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REMARK FROM THE MINISTER OF HEALTH

The targets of the Millennium Development Goals (MDGs) are due to be reached in 2015, just two years after the publication of this book. The Government of Indonesia has dedicated strong attention to reaching these targets. This attention has only been strengthened by an increased allocation of health funds, with about 80% of this increase occurring in the regions. However, several MDG indicators, which are also included in the targets of the National Medium Term Development Plan (RPJMN) for 2010-2014, will be difficult to achieve under the current efforts and strategies. Various projections and estimates have found that the Maternal Mortality Rate (MMR) will not drop fast enough to achieve the target by the deadline in 2015 without a renewed approach.

The results of surveys and research conducted over the past five years have generally shown that under the current approach, the targeted decrease in the MMR will not be achieved by the deadline of the MDGs in 2015. This indicates that a more cost-effective and evidence-based approach is needed. Furthermore, the country’s stagnant Total Fertility Rate (TFR) over the past 10 years shows that the Government’s Reproductive Health Programme and Family Planning Programme require special attention. In recent years, maternal deaths have mostly occurred among women aged under 20, or over 35, and greater numbers of women have begun to have more than three children, with shorter spacing between births.

Health programme managers at the national, provincial and district levels should be able to identify the existing problems and find solutions, using the interventions that have proven to work successfully with the use of local resources. Optimization and synchronization of activities must be conducted. Every district and city must re-examine whether the action plans developed have addressed the existing problems in their region. The role of provinces should be promoted as an extended arm of the central government to assist the districts and cities in carrying out the development of public health. Strategic steps that need to be carried out to optimize efforts to accelerate the reduction of the MMR are detailed in this book.

I extend my appreciation to all stakeholders who have already, are currently, or are planning to participate in accelerating the reduction of the MMR in this country, and all who have contributed to the publication of this book. It is my hope that this book will be useful as a reference for the acceleration of the reduction of the MMR in Indonesia, and can bring the greatest possible results for the health of its

people.

Jakarta, 30 April 2013

Dr. Nafsiah Mboi, SpA, MPH, Health Minister of the Republic of Indonesia

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FOREWORD DIRECTOR GENERAL OF NUTRITION, MATERNAL AND CHILD HEALTH

Thanks to Almighty God for His blessings and the abundance of His grace, that the National Action Plan for the Acceleration of the Reduction of the Maternal Mortality Rate can finally be published. This book was jointly prepared by all programmes involved in the Ministry of Health, as well as professional organizations and donor agencies involved in maternal health in Indonesia.

The National Development Planning Board (Bappenas) has developed a Regional Action Plan to achieve the Millennium Development Goals, or MDGs. In 2010, this Regional Action Plan should be followed up with concrete actions, particularly because the MDG target on reducing maternal deaths is predicted to be difficult to achieve before the deadline in 2015. It is important for stakeholders to read this book, which details the principles of maternal mortality prevention, strategies and interventions − interventions that have proven to be effective for preventing maternal mortality − and the parameters that must be considered by programme managers.

It is expected that this book can serve as a set of guidelines for all actors involved in maternal health at the national and regional levels in developing the programmes and targets that suit the conditions of each region.

Thanks to all parties that have contributed to the preparation of the National Action Plan for the Acceleration of the Reduction of the Maternal Mortality Rate, and especially to Dr. Endang Achadi, MPH, who helped with the formulation of this National Action Plan.

Jakarta, March 2013Director-General of Nutrition, Maternal and Child Health

Dr. Slamet Riyadi Yuwono, DTM&H, MARS

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LIST OF CONTENT

REMARK FROM THE MINISTER OF HEALTH .............................................................................................. i

FOREWORD DIRECTOR GENERAL OF NUTRITION, MATERNAL AND CHILD HEALTH ............................... ii

LIST OF CONTENT .................................................................................................................................... iii

LIST OF ABBREVIATIONS ......................................................................................................................... iv

LIST OF FIGURES ..................................................................................................................................... vii

LIST OF TABLES ...................................................................................................................................... viii

CHAPTER I INTRODUCTION ..................................................................................................................... 1

A. Background ....................................................................................................................... 1

B. Goal ................................................................................................................................... 1

C. Target ................................................................................................................................ 2

CHAPTER II SITUATION ANALYSIS ........................................................................................................... 3

A. Maternal Mortality .......................................................................................................... 3

B. Pathway of maternal mortality ....................................................................................... 4

C. Principles of maternal mortality prevention ................................................................... 5

D. Program Achievement ..................................................................................................... 6

CHAPTER III NATIONAL ACTION PLAN .................................................................................................. 11

A. Goal ................................................................................................................................. 11

B. Challenge, Strategy and Main Program ......................................................................... 11

CHAPER IV MONITORING AND EVALUATION ....................................................................................... 23

A. Achievement Indicator ................................................................................................... 23

B. Mechanism for monitoring of the National Action Plan for the Acceleration of Maternal Mortality Ratio Reduction ............................................................................. 24

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LIST OF ABBREVIATIONS

ANC Antenatal Care

APBD Anggaran Pandapatan dan Belanja Daerah (Regional Budget)

APN Asuhan Persalinan Normal (Normal Delivery)

Balitbangkes Badan Penelitian dan Pengembangan Kesehatan (National Institute of Health, Research and Development)

Bappeda Badan Perencanaan Pembangunan Daerah (Regional Development Planning Board)

Bappenas Badan Perencanaan Pembangunan Nasional (National Development Planning Board)

BDRS Bank Darah Rumah Sakit (Hospital Blood Bank)

BKKBN Badan Kependudukan dan Keluarga Berencana Nasional (the National Population and Family Planning Board)

BPPSDM Badan Pengembangan dan Pemberdayaan Sumber Daya Manusia (Human Resources Development and Empowerment Board)

BPS Bidan Praktik Swasta (Private Practice Midwife)

CSR Corporate Social Responsibility

DPRD Dewan Perwakilan Rakyat Daerah (Regional Representatives Council)

DTPK Daerah Tertinggal, Perbatasan dan Kepulauan (Underdeveloped, Border and Island Regions)

GDON Gawat Darurat Obstetri dan Neonatal (Emergency Obstetrics and Neonatal Care)

GSI Gerakan Sayang Ibu (Mother-Friendly Movement)

HDK Hipertensi Dalam Kehamilan (Hypertension in Pregnancy)

HIV/AIDS Human Immuno-deficiency Virus/Acquired Immuno-deficiency Syndrome

HOGSI Himpunan Obstetri dan Ginekologi Sosial Indonesia (Indonesian Social Gynaecology and Obstetrics Association)

IAKMI Ikatan Ahli Kesehatan Masyarakat (Indonesian Public Health Association)

IBI Ikatan Bidan Indonesia (Indonesian Midwives Association)

ICD 10 International Classification of Diseases

IDAI Ikatan Dokter Anak Indonesia (Indonesian Pediatrics Society)

IDI Ikatan Dokter Indonesia (Indonesian Medical Association)

IDHS Indonesia Demographic and Health Survey

IDI Ikatan Dokter Indonesia(Indonesian Medical Association)

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IDSAI Ikatan Dokter Spesialis Anestesiologi dan Reanimasi Indonesia (Indonesian Society of Anesthesiologists and Reanimateurs)

K4 Antenatal visits occurring four times (4 kali) throughout pregnancy: once each in the first and second trimesters, and twice in the third trimester.

KARS Komisi Akreditasi Rumah Sakit (Hospital Accreditation Commission)

KB Keluarga Berencana, Family Planning

Kemenkes Kementerian Kesehatan, Health Ministry

KIA Kesehatan Ibu dan Anak (Maternal and Child Health)

KIE Komunikasi, Informasi dan Edukasi (Communication, Information and Education)

MMR Maternal Mortality Rate

MDGs Millennium Development Goals

MoU Memorandum of Understanding

NGO Non-Governmental Organization

P4K Program Perencanaan Persalinan dan Pencegahan Komplikasi (Complication

Prevention and Delivery Planning Programme)

Pemda Pemerintah Daerah (Local Government)

Perda Peraturan Daerah (Regional Regulation)

PERSI Perhimpunan Rumah Sakit Seluruh Indonesia (Indonesian Hospital Association)

PKK Pemberdayaan Kesejahteraan Keluarga (Empowerment of Family Welfare)

PMA Perinatal Mortality Audit

PMD Pemberdayaan Masyarakat Desa (Empowerment of Village Community)

PMI Palang Merah Indonesia (Indonesian Red Cross)

PODES Potensi Desa (Village Potential Statistics)

POGI Persatuan Obstetri dan Ginekologi Indonesia (Indonesian Society of Obstetrics and Gynecology)

PONED Pelayanan Obstetri Neonatal Emergensi Dasar (Basic Emergency Obstetric and Neonatal Care)

PONEK Pelayanan Obstetri Neonatal Emergensi Komprehensif (Comprehensive Emergency Obstetric and Neonatal Care)

PP AKI Percepatan Penurunan Angka Kematian Ibu (Acceleration of the Reduction of the Maternal Mortality Rate)

PPDS Program Pendidikan Dokter Spesialis (Doctorate Program in Medicines)

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PPIA Pencegahan Penularan HIV dari Ibu ke Anak (Prevention of the Tranmission of HIV from Mother to Child)

PPNI Persatuan Perawat Nasional Indonesia (Indonesian National Nurses Association)

Puskesmas Pusat Kesehatan Masyarakat (Community Health Centre)

Pusrengunakes Pusat Perencanaan dan Pendayagunaan Tenaga Kesehatan (Center for Health Personnel Plannning and Utilization)

Pustanserdik Pusat Standardisasi, Sertifikasi dan Pendidikan (Center for Standardization, Certification and Education)

RAD Rencana Aksi Daerah (Regional Action Plan)

RAN Rencana Aksi Nasional (National Action Plan)

RB Rumah Bersalin (Birthing House/Maternity Hospital)

Rifaskes Riset Fasilitas Kesehatan (Health Facility Research)

Riskesdas Riset Kesehatan Dasar (Basic Health Research)

RPJMD Rencana Pembangunan Jangka Menengah Daerah (Regional Medium-Term Development Plan)

RPJMN Rencana Pembangunan Jangka Menengah Nasional (National Medium-Term Development Plan)

RPJPN Rencana Pembangunan Jangka Panjang Nasional (National Long-Term Development Plan)

RS Rumah Sakit (Hospital)

SDKI Survei Demografi dan Kesehatan Indonesia (Indonesian Demographic Health Survey)

SJSN Sistem Jaminan Sosial Nasional (National Social Security System)

SPOG Spesialis Obstetri dan Ginekologi (Gynaecology and Obstetrics Specialist)

SUSENAS Survey Sosial Ekonomi Nasional (National Socioeconomic Survey)

UKS Usaha Kesehatan Sekolah (School Health Programme)

UTD Unit Transfusi Darah (Blood Transfusion Unit)

WHO World Health Organization

WUS Wanita Usia Subur (Reproductive Age Women)

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LIST OF FIGURES

Figure 1 : Causes of maternal mortality 2010 .......................................................................................... 3

Figure 2 : Framework of Pathway Concept of Maternal Mortality .......................................................... 5

