskesmas Reformasi Kab. Kupang
Data Manager
CE Mentors
Table 67.
Sister Hospital Teams
RSUD Sanglah Denpasar
Dr. I Ketut Semara Jaya, MM
Dr. A. Misw arihati MM. Dr. Ken
Dr. Ken Wirasandi
Ketua Tim Sister Hospital
Manager Operasional PML
Manajer operasional PONEK/SH
I Wayan Kerthayasa, SE
dr. Tantri Kusmayanti, SE, MM
Wayan Timotious
Bendahara
Koordinator Data dan Pelaporan
Pembantu Bendahara
Dr. Made Darmayasa, SpOG(K)
Dr. Made Kardana, SpA (K)
Dr. IgA. Mahaalit Aribaw a, SpAn (K)
Tim Supervisor Klinis SH
Obgyn Supervisor
Paediatrict Supervisor
Anesthetic Supevisor
Dr. IgA. Mahaalit Aribaw a, SpAn(K)
TIM Klinis Sister Hospital
Residen Obsgin
Residen Anak
Residen Anastesi
Peraw at NICU
Analis Lab PTTD
Tim Supervisi Konsulen (SpOG, SpA, SpAn)
Dr. Sutanto Maduseno, SpPD-KGEH
Diah Anggeraini Hasri
Dr. Rukmono Sisw ishanto, M.Kes., Sp. OG (K)
RSUD DR Sardjito Yogyakarta
Penanggungjaw ab/ Direktur RSUP Sardjito
Asisten Pelaporan
Team Leader Sister Hospital
DR. dr. Sri Mulatsih, SpA(K)
Sekretaris Sister Hospital
Dr. Widodo Trijoko Purw anto
Nining Setiaw ati
Erma Wijayanti, SE
Manajer PML
Bendahara Sister Hospital
Asisten Benhadara
TIM Klinis
Residen Obsgin
Residen Anak
Residen Anestesi
Supervisor Obgin
Supervisor Anak
Supervisor Anestesi
RSUP Dr Soetomo Surabaya
dr. Dodo Anondo.,MPH
Tim Manajemen Sister Hospital RS Soetomo - Soe dan Sikka
Direktur RS Mitra A
Prof. DR. Agung Pranoto, dr.,MKes,SpPD.,KEMD.
Dekan FK Unair
Dr. Bangun Trapsila Purw aka
Team Leader SH
Emilya Indahyati,Drg,MKes
Bendahara
Dr. Nashrullah
Penaggung jaw ab klinik Soe
Indah Purnomosari, SE, MK
Penanggungjaw ab Keuangan
Karjono, SKM
Penanggungjaw ab BLUD
Anang Toni Rahman, SE
Pembantu Admin dan Pelaporan Soe
Ida Mayasari, SKm, Mkes
Sekretaris
TIM klinis RS SOETOMO - SOE
Residen Obgyn
Residen Anak
Residen Anestesi
128
RSUD Dr. Saiful Anwar Malang (Larantuka)
Budi Rahayu, MPH
DR. Dr. Sri Andarini M. Kes
Dr.Muljo Hadi Sungkono,SpOG-K
Naniek Qurrata Akyunin, SST
Ayu Solehati Agustina, S. Keb, Bd
Vidria Handayani Tae, SKM
Mentor Lokal
dr. Hanief Noersjahdu, Sp. S
Tim Manajemen Sister Hospital
Direktur RSSA
Dekan FK Unibraw
Bendahara SH
Asisten Bendahara
Koordinator Pelaporan
Yuliana Danu Beni, AMD Keb
Koordinator PML Atambua
TIM Sister Hospital-RS SAIFUL ANWAR - Larantuka
PPDS. Anastesi
Peraw at Neonatal
RSU Panti Rapih Yogyakarta
dr. Teddy Janong
dr. Triharnoto, SpPD
dr. Lucia Sandra
dr. Robertus Arian Datusanantyo
A. Yollan Permana, S.E., Akt.
dr. John Hartono
Direktur Utama (Penanggung Jaw ab)
Koordinator lapangan dan manajer operasional
Sekretaris Eksekutif Sister Hospital
Bendahara full time
Asisten sekretaris
TIM klinis RS PANTI RAPIH
Residen Obgyn
Residen Anak