Figure 3 : Proportion of the public hospitals that meet the 17 criteria for hospital that provide PONEK for 24 hours .............................................................................................................................. 9

Figure 4 : Proportion of mother receiving danger signs of pregnancy in 2010 .................................... 10

Figure 5 : National Action Plan Framework for the acceleration of MMR Reduction 2013 - 2015 ....... 11

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LIST OF TABLES

Table 1 : Data on normal delivery care quality ........................................................................................ 8

Table 2 : Data on Antenatal Care Quality ................................................................................................ 9

11

CHAPTER I

INTRODUCTION

A. Background Maternal mortality is a result of the interaction of various aspects, which include clinical aspects, health care system aspects and non-clinical aspect affecting the clinical service delivery and implementation of the optimal health care system. Therefore, a common perception and understanding of the stakeholders on the importance and the role of these aspects in addressing maternal mortality are required, and the strategies to address the maternal mortality should be a comprehensive integration of these various aspects. Based on the estimation derived from IDHS in 1990 until 2007 that uses the exponential calculation, the maternal mortality rate in Indonesia in 2015 is 161/100.000 live births, while the MDG target of Indonesia is 102/100,000 live births. The Presidential Instruction No. 3 of 2010 on equitable development requires all governors, head of districts and mayors to prioritize the achievement of the MDG targets in their regional development programs as outlined in the Regional Action Plan for MDGs achievement. In focusing the achievement of MDG Goal 5, that is improve maternal health, the collaboration of all stakeholders to perform effective, efficient and consistent measures is required to accelerate the maternal and neonatal mortality rate reduction in Indonesia. Therefore, the Ministry of Health establishes an action plan for the acceleration of maternal mortality rate reduction 2013-2015, which focuses on 3 strategies and 7 main programs. This Action Plan is expected to create the same understanding for all stakeholders about the concept of maternal and neonatal mortality and the effective and efficient measures to prevent them. These efforts require a strong commitment from all stakeholders to accelerate maternal mortality rate reduction in Indonesia, which is set forth in the Regional Action Plan.

B. Goal

General Achieve the maternal mortality rate target in Indonesia, which is 102/100.000 live births in 2015, and meet the maternal mortality rate target in the regions according to the Regional Action Plan/MDGs/Regional Mid-Term Development Plan for the regions that have achieved the national target.

Specific a) Describe the presidential vision, mission and program that are developed based on the

National Long-Term Development Plan 2005-2025. In this plan, the maternal mortality rate is targeted to fall from 307/100.000 live births in 2008 to 118/100.000 live births in 2014.

b) Provide guidance and directions for the implementation of maternal and neonatal health development at national, provincial, district and city levels, both for the government

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institutions and the community and other stakeholders involved in the improvement of maternal and neonatal health.

c) Focus on improving the health care system to ensure the availability of access to quality obstetric and neonatal care.

C. Target Decision makers at national, provincial, district/city level; program managers; health professionals; professional organizations; community organizations; business sector; and groups that are concerned with maternal health.

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CHAPTER II

SITUATION ANALYSIS

A. Maternal Mortality

1. Definition of maternal mortality According to ICD 10, maternal mortality is defined as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.” The definition explicitly explains that maternal mortality covers a wide scope, which is not only related to the deaths during delivery, but also includes the death of mothers during pregnancy and postpartum. The definition also distinguishes maternal deaths into two categories. The first is a death caused by direct obstetric causes, that is the death directly resulting from pregnancy and childbirth. The second is a death caused by indirect causes, that is the death resulting from previous existing diseases, and is not due to pregnancy or childbirth.

2. Direct causes of maternal mortality Globally, the five major causes of maternal death are hemorrhage, hypertension in pregnancy, infection, obstructed labor and abortion. In Indonesia, maternal mortality is still dominated by three main causes of death, which are hemorrhage, hypertension in pregnancy and infection, but the proportion of these three causes of death have changed. Hemorrhage and infection are decreasing, while hypertension in pregnancy is increasing, with almost 30% of maternal mortality in Indonesia in 2010 are due to hypertension in pregnancy.

Figure 1: Causes of maternal mortality 2010

(Source: Population Census 2010)

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CHAPTER II

SITUATION ANALYSIS

A. Maternal Mortality

1. Definition of maternal mortality According to ICD 10, maternal mortality is defined as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.” The definition explicitly explains that maternal mortality covers a wide scope, which is not only related to the deaths during delivery, but also includes the death of mothers during pregnancy and postpartum. The definition also distinguishes maternal deaths into two categories. The first is a death caused by direct obstetric causes, that is the death directly resulting from pregnancy and childbirth. The second is a death caused by indirect causes, that is the death resulting from previous existing diseases, and is not due to pregnancy or childbirth.

2. Direct causes of maternal mortality Globally, the five major causes of maternal death are hemorrhage, hypertension in pregnancy, infection, obstructed labor and abortion. In Indonesia, maternal mortality is still dominated by three main causes of death, which are hemorrhage, hypertension in pregnancy and infection, but the proportion of these three causes of death have changed. Hemorrhage and infection are decreasing, while hypertension in pregnancy is increasing, with almost 30% of maternal mortality in Indonesia in 2010 are due to hypertension in pregnancy.

Figure 1: Causes of maternal mortality 2010

(Source: Population Census 2010)

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3. Indirect causes of maternal mortality The definition of maternal mortality indicates that maternal mortality does not only include the deaths caused by delivery, but is also related to deaths caused by non-obstetric causes. An example is a pregnant woman who dies from tuberculosis, anemia, malaria, heart disease, etc. These diseases are considered to aggravate pregnancy, increase the risk of morbidity and mortality. The proportion of indirect causes of maternal deaths in Indonesia is quite significant, which is about 22%, so attention should be given to prevention and treatment. In dealing with the indirect causes, coordination with other medical disciplines in a hospital or between hospitals, such as with internal medicine and surgery, is required.

4. Maternal mortality in Millenium Development Goals Indicator for improved maternal health in the Millennium Development Goals (MDGs) is a reduction of maternal mortality rate associated with improved childbirths attended by skilled health personnel (MDG Target 5a). But this effort is not enough, because reducing maternal mortality rate can not be done simply by addressing the direct causes, but also by overcoming the indirect causes. Therefore, the efforts to reduce maternal mortality rate should also be supported by other reproductive health-related efforts, including increased antenatal care coverage, declined adolescent birth rate, increased contraceptive prevalence rate and declined unmet need of family planning. The four indicators are set forth in the MDG Target 5b: universal access to reproductive health, while the last two additional indicators are the efforts of the family planning program. The "4 Too" factor (too young, too close, too many and too old) is one of the indirect causes of maternal mortality that can be overcome with family planning services.

B. Pathway of maternal mortality

It is estimated that 15% pregnancy and birth will have complications. Most of these complications can be life-threatening, but most of them can be prevented and treated if: 1) the mothers immediately seek medical treatment, 2) the health personnel perform the appropriate treatment procedures, including using a partograph to monitor the progress of labor and implementation of the active management stage III to prevent postpartum hemorrhage; 3) the health personnel are able to identify early complications; 4) if complications occur, the health personnel are able to provide first aid and perform stabilization to the patients prior to making referral; 5) the referral process is effective; 6) the hospital services are prompt and appropriate. Thus, the complications that require treatment in a hospital need a continuum of care, covering the basic services through hospital services. The above mentioned step 1 through step 5 will not be helpful if the step 6 is inadequately performed. On the contrary, the adequate hospital care will not be beneficial if the patient suffering from complications is not referred to hospital services (Figure 2)

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Figure 2. Framework of Pathway Concept of Maternal Mortality

C. Principles of maternal mortality prevention Most of the maternal deaths should be preventable, because most obstetric complications can be handled. At least there are three conditions that need to be observed to save a mother:

a) First, obstetric complications are unpredictable, so they will occur to any pregnant

woman at any time (during pregnancy, childbirth or postpartum, especially the first 24 hours after delivery). This condition puts any pregnant woman at risk of having obstetric complications that may threaten their life.

b) Secondly, every pregnancy has a risk, so every pregnant woman should have an

access to adequate services required when complications occur. Most complications can be life-threatening and should be immediately attended at the hospitals that can provide obstetric and neonatal emergency care.

c) Thirdly, most of the maternal deaths occur during delivery and in the first 24 hours after delivery, which are a very short period, so the access and quality of care in this period should be prioritized to give high leverage in reducing maternal mortality.

In reality, preventive measures and treatment of complications mentioned above are not usually performed, because of the delays, which include:

A pregnant/giving birth mother dies because the complications they are suffering from are not attended in timely and appropriate manner

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6

a) Delays in making a decision Delays in making a decision at the community level are attributed to the following conditions: 1) The mother is late to seek assistance from health professionals despite the available

access to them for 24 hours a day and 7 days a week due to the constraints of traditions/beliefs in decision-making in the family, and the inability to provide non-medical costs and other medical costs (particular type of medicines, blood type check, transportation to find blood/medicines, etc.).

2) The family is late to refer the mother to health professionals due to lack of understanding about the life-threatening signs.

3) The health professionals are late to perform the preventive measures and/or identify the complications early due to lack of optimal competence, such as handling normal delivery care according to the standard and providing first aid for obstetric and neonatal emergency.

4) The health professionals are not able to advocate the importance of making a prompt referral to the patient and her families to save the mother's life.

b) Delays in reaching the referral hospitals and ineffective referral, which can be caused

by: 1) Geographical issues 2) Constraints of means of transport 3) Stabilization of patients with complications (such as pre-shock) is not

performed/not effective, because the health professionals’ skills are not optimal and/or the medicines/medical devices are not available.

4) Monitoring of the referred patients is not performed or performed but is not followed by necessary actions.

c) Delays in getting adequate care in referral hospitals, which can be caused by

1) Ineffective administrative system of emergency care in hospitals. 2) The required health professionals (obstetrician/gynecologist, anesthesiologist,

paediatrician, etc.) are not available. 3) Lack of skillful health professionals despite available access to them 4) Incomplete/unavailable infrastructure, such as emergency room, delivery room,

medical instruments and medicines. 5) Blood is not immediately available 6) Patients arrive at the hospital in a critical condition that is difficult to save. 7) Lack of clear admission procedure for emergency cases to prevent rejection of

patients or to make an effective referral to other hospitals. 8) Lack of information for the community about the capacity of the health care

facilities that are referred to in handling obstetric and neonatal emergency, so adequate service is not obtained

D. Program Achievement

One of the massive government efforts to reduce maternal mortality rate is the program that assigns midwives in the villages, which has been initiated since the 1990s. The program aims to bring people's access closer to the health services for mothers and newborns, especially during pregnancy and childbirth. However, since the midwife education only

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takes a short time, approximately 54,000 in 6 years, the quality of some midwives still needs to be improved to meet the standards of competence Based on the regular reports on maternal health from the Provincial Health Office in 2011, until today there are 66,442 village midwives that are registered, but only about 54,369 of them (82%) live in the villages. In addition, village midwives’ ability in providing standardized delivery care is hampered by housing facilities that also serve as a village health post. The Indonesia Health Profile Data of 2011 shows that the number of village health posts in 2011 are only 53,152. In addition, the number of midwives who have received training on normal delivery care is only 35,367 (52.6%). The training components include the active management stage III to prevent partial postpartum hemorrhage and the use of partograph to detect problems in delivery process. Since not all villages have a midwife, and only some midwives are trained to have adequate skills, delivery care that meets the standards can be performed in health care facilities (community health centers that provides inpatient care or basic obstetric and neonatal emergency care/PONED). Delivery in health care facilities has several advantages: there are more than one health personnel to attend the delivery, especially in the case of complications, and thus monitoring of patients can be done more intensively by turns; overcome the shortage of midwives as rotational assignments can be done in a health care facility; since the delivery is not taken place at the patient’s home, family pressure and unfavorable conditions of the house for the midwife can be avoided; the availability of equipment and medicines in the health care facilities is more certain; health care facilities are usually located in the area from which it is more convenient to reach the hospital. The implementation of normal delivery care standards in basic health facilities has met the expectation as shown by the declining proportion of hemorrhage and infection. However, the quality of maternity care still needs to be improved. The results of Quality Maternal Health Services Study in 2012, which was conducted in 20 districts/cities in Indonesia, show that the adherence of health professionals in using a partograph, performing a physical examination and documenting the examination results is still low, whereas a thorough physical examination and proper use of a partograph can prevent delivery complications. (Table 1)

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The maternal and neonatal deaths are highly influenced by the promptness and and accuracy of the measures taken during emergency. The existence of the community health centers that have a capacity to provide PONED is a solution to bring the public access closer to obstetric and neonatal care to prevent complications and/or get a first aid during obstetric and neonatal emergency on the conditon that the service provided meets the adequate standards of care. However, the coverage and quality of basic services still need to be improved. The data from the 2011 health facilities research shows that 241 districts in Indonesia (60%) do not have 4 community health centers that provide PONED per district as required. Only 69.7% of community health centers have a medical device to check the hemoglobin (Hb) and only 42.6% of community health centers that provide PONED have MgSO4, while hemorrhage and eclampsia are two major causes of maternal death. Of all the community health centers that provide emergency care, including PONED, only 76.5% have a means of transportation (ambulance or motor boat). Most obstetric and neonatal emergency cases can be treated in a basic health care facility using a simple technology, so the improved emergency obstetric and neonatal emergency care at community health centers should provide a substantial contribution to the prevention of maternal and neonatal mortality. Hospital as a final referral place of obstetric and neonatal cases has an important role in saving mothers and newborns, because about 5-15% of complications cases require actions that can only be performed at hospitals, such as caesarean sectio and blood transfusions. The 2011 Health Care Facilities Research shows that only 7.6% of public hospitals meet the 17 criteria for hospitals which have the capacity to provide PONEK for 24 hours and 7 days a week (Figure 3). Lack of means and retention of Obstetrician and Gyneacologist is the major cause that makes a hospital unable to provide PONEK for 24 hours and 7 days a week.

NORMAL DELIVERY CARE Hospital* Community health center*

Complete the medical record 68,6% 61,4% Complete the general physical and obstetric examination

52,1% 57,3%

Use a partograph 41,0% 68,3% Use a cardiotography (CTG) 19,0% 2,5%

Perform delivery care stage I 73,8% 83,8%

Observe indication and symptom stage II 80,0% 85,0% Prepare delivery care 60,6% 65,8% Ensure full opening of the cervix 72,5% 77,5% Ensure good condition of the fetus 77,5% 75,0%

Document the examination results 20,0% 42,5%

Table 1: data on normal delivery care quality

(Source: Quality maternal health services study, Min. of Health- WHO-HOGSI, 2012)

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Figure 3: Proportion of the public hospitals that meet the 17 criteria for hospitals that

provide PONEK for 24 hours (Source: Basic Health Care Facilities Research 2011)

One of the successful prevention of maternal mortality lies in the accuracy of decision making in the event of complications. It can be achieved if the family has a good basic knowledge about pregnancy and childbirth, so they can make a delivery planning and are prepared to face the complications as early as possible.

Table 2: Data on Antenatal Care Quality

ANTENATAL CARE Hospital* Community

health center*

Complete the medical record 33,86% 48,52% Complete the general physical and obstetric examination

50,00% 59,38%

Provide counseling and education 24,17% 45,00%

Perform regular supporting examination 39,38% 19,69%

Perform supporting examination in the event of indications

49,00% 52,50%

Provide supplements and vaccination 62,50% 73,13%

The results of the 2010 Basic Health Research shows that about 45% of mothers claim to receive information about the danger signs of pregnancy during ANC (Figure 4). This is reinforced by the results of the 2012 Maternal Care Quality Study that shows that only 24% of hospitals and 45% of community health centers perform appropriate counseling and education according to the current standard during ANC. Both of these indicate that the role of health professionals in providing information and advocacy to mothers and families during ANC is still weak, so the knowledge of families and communities to develop a childbirth planning is also poor (Table 2).

(Source: Maternal Care Quality Study, Min. of Health-WHO-HOGSI, 2012)

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Figure 4: Proportion of mothers receiving danger signs of pregnancy in 2010 (Source: Basic Health Care Research 2010)

Delivery Planning and Complications Prevention Program, which was introduced in 2007, was implemented in 63,000 villages across Indonesia in 2011. It is necessary to ensure the implementation of this program in these villages to help families develop a delivery planning and realize the plan well in time.

Other activities prior to this program that involve the community is Mother Friendly Movement which was popular in the year 2000s. Unfortunately this activity has faded lately, whereas it is considered to be quite capable of raising the maternal health issues in the community because it increases the decision makers’ concern at all government levels. The integration of strengthened delivery planning and complication prevention program, alert villages and Mother Friendly Movement is one of the solutions to empower families and communities in maternal health.

The measures to reduce maternal mortality rate can not be separated from the family planning

services, as they are related to the prevention of unwanted pregnancy and the 4-too factors. But in the last 10 years the participation rate of modern family planning (Contraceptive Prevalence Rate/CPR) only increases very slightly, which is from 56.7 % (2002) to 57.9% (2012). The rate of unmet need of family planning participants also declines very slightly, from 8.6% (2002) to 8.5% (2012). The measures taken to increase CPR and reduce unmet need among others are including

family planning services in the maternity insurance package which has eliminated financial barriers in obtaining family planning services, and utilizing an integrated antenatal care,

maternal class and Delivery Planning and Pregnancy Prevention Program to improve mothers’ and families’ knowledge about family planning.

Mothers receive information about the danger signs of pregnancy

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CHAPTER III

NATIONAL ACTION PLAN

A. Goal

Accelerate the reduction of maternal and neonatal mortality and morbidity rate in Indonesia.

B. Challenge, Strategy and Main Program The National Action Plan is implemented in the decentralization context in the form of the Regional Action Plan, which ensures a steady integration in health development planning and budget allocation process. It focuses on mothers and newborns health care according to the current standard, which is cost-effective and based on the evidence at all health care levels and health referrals in both government and private sectors.

Figure 5: National Action Plan Framework for the Acceleration of MMR Reduction 2013 – 2015

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CHAPTER III

NATIONAL ACTION PLAN

A. Goal

Accelerate the reduction of maternal and neonatal mortality and morbidity rate in Indonesia.

B. Challenge, Strategy and Main Program The National Action Plan is implemented in the decentralization context in the form of the Regional Action Plan, which ensures a steady integration in health development planning and budget allocation process. It focuses on mothers and newborns health care according to the current standard, which is cost-effective and based on the evidence at all health care levels and health referrals in both government and private sectors.

Figure 5: National Action Plan Framework for the Acceleration of MMR Reduction 2013 – 2015

Challenges :

1.Community access to health facilities already increased but coverage and quality of care are not optimal yet

2.Limited strategic resources for maternal and neonatal health

3.Community knowledge and awareness on maternal health are still low

Strategy :

1.Improve coverage and quality of maternal health care

2.Enhance local government and private sector’s role in maternal health efforts

3.Family and community empowerment

MMR 102/ 100,000 LB (2015)

Main program :1. Assurance of village midwifecompetence according to the standard

2. Assurance of the availability of health care facilities that can provide delivery care 24/7 according to the standard

3. Assurance of the function of all PONED community health centers and PONEK hospitals in at district/city level to work 24/7 in accordance with the standard

4. Assurance of the implementation of effective referral for complications cases

5. Assurance of Local Governments Support for the Implementation of the Acceleration of Maternal Mortality Rate Reduction Program

6. Improvecross-sectoral and private sector partnership

7. Improved Understanding and Implementation Program of the Delivery Planning and Complications Prevention Program (P4K) inthe Community

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1. Challenges Three main challenges related to the acceleration of maternal mortality rate reduction are access to the quality services in health care facilities that is not optimal, limited strategic resources for maternal and neonatal health, and community knowledge and

awareness on maternal health are still low.

2. Strategies used to achieve the maternal mortality target in 2015 2.1. Improved coverage and quality of maternal health care

Very strong evidences suggest that the life safety of women during pregnancy, childbirth and puerperium is strongly influenced by the access to quality obstetric care at all times, especially since every pregnancy and childbirth have a risk of life-threatening complications. The concept of continuum of obstetric care that is delivered in the previous chapter underlies the significance of the improved coverage and quality of care as such that every woman who is undergoing complications during pregnancy and childbirth has an access to the quality health care in a timely and appropriate manner. This continuum of care is particularly important during the period of laboring process and during the first 24 hours after delivery for in these very short periods the majority of maternal deaths occur. Access to health care for certain cases that can aggravate the condition of women during pregnancy, childbirth and puerperium, and for the cases that have widespread health and social implications in the future, namely anemia, malaria in endemic areas, HIV and AIDS, post abortion care and teen pregnancy, needs attention significantly.

2.2. Enhancing the role of local governments in the regulations that can effectively support the implementation of the program Health care system is a part of a public service system that is in some aspects is highly regulated by local policies and regulations, such as the provision and placement of health professionals and supporting health personnel, and the provision of health infrastructure. Health professionals are at the forefront of the implementation of health care programs. Therefore, the policy on health professional assignment has a very strategic position that needs to be regulated clearly and firmly. The policy needs to be complemented with a clear application of reward and punishment, both for specialists, medical doctors, midwives, and other health-related personnel. Since the optimal health care outcomes are strongly influenced by the quality of service, the assurance of health professional competence requires attention through various actions, including adequate pre-service education, in-service training for health professionals, appropriate implementation of health

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professionals’ authorities, certification for health professionals and health care facilities, and audit of health professionals’ services and health care facilities. The role of local and central government in the regulation about the availability and quality of health professionals is expected to function effectively. The availability of competent personnel is not enough without the support of adequate means and infrastructure, including the availability of blood 24/7. Good coordination between the blood transfusion unit of general hospitals at district level and the Indonesian Red Cross, the blood transfusion unit of genral hospitals at provincial level and the blood transfusion unit of private hospitals in the provision of blood for patients is necessary. Strengthening the referral system requires a strong support from the local governments and other stakeholders as such that patients who are referred are attended immediately. Support is very much needed given the referral process requires involvement of various stakeholders, namely the community, health professionals and basic health care faclities, hospitals (public and private) including blood transfusion unit of hospitals and the Indonesian Red Cross. Regionalization which is adapted to the conditions of each region needs to be considered to clarify the referred destination. Regionalization include clusters of island, coast, urban area and the nearest district, etc. In this case, support through gubernatorial regulations may help the referral regionalization efforts. The role of private sector in health care to public can not be ignored given the capacity of the government health care facilities is limited and lately people tend to choose the health care provided by private sector, especially in urban areas. Therefore, private sector should have an active role in jointly delivering the best health care that suits the public needs, regulated by a regional regulation. The explanation above indicates that a strong role of the local governments in regulating the optimal implementation of health care for public is essential, including regulating the role of various government sectors, the role of civil society organizations and private sector. The central government’s role needs to be coordinated in order to mutally complement the good implementation of health care in the regions.