Residen anestesi
RSUD Dr Saiful Anwar Malang (Lembata)
Budi Rahayu, MPH
Dr. Karyono Mintaroem, Sp, PA
Dr.Muljo Hadi Sungkono,SpOG-K
Mohammad Ridw an
Qoyyun Istiqomah SE
Dr.Eko Sulistyono,SpA
Dr. Soenarsongko SKM, M.Kes
Dr. Susilow ati
Direktur RSSA
Dekan FK Unibraw
Bendahara SH/PML Lew oleba
Sekretaris SH/PML Lew oleba
Koordinator Sister Hospital Lew oleba
Koordinator PML Atambua
Koordinator PML Lew oleba
TIM Sister Hospital-RS SAIFUL ANWAR - LEWOLEBA
PPDS. Obsgin
PPDS Anak
PPDS. Anastesi
Peraw at Neonatal
Analis Lab UTD
Petugas Elektromedik
RSA Harapan Kita Jakarta
Direktur RSAB
Didi Danukusumo
Dr. Elise
Andreas
Antonia Katona, SKM
dr. Muhammad Ilhami
DR. Dr. Setyaw ati Lusyati, Sp. Ak, Ph.D
Penanggung Jaw ab Program SH
Team Leader Program SH
Wakil Ketua Pelaksana
Sekretaris Sister Hospital
Staf Sekretariat
Korlap
TIM klinis-RS HARAPAN KITA
Spesialis Obgin
Spesialis Anak
Spesialis Anestesi
Peraw at
Tim Monev
RSUP Dr Kariadi Semarang
dr. Bambang Wibow o, Sp.OG
Dr. Endang Ambarw ati, Sp. KFR (K)
dr. Bambang Sudarmanto,Sp.A(K)
dr.Adhie Nur Radityo MSi Med SpA
dra. Suhardiningsiih
Ahmad Komaruddin, SE
Direktur Utama RSUP Dr.Kariadi
Dekan Fakultas Kedokteran Undip
Manajer SH
Manajer PML/Sekretaris SH
Asisten Bendahara
TIM klinis-RS KARIADI
Spesialis Obsgyn
DR. dr. Alisungkar, SpOG
Muhammad Hatta, MKM
Anggi Ginanjar
Yeli Sulastri, S.ST
RSUPN Ciptomangunkusumo
Manager Operasional / Sekretaris
Bendahara
Sekretaris
TIM klinis-RSCM
Residen Obsgin
Residen Anak
Residen Anestesi
Prof. dr. Laksono Trisnantoro, MSc, PhD
dr. Hanevi Djasri, MARS
Ni Luh Putu Eka Andayani
Yos Hendra
dr. Sitti Noor Zaenab, MKes
Armiatin
Andriani Yulianti
Dr. I Wayan Agung Indraw an SpOG-K
Atik Triratnaw ati
Tim PHO, IDAI, POGI, Undana
dr. Agus Sunatha, Sp.OG (POGI)
dr. M.K.Daradjati, Sp.A, IDCLC (IDAI)
Dr. Irene Kathrene Davis (IDAI)
dr. SMJ Koamesah (UNDANA)
Stevi Ardianto Napoe
Dedison Asanab (P2K3 Undana)
drg. Puti Aulia Rahma, MPH
Yulis Yuhiba
Anantasia Noviana, SE
Dw i Handono
Megarini Sulistyo
Erny Linda
PKMK Universitas Gajah Mada
Penanggung jaw ab Program
Koordinator Program Klinis & Outsourcing
Koordinator Program PML
Konsultan PML
Koordinator Program Manual Rujukan
Asisten Analis Data Manual Rujukan
Koordinator Lapangan SH & PML
Konsultan Monev Klinis
Konsultan Monev Kualitatif :
Tim Pendamping Monev Klinis & Kualitatif
Anggota
Anggota
Anggota
Anggota
Anggota
Anggota
Asisten Analisis Data & Laporan
Web Master - Clinical Services
Manajer Keuangan
Konsultan Unit Pengiriman Residen
Manajer Kuangan PML
Asisten Keuangan untuk verifikasi
Full-Time
Part-Time
129

permata yg hilang

Transcription

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