2.3. Family and Community Empowerment

Decision on pregnancy and childbirth arrangement should be made together by a mother with her husband and her family. It is not a decision that is not desired by the mother, either because of medical reasons or other reasons related to readiness. Families should have an understanding that every pregnancy is desired by the mother, including when pregnancy is wanted and how many children are desired. It is also necessary to improve the knowledge and attitudes of family and society in general regarding the importance of understanding that every pregnancy has a risk of life-threatening complications, and therefore a planning for good delivery and

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prevention, and for finding immediate help in the event of complications is required (the availability of transportation, funding and potential blood donors). Knowledge of the risk of complications in pregnancy, childbirth and puerperium as well as information about family planning are important to gain since adolescence, so teenagers can plan the right age to get married, the number of children desired and arrange the pregnancy interval. Education to improve the knowledge, understanding and participation of youth/community including teachers is given through youth friendly health service program that aims to prevent teens from having risky sexual behavior, such as unwanted pregnancy, whch may result in unsafe abortion and may ultimately lead to maternal death.

3. Main Program

The selected main program is the program that is considered to have high leverage for accelerating maternal mortality rate reduction, because it ensures the availability of quality services that can be accessed at any time, which include: 1. Mother and child health service delivery at village level in accordance with the

standards 2. Provision of basic health care facilities which are able to provide delivery care

according to the standard for 24 hours 7 days a week 3. Assurance of the entire PONED community health center and PONEK hospital for 24

hours 7 days a week to work according to the standard. 4. Implementation of effective referral in case of complications 5. Strengthening the district/city government in decentralized health governance

programs (regulation, financing, etc.). 6. Implementation of cross-sectoral and private partnership. 7. Improved behavior change and community empowerment through understanding

and implementation of delivery planning and complications prevention program and integrated service posts.

4. Program and Activities

4.1. Assurance of village midwife competence according to the standard 4.1.1. Provide health care facilities in the village (village health posts) at the

locations where access to a more complete service has not been met. Clarification about the functions of village health posts is needed based on the conditions of each region.

a. Provision of health care facilities at village health posts b. Provision of midwife kits, including Hb checking device

4.1.2. Improve midwife skills on delivery care and integrated antenatal care

a. Normal delivery care training: for village midwives who have not receive such training (including adequate hands-on training) and for midwives whose competence has not met the standards.

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b. Integrated training on normal delivery care c. Training for midwives in providing counseling and education to the

community about maternal and infant health and nutrition, so the midwives can be more effective in changing people's attitudes and make them more vigilant in dealing with pregnancy and better prepared in the event of complications. The training programs must be equipped with the post-training evaluation component and periodic monitoring, for example through self assessment using checklists.

4.1.3. Maintain/improve the quality of mother and child health care by increasing facilitative supervision on village midwives.

4.2. Assurance of the availability of health care facilities that can provide delivery care 24/7 according to the standard

4.2.1. Improve detection and first aid for complications cases and effective referrals

a. Increase the number of community health centers which can provide delivery

care in accordance with the working standard 24/7 Complement/add maternity room at community health centers Complement the infrastructures, including medicines Train the community health centers’ team to work 24/7, including

performing detection and first aid for complications cases and effective referrals.

b. Conduct an integrated antenatal care, including prevention of HIV transmission from mother to child.

c. Conduct screening of hemoglobin examination for any mother who checks their pregnancies at health care facilities.

4.2.2. Increase the number of health care facilities that can handle complications:

a. Increase the number of community health centers that provide PONED 24/7 : Fill/add PONED trained team. Ideally, 2 trained teams are available in

every community health center that provides PONED, so the service is available for 24 hours 7 days a week. In circumstances where two teams can not be afforded, it is expected that an in-house training can be given to the staff of community health centers.

Complement the facilities and infrastructures of community health centers that provide PONED, including medicines

Conduct a refreshment training for the existing PONED team given complications cases are rarely encountered

Ensure the availability of referred means of transportation and adequate communication

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b. Establish community health centers which can provide PONED 24/7 in remote areas and islands, with special guidance and supervision from PONEK hospitals, so community health centers that provide PONED and effective referral can function properly.

4.2.2.1. Build coordination and cooperation with referral hospitals, which are located

in the same region and in other regions (provincial hospitals, hospitals in border regions, military hospitals, private hospitals) to expand the access to complications case referrals in hospitals.

4.2.3. Optimize the utilization of health insurance for eligible people (maternity insurance, national social security system) by: a. Building coordination with various stakeholders to implement maternity

insurance/national social security system at every level of service, so the main tasks and functions of every stakeholder are clear.

b. Providing information to the public about the rights and obligations related to health insurance.

4.2.4. Improve quality of service

a. Improve the skills of health professionals at basic level using a variety of approaches, including training, apprenticeship, and in-house training, to make them competent in performing normal delivery care, including prevention of complications, so the cases referred to the hospitals are not normal delivery cases. Conversely, improve the ability of health professionals to be able to identify complications cases early, provide first aid for complications cases and make a referral for cases that require effective treatment in hospital, including monitoring and stabilizing the patients during referral process so they arrive at the hospital in timely and appropriate manner.

b. PONEK hospitals provides guidance for PONED community health centers c. Perform the Maternal Perinatal Audit on maternal and neonatal mortality

cases and provide the follow-up actions. d. Implement back referral to allow the referrers learn from the results of

their actions and continue to perform the monitoring of post-hospitalized patients.

e. Conduct facilitative supervision on PONED services performed by a coordinating district midwife or other designated health professionals.

4.3. Assurance of the function of all PONED community health centers and PONEK hospitals in at district/city level to work 24/7 in accordance with the standard 4.3.1. Improve the quality of health personnel in referral hospitals in handling

complications cases in a timely and appropriate manner, including the availability of service standards guidelines for complication cases

4.3.2. Build coordination and cooperation with other referral hospitals, either in the same region or the nearest region, which are the hospitals of higher type, private hospitals/maternity hospitals and military hospitals, to expand

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the access for complications cases to the hospitals as part of a referral network.

4.3.3. Ensure the access to safe blood a. Improve and strengthen the cooperation with the Indonesian Red Cross. b. Improve the function of blood transfusion unit c. Ensure all hospitals have a hospital blood bank d. Establish a network of inter-hospital blood provision, both between

hospitals in the same region and or in different region, to improve the cooperation between hospitals, both in the same region and outside the region (province or district and other cities) on blood provision.

4.3.4. Improve postpartum family planning services in collaboration with other

relevant sectors, notably hospitals and the National Family Planning Coordinating Board.

4.3.5. Ensure the availability of obstetric and neonatal care at any time (24 hours 7 days) a. Complement/add personnel to ensure the service delivery for 24/7:

At least 1 team that is able to perform PONEK or handle emergency cases is available with such arrangement that the services are available for 24 hours 7 days. In circumstances where a full team can not always be available, it is expected that an in-house training is given by the trained team/staff to other hospital staff, so the service can still be provided. In circumstances where there is no PONEK team or team that can provide emergency care, especially in remote areas and islands, it is necessary to consider specific approach, including building cooperation with post-graduate training institutions and provincial hospitals. The team includes caesarean section operators (obstetrician and gynecologist/post-graduate student of obstetrics), anesthesia operators (anesthesiologist/post-graduate student of anesthesiology, assistant), midwives and nurses.

b. Complement/add the facilities and infrastructure: operating room and its priority use arrangement, C-section kits, medicines, blood, etc.

c. Conduct innovative approaches for the hospitals undergoing human resources shortage, particularly in remote border areas and islands. Provision of guidance model and assignment of personnel from larger hospitals in the same region or outside the region (provincial hospitals or nearest hospitals) in regional hospitals are an alternative to be explored. For example is the sister hospital program which supports mother and child health revolution program in East Nusa Tenggara, so the continuum of care can be provided.

4.3.6. Improve the quality of mother and child health care

a. Improve the skills of health professionals: midwives, physicians and specialists, through trainings, apprenticeships, in-house trainings and guidance.

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b. Conduct audits on every maternal and neonatal death occurring in the hospitals.

c. Optimize supervision and quality assurance in the hospitals. d. Use a service edict to increase the role of the society in improving the

service quality.

4.3.7. Strengthen the health care system in hospitals a. Develop/modify policies in health care facilities: admission flow and

handling of obstetric and neonatal emergency cases, availability and proper functioning of the emergency room, etc.

b. Implement back referral made by the hospitals to the referrers, so the referrers can get a learning and perform monitoring of the post-hospitalized patients.

4.4. Assurance of the implementation of effective referral for complications cases 4.4.1. Ensure the availability of referral guidelines.

a. Develop/establish clear referral guidelines at national level. b. Develop/establish clear referral guidelines and operations at local level,

including the function and role of every level of service, as such that the service is utilized as needed.

c. Develop guidelines for back referral, which is made by the hospitals to the referrers.

d. Develop guidelines for referral system for patients who use the maternity insurance program/National Social Security System or other government health insurance programs.

4.4.2. Ensure the availability of firm referral system: a. Develop/strengthen a mutually agreed networking system, which includes

"Vertical Reference Network" between basic services and services at a higher level (hospital services), and "Horizontal Referral Network" between hospitals (public and private); between village midwives or midwives at a community health center and the Central Statistics Agency, between a PONED community health center and a maternity hospital, etc.

b. Develop/strengthen a mutually-agreed regional networking system, especially to handle remote and border areas.

c. Develop a referral communication system that has two objectives as follows: a. Provide service guidance (by an obstetrician/gynecologist to general

practitioners or midwives in the field, by a senior midwife to midwives in the field, etc. )

b. Obtain a confirmation about the availability of the referral hospital services (the availability of doctor, bed, blood, medicines, etc.).

d. Strengthen the admission and handling system for emergency cases in the hospitals, including handling flow, coordination with obstetrician or post-graduate students of obstetrics, and coordination with other specialists associated with maternal deaths due to indirect causes.

e. Develop/strengthen a mutually-agreed networking system for remote areas and islands.

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4.5. Assurance of Local Governments Support for the Implementation of the Acceleration of Maternal Mortality Ratio Reduction Program.

The local government support is generated through the District Team Problem Solving (DTPS) approach, which includes

4.5.1. Regulation on the procurement and assignment of health professionals a. Submit a proposal to the central and local governments to meet the manpower

needs at various levels of health care facilities, so people have access to maternity and neonatal services required at all times. The proposal includes Completing the manpower at PONED and PONEK health care facilities that do

not have trained personnel. Gradually assigning at least 1 PONED team, and if possible 2 teams PONED

health care facilities in certain areas gradually. Gradually assigning at least 1 PONEK team, and if possible 2 teams at PONEK

hospitals in certai areas. Ensuring the availability of medical specialists at PONEK hospitals or public

hospitals that have not obtained PONEK status. b. Submit a proposal to the local governments to secure the assignment of health

professionals who have received PONED/PONEK training, so they will not be transferred or replace them with other personnel who have equal capacity and have been previously prepared.

4.5.2. Regulation on the procurement and assurance of the availability of necessary

equipment and medicines in every health care facility. a. Improve and strengthen coordination with the national and local

governments, so the availability of necessary equipment and medicines is assured at all times, including the process of application, procurement, distribution, and storage

b. Improve and strengthen coordination with the Indonesian Red Cross regarding the blood provision, if necessary through a Memorandum of Understanding at local level.

c. Improve and strengthen coordination between hospitals, public and and private, both within the region and outside the region (provincial hospitals or the nearest hospital), in the provision of equipment, medicines and blood, if necessary through a Memorandum of Understanding at local level.

4.5.3. Regulation on the administrative and financial governance

a. Submit a proposal to the local governments to increase the regional budget allocation to support health activities that have a high leverage to achieve the MDG 5, that is the availability of continuum of care, which includes the availability of competent midwives, health care facilities capable of providing PONED and hospitals capable of providing PONEK

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b. Submit a proposal to the local governments about the need for breakthrough efforts related to maternal and neonatal care, including considering the emergency aspects in service delivery (after working hours).

c. Submit a proposal to the local governments to make clear regulations for border and remote areas, including the regulation governing the referral system of obstetric and neonatal cases to facilitate the people in these areas to access the health care facilities nearby.

4.5.4. Regulation on improved quality/skills of health professionals

a. Submit a proposal to the local governments to improve the quality and clinical skills of health professionals through training, apprenticeship or other training programs.

b. Recommend licensing for establishing schools and colleges in the regions that refer to the applicable standards of professional competence. The local government can work together with the relevant professional organizations. Ministry of Health also oversees the implementation of teaching-learning process in medical educational institutions.

c. Conduct socialization of the Health Minister Decree of 2009 on health training through the board of human resources development and empowerment.

4.5.5. Regulation on maternal and neonatal health information system a. Develop guidelines on integrated recording and reporting system (vertically

and horizontally). b. Establish key indicators for monitoring and evaluation purposes c. Conduct an analysis and utilization of information as a basis for determining

policies and programs.

4.5.6. Assurance of support for other required regulations 1. Develop macro and fundamental policies related to community health

center. These policies include the concept of community health center, specific workforce and financial governance.

2. Develop regulations to determine priority health care areas. 3. Conduct socialization of the national referral guidelines (Health Minister

Regulation No. 1/2012). 4. Develop regulations on the referral system at district/city level. 5. Conduct advocacy on delayed marriage based on health considerations.

4.6. Cross-Sectoral and Private Partnership Improvement Program

Work with other sectors as follows:

1. Medical education institutions to work in local hospitals to ensure the availability of adequate service 24 hours/7 days, such as through the assignment of post-graduate students of obstetrics program.

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2. Private sector which directly provides obstetric care (maternity hospitals, clinics, general hospitals) is expected to build coordination in providing obsetric care to the community, including in the referral system, through a Memorandum of Understanding (MoU) on Cooperation.

3. Private sector which has indirect roles (medical educational institutions, companies’ CSR program) is expected to work together to improve the obstetric coverage and care, either through the improved quality of students of health-related program based on the national standards, or through the utilization of CSR funds.

4. The National Family Planning Coordinating Board, to improve access for all women of childbearing age to information on reproductive health and access to family planning methods.

5. Primary and secondary education sectors, to increase access for all adolescents, especially girls, in schools (school health unit) to information on reproductive health. The implementation of 12-year compulsory education is expected to be utilized by the health sector to convey the information related to reproductive health and other health-related information.

6. Professional organization, to increase its role in improving the quality of services of its members, such as through training, apprenticeship, coaching and arrangement of professional licence registration. The local governments and the local health offices are expected to work with the professional organizations in accordance with their respective roles as agreed upon.

7. Religious sector, to improve access for all girls in religion-based schools, madrasah (school health unit) and all brides-to-be who register their marriage at the office of religious affairs, to information on reproductive health, including body readiness for first pregnancy.

8. Religious organizations can play a role in at least two aspects Delivery of health information, such as information on reproductive health and

health insurance (maternity insurance, national social security system), through the existing organization networks, and As part of the Local Health Service Network

9. Develop/improve other partnerships according to the circumstances and conditions of the regions.

4.7. Improved Understanding and Implementation Program of the Delivery Planning and Complications Prevention Program in the Community

4.7.1. Conduct a reorientation and reactivate the concept of community

preparedness in facing the delivery a. Conduct a reorientation for all relevant health personnel regarding the

delivery planning and complications prevention program to create the same and appropriate understanding about the program concept, including the purpose and benefits of the program, and the measures that must be taken.

b. Conduct an orientation for health cadres and communities about the danger signs of pregnancy and childbirth as well as their role in the delivery planning and complications prevention program.

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c. Reactivate the mother friendly movement at all levels (national, provincial, and district)

4.7.2. Conduct an orientation about the importance of necessary measure during

pregnancy and childbirth a. Conduct maternal class using mother and child health guide book b. Socialize the danger signs of pregnancy and childbirth through appropriate

media to every segment of society in accordance with the acceptable culture and norms.

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CHAPER IV

MONITORING AND EVALUATION

A. Achievement Indicator

1. Achievement of the Acceleration of Maternal Mortality Ratio Reduction Program a) Outcome Indicator

Maternal Mortality Ratio: The total number of maternal deaths (according to the definition of ICD 10) in a region divided by the total number of live births in the same region in a specified period of time, represented in unit per 100,000 live births

Delivery assisted by skilled attendants: The total number of births attended by health professionals in a region divided by the total number of women giving birth in the same region in a specified period of time, represented in percent.

Age Specific Fertility Rate, 15-19 years old

The total number of birth to women of a specified age group (15-19 years) per 1000 women of the same age group in the same region in a specified period of time, represented in per mil.

Antenatal care visit in 4 times during pregnancy : The total number of antenatal care visits in 4 times in a region, which are at least 1 time in Trimester 1, 1 time in Trimester 2 and 2 times in Trimester 3, divided by the total number of pregnant women in the same region in a specified period of time, represented in percent.

Delivery in health care facilities: The total number of births assisted by health professionals in health facilities (community health centers and hospitals) in a region divided by the number of women giving birth in the same region in a specified period of time, represented in percent. It is necessary to distinguish delivery in non-hospital health care facilities from delivery in hospitals.

Proportion of obstetric complications attended in the hospitals that provide obstetric and neonatal emergency care (PONEK hospitals or hospitals that have

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not gained/do not gain PONEK status, but capable of providing emergency care): The total number of obstetric complications attended in a hospital (PONEK hospitals or hospitals that have not gained/do not gain PONEK status, but capable of providing emergency care) in a region, divided by the estimated total complications (= number of pregnancies * 15%) in the same region in a specifed period of time, represented in percent.

b) Output/Process Indicator: As outlined in the attached matrix, including policies and

regional regulations.

2. Regional Budget Allocation: trend and amount of the allocation in accordance with the needs of maternal and neonatal health programs.

3. Cross-sectoral and Private Cooperation: a cross-sectoral and private cooperation

document (MoU). B. Mechanism for monitoring of the National Action Plan for the Acceleration of

Maternal Mortality Ratio Reduction Monitoring of the National Action Plan for the acceleration of maternal mortality ratio reduction can be done using the monthly activity report of maternal health programs on

1) Strengthening and development of integrated recording and reporting system which

becomes the consensus on the data/information that needs to be collected regularly or periodically. It has a simple format but contains important information about maternal health (MDG 5 indicators and other output/outcome indicators which is considered important) and reporting flow (vertical from community health centers to the health office, and horizontal between hospitals and the health office).

2) Analysis of regular reports from provincial and district/municipal health offices on the key indicators, including health professionals’ delivery coverage, delivery at health care facilities, delivery location, number of maternal deaths and activity reports according to the established indicators.

3) Periodic dissemination of information on the development of key indicators of maternal and neonatal health to various stakeholders.

4) Supervision conducted in stages for provinces and districts/cities to directly identify the problems on the acceleration of maternal mortality rate reduction and try to solve them.

5) Monitoring and evaluation team meeting on the acceleration of maternal and neonatal mortality reduction that involves all relevant stakeholders, namely: Ministry of Internal Affairs, Ministry of Health, Ministry of National Development Planning/National Development Planning Board, Ministry of Women's Empowerment and Child Protection, National Family Planning Coordinating Board, Family Welfare Empowerment Movement Team, professional organizations (POGI, IDAI, IDSAI, IDI, IBI, PPNI, IAKMI), KARS, PERSI, Arsada, NGOs and maternal health oberservers organizations.

6) Data-based annual planning that is integrated with all of the available funding resources

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In addition to regular/periodic data collection, other data that is available can be used for evaluation, such as SP, IDHS, SUSENAS, PODES, basic health research and health care facilities research.

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Attachment:

Explanation about Matrix Strategy, Output, Program/Activities, Indicators, Targets and Implementation Actor

The following matrix describes the sub-programs or activities of the 7 main programs that need to be done in the period of 2013-2015 to accelerate the achievement of maternal and neonatal mortality rate target. The main programs selected for the National Action Plan 2013-2015 are the programs that focus on the continuum of care, which, if implemented entirely, has proven to have high leverage for reducing maternal and neonatal mortality rate. Therefore, although other programs are also important, within the next 3 years it is expected that the programs focus and activities refer to the 7 main programs. Each activity will have the indicators that will be used as the basis for periodic progress evaluation, which are conducted quarterly, annually or in other periods of time. Baseline data can be filled with the achievements in 2012 according to the available data. In circumstances where there is not any data at all, it should be denoted by "no data", then the data in 2013 is used as a baseline for evaluation in subsequent years. Annual achievement targets need to be filled in accordance with the existing conditions. Since the reduction of maternal and neonatal maternity rate involves cross programs and cross-sectors, including the government at national, provincial, district and city level, private sector, universities, professional organizations and communitis, the responsible party of every activity should be clarified. Thus the efficiency and effectiveness of the program can be achieved. It is expected that every province, district and city can fill in the Matrix in its Regional Action Plan

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Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

Init

ial A

ctiv

ity

O

rien

tatio

n of

pat

hway

con

cept

and

con

tinuu

m o

f car

efor

all

heal

th

pers

onne

lare

nec

essa

ry, s

o th

ey h

ave

the

sam

e re

fere

nce

and

perc

eptio

ns a

bout

the

dire

ctio

n of

the

polic

y an

d pr

ogra

m

Impl

emen

tatio

n of

the

orie

ntat

ion

for

heal

th p

erso

nnel

at

nat

iona

l, pr

ovin

cial

and

di

stri

ct le

vel

All

dist

rict

s an

d ci

ties

have

rece

ived

th

e or

ient

atio

n by

the

end

of s

econ

d qu

arte

r 201

3

Stra

tegy

1: I

mpr

ovin

g co

vera

ge a

nd q

ualit

y of

mat

erna

l hea

lth s

ervi

ce d

eliv

ery

1.

A

ssur

ance

of

villa

ge m

idw

ife

com

pete

nce

acco

rdin

g to

the

stan

dard

1.1.

Prov

ide

heal

th

care

faci

litie

s in

vi

llage

s(vi

llage

he

alth

pos

ts)

1.1.

1. P

rovi

sion

of v

illag

e he

alth

pos

ts

Num

ber o

f vi

llage

hea

lth

post

s av

aila

ble

in a

sub

dist

rict

The

num

ber

of v

illag

e he

alth

pos

ts

incr

ease

s ev

eryy

eara

ccor

ding

to th

e ta

rget

of e

ach

regi

on, a

ndin

201

5the

nu

mbe

r of

vill

age

heal

th p

osts

ha

vein

crea

seda

t lea

stby

30%

co

mpa

red

to 2

012

(10%

per

year

)

Cent

er fo

r he

alth

pr

omot

ion

Min

. of H

ealth

, H

ealth

Off

ice

at

Prov

inci

al,

Dis

tric

t and

City

, Lo

cal

Gov

ernm

ent,

Re

gion

al

Dev

elop

men

t Pl

anni

ng B

oard

; pr

ofes

sion

al

orga

niza

tion

2826

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

1.

1.2.

Pro

visi

on o

f mid

wife

ki

ts e

quip

ped

with

H

b ch

ecki

ng d

evic

e

Num

ber o

f m

idw

ives

who

ha

s m

idw

ife k

its

in a

dis

tric

t and

ci

ty

By th

e en

d of

201

3 or

the

late

st a

t the

be

ginn

ing

of 2

014

all m

idw

ives

al

read

y ha

ve m

idw

ife k

its a

ccor

ding

to

the

stan

dard

Dir

ecto

rate

of

Mat

erna

l Hea

lth

1.2.

Impr

ove

mid

wife

sk

ills

on

child

birt

h an

d in

tegr

ated

an

tena

tal c

are

1.2.

1. N

orm

al d

eliv

ery

care

trai

ning

for

villa

ge m

idw

ives

Num

ber o

f m

idw

ives

who

ha

s at

tend

ed

the

norm

al

deliv

ery

care

tr

aini

ng a

nd/o

r ot

her s

kills

im

prov

emen

t tr

aini

ngs

Num

ber

of m

idw

ives

who

have

ad

equa

te

com

pete

ncet

hrou

ghtr

aini

ngsi

ncre

ase

ever

yyea

r acc

ordi

ng to

the

targ

et o

f ea

ch re

gion

.By

2015

allm

idw

ives

alre

ady

have

appr

opri

atec

ompe

tenc

e ac

cord

ing

to th

e st

anda

rd

Dir

ecto

rate

of

Mat

erna

l Hea

lth

1.

2.2.

Tra

inin

g on

in

tegr

ated

AN

C

Num

ber o

f in

tegr

ated

AN

C tr

aini

ngs

whi

ch

have

bee

n co

nduc

ted

Num

ber o

f the

inte

grat

edA

NCt

rain

ings

th

at h

ave

been

con

duct

ed in

crea

se

ever

yyea

r acc

ordi

ng to

the

targ

et o

f ea

ch r

egio

n. In

2015

the

AN

Cint

egra

tedt

rain

ing

has

been

im

plem

ente

dfor

allp

erso

nnel

Dir

ecto

rate

of

Mat

erna

l Hea

lth

1.

2.3.

Tra

inin

g fo

r vi

llage

m

idw

ives

in g

ivin

g co

unse

ling

and

educ

atio

n to

the

com

mun

ity to

mak

e th

em m

ore

aler

t

Num

ber o

f vi

llage

mid

wiv

es

trai

ned

in g

ivin

g co

unse

ling

and

educ

atio

n

Trai

ning

for v

illag

e m

idw

ives

in g

ivin

g co

unse

ling

and

educ

atio

n be

gins

in

2013

and

incr

ease

s ev

ery

year

ac

cord

ing

to th

e ta

rget

of e

ach

regi

on.

In 2

015

the

coun

selin

g an

d ed

ucat

ion

Dir

ecto

rate

of

Mat

erna

l Hea

lth

Dir

ecto

rate

of

nurs

ing

serv

ice

and

publ

ic

heal

th M

in. o

f H

ealth

,

2927

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

trai

ning

is c

ondu

cted

for 3

0% o

f vill

age

mid

wiv

es

Prov

inci

al, ,

D

istr

ict/

City

Le

vel

1.3.

Mai

ntai

n/in

crea

se

the

qual

ity o

f m

othe

r and

chi

ld

heal

th c

are

1.3.

1. I

mpr

ove

faci

litat

ive

supe

rvis

ion

for

villa

ge m

idw

ives

Num

ber o

f co

mm

unity

he

alth

cen

ters

co

nduc

ting

faci

litat

ive

supe

rvis

ion

Num

ber o

f com

mun

ity h

ealth

cen

ters

co

nduc

ting

faci

litat

ive

supe

rvis

ion

incr

ease

s ev

ery

year

in a

ccor

danc

e w

ith th

e ta

rget

of e

ach

area

. In

2015

al

l com

mun

ity h

ealth

cen

ters

hav

e co

nduc

ted

faci

litat

ive

supe

rvis

ion

for

all v

illag

e m

idw

ives

reg

ular

ly

Dir

ecto

rate

of

Mat

erna

l Hea

lth

Dir

ecto

rate

of

nurs

ing

serv

ice

and

publ

ic

heal

th M

in. o

f H

ealth

, Pr

ovin

cial

, ,

Dis

tric

t/Ci

ty

Leve

l

2.

A

ssur

ance

of

the

avai

labi

lity

of h

ealth

car

e fa

cilit

ies

capa

ble

of

prov

idin

g de

liver

y ca

re

24/7

in

acco

rdan

ce

with

the

wor

king

st

anda

rd

2.1.

Impr

ove

dete

ctio

n an

d fir

st a

id fo

r co

mpl

icat

ions

ca

ses

and

effe

ctiv

e re

ferr

als

2.1.

1.

Incr

ease

the

num

ber o

f com

mun

ity

heal

th c

ente

rs c

apab

le o

f pr

ovid

ing

deliv

ery

care

ac

cord

ing

to th

e w

orki

ng

stan

dar

24/7

Com

plem

ent/

add

mat

erni

ty

room

at

co

mm

unity

he

alth

ce

nter

s

Com

plem

ent

mea

ns a

nd

infr

astr

uctu

res,

inc

ludi

ng

med

icin

es

Tr

ain

the

com

mun

ity

Num

ber o

f co

mm

unity

he

alth

cen

ter

capa

ble

of

prov

idin

g m

ater

nity

car

e 24

/7

Num

ber o

f com

mun

ity h

ealth

cen

ters

ca

pabl

e of

pro

vidi

ng m

ater

nity

and

ne

onat

al c

are

incr

ease

s ev

ery

year

in

acco

rdan

ce w

ith th

e ta

rget

of e

ach

regi

on. I

n 20

15 5

0% o

f the

com

mun

ity

heal

th c

ente

rs in

dis

tric

t are

as a

nd

100%

in c

ity a

reas

are

cap

able

of

prov

idin

g m

ater

nity

and

neo

nata

l ca

re.

Dir

ecto

rate

of

Basi

c H

ealth

Ca

re

Dev

elop

men

t (B

UKD

)

Prov

inci

al,

Dis

tric

t and

City

H

ealth

Off

ice,

Lo

cal

Gov

ernm

ent,

Re

gion

al

Dev

elop

men

t Pl

anni

ng B

oard

; ho

spita

ls;

prof

essi

onal

or

gani

zatio

n

3028

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

heal

th c

ente

rs’ t

eam

to

wor

k 24

/7, i

nclu

ding

pe

rfor

min

g de

tect

ion

and

first

aid

for

com

plic

atio

ns c

ases

and

ef

fect

ive

refe

rral

s

2.1.

2. C

ondu

ct a

n in

tegr

ated

AN

C,

incl

udin

g pr

even

tion

of H

IV tr

ansm

issi

on

from

mot

her

to c

hild

% o

f com

mun

ity

heal

th c

ente

rs in

di

stri

ct a

nd c

ity

area

s im

plem

entin

g th

e in

tegr

ated

A

NC

Num

ber o

f com

mun

ity h

ealth

cen

ters

in

ditr

ict a

nd c

ity a

reas

impl

emen

ting

the

inte

grat

ed A

NC

incr

ease

s ev

ery

year

in a

ccor

danc

e w

ith th

e ta

rget

of

each

reg

ion.

In 2

015

all c

omm

unity

he

alth

cen

ters

hav

e im

plem

ente

d th

e in

tegr

ated

AN

C

Dir

ecto

rate

of

Mat

erna

l Hea

lth

Min

. of H

ealth

, H

ealth

off

ice

at

prov

inci

al,

dist

rict

and

city

le

vel

Dir

ecto

rate

of

nurs

ing

serv

ice

and

publ

ic

heal

th M

in. o

f H

ealth

, Pr

ovin

cial

, ,

Dis

tric

t/Ci

ty

Leve

l

2.

1.3.

Con

duct

Hb

scre

enin

g fo

r ev

ery

preg

nant

wom

an

chec

king

thei

r pr

egna

ncy

at h

ealth

ca

re fa

cilit

ies

% o

f com

mun

ity

heal

th c

ente

rs

cond

uctin

g H

b ex

amin

atio

n an

d re

port

ing

the

annu

al a

nem

ia

prev

alen

ce

Num

ber o

f com

mun

ity h

ealth

cen

ters

co

nduc

ting

Hb

exam

inat

ion

and

repo

rtin

g th

e an

emia

pre

vale

nce

of

preg

nant

mot

hers

incr

ease

s ev

ery

year

. By

the

end

of 2

013

or th

e la

test

at

the

begi

nnin

g of

201

4 al

l co

mm

unity

hea

lth c

ente

rs h

ave

cond

ucte

d H

b ex

amin

atio

n re

gula

rly

and

repo

rted

the

annu

al a

nem

ia

prev

alen

ce e

very

yea

r

Cent

er o

f Dat

a an

d In

form

atio

n

An

inte

grat

ed

mot

her a

nd

An

inte

grat

ed m

othe

r and

chi

ld h

ealth

Ce

nter

of D

ata

Prov

inci

al,

3129

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

child

hea

lth

info

rmat

ion

syst

em is

es

tabl

ishe

d

info

rmat

ion

syst

em is

ava

ilabl

e in

20

13

and

Info

rmat

ion

Dis

tric

t and

City

Le

vel

2.2.

Incr

ease

the

num

ber o

f fa

cilit

ies

whi

ch

can

prov

ide

trea

tmen

t for

co

mpl

icat

ions

2.2.

1.

Incr

ease

the

num

ber o

f com

mun

ity

heal

th c

ente

rs w

hich

pr

ovid

es P

ON

ED 2

4/7,

pr

iori

tizin

g th

e re

mot

e ar

eas:

Fill

/add

trai

ned

PON

ED

team

Com

plem

ent t

he m

eans

an

d in

fras

truc

ture

, in

clud

ing

med

icin

es, a

t co

mm

unity

hea

lth

cent

ers

Co

nduc

t a re

fres

hmen

t tr

aini

ng fo

r the

exi

stin

g PO

NED

team

giv

en

com

plic

atio

ns c

ases

are

ra

rely

enc

ount

ered

En

sure

the

avai

labi

lity

of

refe

rred

mea

ns o

f tr

ansp

orta

tion

and

adeq

uate

co

mm

unic

atio

n

% o

f com

mun

ity

heal

th c

ente

rs

capa

ble

of

prov

idin

g PO

NED

24/

7 in

di

stri

ct a

nd c

ity

area

s

All

of th

e ex

isiti

ng P

ON

ED c

omm

unity

he

alth

cen

ters

are

func

tioni

ng 2

4/7

by

the

end

of 2

013.

N

umbe

r of c

omm

unity

hea

lth c

ente

rs

capa

ble

of p

rovi

ding

PO

NED

incr

ease

s ev

ery

year

in a

ccor

danc

e w

ith th

e ta

rget

of e

ach

regi

on, a

nd in

201

5 al

l co

mm

unity

hea

lth c

ente

rs th

at

prov

ide

emer

genc

y ca

re c

an p

rovi

de

PON

ED24

/7

Dir

ecto

rate

of

Basi

c H

ealth

Ca

re

Dev

elop

men

t

3230

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

2.3.

Build

coor

dina

tion

and

coop

erat

ion

with

re

ferr

al

hosp

itals

, whi

ch

are

loca

ted

in

the

sam

e re

gion

an

d in

oth

er

regi

ons

(pro

vinc

ial

hosp

itals

, ho

spita

ls in

bo

rder

regi

ons,

m

ilita

ry

hosp

itals

, pri

vate

ho

spita

ls) t

o ex

pand

the

acce

ss to

co

mpl

icat

ions

ca

se re

ferr

als

in

hosp

itals

2.3.

1. B

uild

coo

rdin

atio

n w

ith th

e re

leva

nt

sect

ors

to e

stab

lish

a sy

stem

of r

efer

ral

from

com

mun

ity

heal

th c

ente

rs to

ho

spita

ls.

Num

ber o

f di

stri

cts

and

citie

s th

at h

ave

a re

ferr

al s

yste

m

and

MoU

Gui

delin

efor

ref

erra

l sys

tem

is

com

plet

ed b

y M

in. o

f Hea

lth in

201

3,

and

dist

ribu

ted

to a

ll pr

ovin

ces.

A

t pro

vinc

ial l

evel

, the

gui

debo

ok is

ad

apte

d to

the

loca

l con

ditio

ns o

f ea

ch re

gion

(inc

ludi

ng d

evel

opm

ent o

f M

oU, c

oope

ratio

n/co

ordi

natio

n w

ith,

stak

ehol

ders

, nam

ely

the

loca

l go

vern

men

ts, d

istr

ict h

ospi

tals

, hea

lth

offic

es, p

riva

te h

ospi

tals

and

pri

vate

cl

inic

s) a

nd th

en d

istr

ibut

ed to

the

dist

rict

s an

d ci

ties

in m

id/t

he e

nd o

f 20

13.

The

MoU

is is

sued

and

the

refe

rral

G

uide

lines

tart

s to

be

used

by

all

regi

ons

at th

e be

ginn

ing

of 2

014.

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s (B

UKR

)

The

inte

grat

ed

mot

her a

nd

child

in

form

atio

n sy

stem

is

esta

blis

hed

The

inte

grat

ed m

othe

r and

chi

ld

heal

th in

form

atio

n sy

stem

(ver

tical

an

d ho

riso

ntal

) is

avai

labl

e by

the

end

of 2

013

Cent

er o

f Dat

a an

d In

form

atio

n

3331

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

2.4.

Opt

imiz

e ut

iliza

tion

of

heal

th in

sura

nce

for e

ligib

le

peop

le

(mat

erni

ty

insu

ranc

e,

natio

nal s

ocia

l se

curi

ty s

yste

m)

2.4.

1. B

uild

coo

rdin

atio

n w

ith v

ario

us

stak

ehol

ders

to

impl

emen

t m

ater

nity

in

sura

nce/

natio

nal

soci

al s

ecur

ity

syst

em a

t eve

ry le

vel

of s

ervi

ce, s

o th

e m

ain

task

sand

fu

nctio

ns o

f eve

ry

stak

ehol

der a

re

clea

r

The

coor

dina

ting

mec

hani

sm fo

r th

e im

plem

enta

tion

of m

ater

nity

in

sura

nce/

natio

nal s

ocia

l se

curi

ty s

yste

m

is e

stab

lishe

d

Coor

dina

ting

mec

hani

sm fo

r the

im

plm

enta

tion

of m

ater

nity

in

sura

nce/

natio

nal s

ocia

l sec

urity

sy

stem

in d

istr

ict a

nd c

ity a

reas

is

esta

blis

hed

in 2

013

Cent

er fo

r H

ealth

Sec

urity

Fi

nanc

ing

2.

4.2.

Pro

vide

info

rmat

ion

to th

e pu

blic

abo

ut

the

righ

ts a

nd

oblig

atio

ns re

late

d to

hea

lth in

sura

nce

Dis

sem

inat

ion

of

info

rmat

ion

to

publ

ic a

bout

the

righ

ts a

nd

oblig

atio

ns

rela

ted

to h

ealth

in

sura

nce

has

be

en d

one

Dis

sem

inat

ion

of in

form

atio

n to

pub

lic

abou

t the

rig

hts

and

oblig

atio

ns

rela

ted

to h

ealth

insu

ranc

e h

as b

een

cond

ucte

d in

all

subd

istr

icts

and

vi

llage

s by

hea

lth p

erso

nnel

at t

he

begi

nnin

g of

201

4

Cent

er fo

r H

ealth

Sec

urity

Fi

nanc

ing

2.5.

Impr

ove

qual

ity

of s

ervi

ce

2.5.

1. Im

prov

ethe

ski

lls o

f he

alth

pro

fess

iona

ls

at b

asic

leve

l th

roug

h tr

aini

ngs,

ap

pren

tices

hips

, and

in

-hou

se tr

aini

ngs

in

Num

ber o

f he

ath

prof

essi

onal

s at

tend

ing

PON

ED tr

aini

ng:

mid

wiv

es,

All

PON

ED te

ams

(mid

wiv

es,

phys

icia

ns, n

urse

s) a

t com

mun

ity

heal

th c

ente

rs h

ave

atte

nded

PO

NED

tr

aini

ng b

y th

e en

d of

201

3

Num

ber

of h

ealth

pro

fess

iona

ls a

t

Cent

er o

f Ed

ucat

ion

and

Trai

ning

for

App

arat

us

3432

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

both

ini P

ON

ED o

r no

n-PO

NED

co

mm

unity

hea

lth

cent

ers

phys

icia

ns,

nurs

es

Num

ber o

f he

alth

pr

ofes

sion

als

who

has

take

n ap

pren

tices

hip/

atte

nded

PO

NED

in

-hou

se

trai

ning

: m

idw

ives

, ph

ysic

ians

, nu

rses

PON

ED c

omm

unity

hea

lth c

ente

rs

(oth

er th

an P

ON

ED te

am) t

akin

g ap

pren

tices

hip/

atte

ndin

g PO

NED

in-

hous

e tr

aini

ngs

incr

ease

s ev

ery

year

N

umbe

r of

hea

lth p

rofe

ssio

nals

at

non-

PON

ED c

omm

unity

hea

lth c

ente

rs

that

has

take

n ap

pren

tices

hip/

atte

ndin

g PO

NED

in-

hous

e tr

aini

ngs

incr

ease

s ev

ery

year

ac

cord

ing

to th

e ta

rget

of e

ach

regi

on

2.

5.2.

PO

NEK

hos

pita

ls

prov

ide

guid

ance

for

PON

ED c

omm

unity

he

alth

cen

ters

. It

can

be d

one

in th

e co

mm

unity

hea

lth

cent

ers

or in

PO

NEK

ho

spita

ls

Num

ber o

f PO

NED

co

mm

unity

he

alth

cen

ters

re

ceiv

ing

regu

lar

guid

ance

In 2

013

stra

tegi

es o

f gui

danc

e pr

ovid

ed b

y PO

NEK

hos

pita

ls fo

r PO

NED

com

mun

ity h

ealth

cen

ters

ha

ve b

een

deve

lope

d an

d ag

reed

up

on b

y al

l sta

keho

lder

s in

the

regi

ons.

In

201

4 al

l PO

NEK

hos

pita

ls h

ave

prov

ided

gui

danc

e fo

r PO

NED

co

mm

unity

hea

lth c

ente

rs p

erio

dica

lly

Dir

ecto

rate

of

Basi

c H

ealth

Ca

re

Dev

elop

men

t

2.

5.3.

Per

form

the

Mat

erna

l Per

inat

al

Num

ber o

f di

stri

cts/

citie

s N

umbe

r of d

istr

icts

/citi

es p

erfo

rmin

g M

ater

nal P

erin

atal

Aud

it an

d its

D

irec

tora

te o

f M

ater

nal H

ealth

3533

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

Aud

it an

d fo

llow

up

actio

ns w

hich

may

in

clud

e im

prov

ed

know

ledg

e an

d sk

ills

of h

ealth

per

sonn

el,

fulfi

lling

the

need

fo

r m

edic

al

equi

pmen

t and

m

edic

ines

, mod

ified

po

licie

s, e

tc.

perf

orm

ing

Mat

erna

l Pe

rina

tal A

udit

min

imum

2

times

a y

ear

follo

w-u

p ac

tion

incr

ease

eve

ry y

ear.

In

201

3 at

leas

t the

2-t

ime

Mat

erna

l Pe

rina

tal A

udit

that

is fo

llow

ed b

y th

e ne

cess

ary

actio

ns is

con

duct

ed.

In 2

015

all d

istr

icts

and

citi

es c

ondu

ct

the

Mat

erna

l Per

inat

al A

udit

that

is

follo

wed

by

the

nece

ssar

y ac

tions

4

times

2.

5.4.

Impl

emen

t bac

k re

ferr

al to

allo

w th

e re

ferr

ers

lear

n fr

om

the

resu

lts o

f the

ir

actio

ns a

nd c

ontin

ue

tope

rfor

m th

e m

onito

ring

of p

ost-

ho

spita

lized

pat

ient

s

Num

ber o

f di

stri

cts/

citie

s th

at h

ave

bac

k re

ferr

al

mec

hani

sm

Gui

delin

eon

the

refe

rral

sys

tem

(in

clud

ing

back

refe

rral

) is

com

plet

ed

by th

e M

in. o

f Hea

lth in

201

3 an

d is

ad

apte

d to

the

loca

l con

ditio

ns o

f ea

ch re

gion

. The

Gui

delin

esta

rts

to b

e us

ed b

y al

l reg

ions

at t

he b

egin

ning

of

2014

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s

2.

5.5.

Con

duct

faci

litat

ive

supe

rvis

ion

on

PON

ED c

are

perf

orm

ed b

y a

coor

dina

ting

dist

rict

m

idw

ife o

r ot

her

desi

gnat

ed h

ealth

pr

ofes

sion

als

Num

ber o

f di

stri

ct a

nd c

ities

in

a p

rovi

nce

cond

uctin

g fa

cilit

ativ

e su

perv

isio

n on

PO

NED

Num

ber

of d

istr

icts

and

citi

es

cond

uctin

g fa

cilit

ativ

e su

perv

isio

n on

PO

NED

ser

vice

s re

gula

rly

incr

ease

s ev

ery

year

in a

ccor

danc

e w

ith th

e ta

rget

of e

ach

regi

on.

In 2

014

all d

istr

icts

and

citi

es h

ave

cond

ucte

d fa

cilit

ativ

e su

perv

isio

n re

gula

ry

Dir

ecto

rate

of

Mat

erna

l Hea

lth

Dir

ecto

rate

of

nurs

ing

serv

ice

and

publ

ic

heal

th M

in. o

f H

ealth

, Pr

ovim

ce,

Dis

tric

t/Ci

ty

3634

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

3.

A

ssur

ance

of

the

func

tion

of

all P

ON

EK

hosp

itals

at

dist

rict

/city

le

vel t

o w

ork

24/7

in

acco

rdan

ce

with

the

stan

dard

3.1.

Impr

ove

the

qual

ity o

f hea

lth

pers

onne

l in

refe

rral

hos

pita

ls

in h

andl

ing

com

plic

atio

ns

case

s in

a ti

mel

y an

d ap

prop

riat

e m

anne

r,

incl

udin

g th

e av

aila

bilit

y of

gu

idel

ines

on

stan

dard

of

care

for

com

plic

atio

n ca

ses

3.1.

1. C

ondu

ct c

linic

al

man

agem

ent

trai

ning

s, in

clud

ing

trai

ning

s on

PO

NEK

, lif

e sa

ving

ski

lls a

nd

othe

r tr

aini

ngs,

for

heal

th p

rofe

ssio

nals

in

hos

pita

ls to

en

able

them

han

dle

com

plic

atio

ns c

ases

re

ferr

ed to

hos

pita

ls

Clin

ical

m

anag

emen

t tr

aini

ngs,

in

clud

ing

trai

ning

s on

PO

NEK

, life

sa

ving

ski

lls a

nd

othe

r tr

aini

ngs,

fo

r he

alth

pr

ofes

sion

als

in

hosp

itals

are

co

nduc

ted

to

enab

le th

em to

ha

ndle

the

com

plic

atio

ns

case

s re

ferr

ed to

ho

spita

ls

All

dist

rict

hos

pita

ls h

ave

a te

am o

f tr

aine

d he

alth

pro

fess

iona

ls

(obs

tetr

ics/

gyne

olog

y, p

edia

tric

s an

d an

esth

esio

logy

and

pos

t gra

duat

e st

uden

ts o

f PPD

S) w

ho is

cap

able

of

prov

idin

g PO

NEK

ser

vice

by

the

end

of

2014

.

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s

Loca

l G

over

nmen

t;

Regi

onal

D

evel

opm

ent

Plan

ning

Boa

rd;

Hea

lth O

ffic

e at

Pr

ovin

cial

, D

istr

ict

and

City

Le

vel;

Hos

pita

ls;

Prof

essi

onal

O

rgan

izat

ions

3.2.

Build

co

ordi

natio

n an

d co

oper

atio

n w

ith

othe

r re

ferr

al

hosp

itals

, in

clud

ing

the

hosp

itals

of

high

er ty

pe,

priv

ate

hosp

itals

/mat

ern

3.2.

1. B

uild

coo

rdin

atio

n an

d de

velo

p a

coop

eativ

e co

nsen

sus

with

oth

er

refe

rral

hos

pita

ls,

whi

ch a

re th

e ho

spita

ls o

f hig

her

type

, pri

vate

ho

spita

ls/m

ater

nity

ho

spita

ls a

nd

MoU

or

mec

hani

sm/g

uid

elin

es fo

r co

ordi

natio

n an

d co

oper

atio

n w

ith re

ferr

al

hosp

itals

is

deve

lope

d

Ever

y di

stri

ct/c

ity a

lrea

dy h

as a

n M

oU

or c

oope

ratio

n in

201

4 D

irec

tora

te fo

r de

velo

pmen

t of

refe

rral

st

anda

rds

3735

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

ity h

ospi

tals

and

m

ilita

ry

hosp

itals

, to

expa

nd th

e ac

cess

for

com

plic

atio

ns

case

s in

hos

pita

ls

mili

tary

hos

pita

ls, t

o ex

pand

the

acce

ss

for

com

plic

atio

ns

case

s in

hos

pita

ls

3.3.

Ensu

re th

e ac

cess

to s

afe

bloo

d

3.3.

1. Im

prov

e an

d st

reng

then

the

coop

erat

ion

with

th

e In

done

sian

Red

Cr

oss

Coop

erat

ion

betw

een

the

Indo

nesi

an R

ed

Cros

s an

d ho

spita

ls’ b

lood

tr

ansf

usio

n un

it on

blo

od

prov

isio

n is

es

tabl

ishe

d

Coop

erat

ion

betw

een

the

Indo

nesi

an

Red

Cros

s an

d ho

spita

ls’ b

lood

tr

ansf

usio

n un

it in

all

dist

rict

s/ci

ties

on b

lood

pro

visi

on is

agr

eed

upon

by

the

end

of 2

013

Dir

ecto

rate

of

Basi

c H

ealth

Ca

re

Dev

elop

men

t

3.

3.2.

Impr

ove

the

func

tion

of b

lood

tr

ansf

usio

n un

it

A b

lood

tr

ansf

usio

n un

it is

ava

ilabl

e in

ho

spita

ls a

nd

func

tioni

ng in

ac

cord

ance

with

th

e st

anda

rd

All

publ

ic h

ospi

tals

’ blo

od tr

ansf

usio

n un

it ar

e fu

nctio

ning

by

the

end

of

2013

Dir

ecto

rate

of

Basi

c H

ealth

Ca

re

Dev

elop

men

t

3.

3.3.

Impr

ove

the

coop

erat

ion

betw

een

hosp

itals

,

MoU

/coo

pera

tion

betw

een

MoU

/coo

pera

tion

betw

een

hosp

itals

, in

the

sam

e re

gion

or

ousi

de th

e D

irec

tora

te o

f Ba

sic

Hea

lth

3836

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

both

in th

e sa

me

regi

on a

nd o

utsi

de

the

regi

on,o

n bl

ood

prov

isio

n

hosp

itals

, in

the

sam

e re

gion

or

ousi

de th

e re

gion

, on

bloo

d pr

ovis

ion

regi

on, o

n bl

ood

prov

isio

n is

es

tabl

ishe

d by

the

end

of 2

013

Ca

re

Dev

elop

men

t

3.4.

Impr

ove

post

pa

rtum

fam

ily

plan

ning

ac

cept

ors

N

umbe

r of

post

part

um

fam

ily p

lann

ing

acce

ptor

s in

ho

spita

ls

incr

ease

s ev

ery

year

Num

ber o

f pos

tpar

tum

fam

ily

plan

ning

acc

epto

rs in

hos

pita

ls

incr

ease

s ev

ery

year

in a

ccor

danc

e w

ith th

e ta

rget

of e

ach

regi

on

In 2

015

the

num

ber

of p

ostp

artu

m

mot

hers

who

bec

ome

fam

ily p

lann

ing

acce

ptor

s in

crea

se b

y 50

% c

ompa

red

to th

e pr

evio

us y

ear

Dir

ecto

rate

of

Mat

erna

l Hea

lth

3.5.

Ensu

re th

e av

aila

bilit

y of

ob

stet

ric

and

neon

atal

car

e at

an

y tim

e (2

4 ho

urs

7 da

ys)

3.5.

1. C

ompl

emen

t/ad

d pe

rson

nel t

o en

sure

th

e se

rvic

e de

liver

y 24

/7. P

rovi

de a

PO

NEK

team

ca

pabl

e of

pro

vidi

ng

emer

genc

y ca

re,

incl

udin

g a

caes

aria

n se

ctio

n op

erat

ors

(obs

tetr

icia

n/gy

neco

logi

st, p

ost-

grad

uate

st

uden

t of

obst

etri

cs),

Num

ber o

f PO

NEK

hos

pita

ls

capa

ble

of

prov

idin

g se

rvic

es 2

4/7

In 2

014

all d

istr

ict p

ublic

hos

pita

ls c

an

serv

e as

a P

ON

EK h

ospi

tal 2

4/7

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s

3937

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

pedi

atri

cian

, A

nest

hesi

olog

ist a

nd

para

med

ics,

mid

wife

an

d nu

rse

3.

5.2.

Com

plem

ent

/add

the

infr

astr

uctu

re:

oper

atin

g ro

om a

nd

its p

rior

ity u

se

arra

ngem

ent,

C-

sect

ion

kits

, m

edic

ines

, blo

od,

etc

Dis

tric

t pub

lic

hosp

itals

hav

e fa

cilit

ies

and

infr

astr

uctu

res

acco

rdin

g to

the

serv

ice

stan

dard

All

dist

rict

hos

pita

ls h

ave

com

plet

e fa

cilit

ies

and

infr

astr

uctu

res

in 2

014

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

3.

5.3.

Con

duct

inno

vativ

e ap

proa

ches

ac

cord

ing

to th

e lo

cal c

ondi

tions

for

the

hosp

itals

un

derg

oing

hum

an

reso

urce

s sh

orta

ge,

part

icul

arly

in

rem

ote

bord

er a

reas

an

d is

land

s. F

or

exam

ple

is th

e si

ster

ho

spita

l pro

gram

im

plem

ente

d in

Eas

t N

usa

Teng

gara

Inno

vativ

e ac

tions

to

redu

ce h

uman

re

sour

ces

gap,

in

clud

ing

med

ical

sp

ecia

lists

, are

ta

ken

In 2

013s

tudy

on

the

inno

vativ

e ac

tions

is

ava

ilabl

e

In 2

014

the

impl

emen

tatio

n be

gins

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s

Nat

iona

l, Pr

ovin

cial

, D

istr

ict/

City

Le

vel

4038

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

3.6.

Impr

ove

the

qual

ity o

f se

rvic

es

3.6.

1. Im

prov

e th

e sk

ills

of

heal

th p

rofe

ssio

nals

: m

idw

ives

, phy

sici

ans

and

spec

ialis

ts,

thro

ugh

trai

ning

s,

appr

entic

eshi

ps, i

n-ho

use

trai

ning

s an

dgui

danc

e

Num

ber o

f ho

spita

l pe

rson

nel:

mid

wiv

es,

phys

icia

ns, p

ost

grad

uate

st

uden

ts o

f m

edic

ines

, at

tend

ing

PON

EK tr

aini

ng

or in

-hou

se

trai

ning

or

taki

ng in

tern

ship

In 2

014

all P

ON

EKte

ams

in h

ospi

tals

ha

ve b

een

trai

ned

In 2

015

all d

istr

ict h

ospi

tals

hav

e co

nduc

ted

impr

ovem

ent o

f kn

owle

dge

and

skill

s on

mat

erni

ty a

nd

neon

atal

for

all h

ealth

per

sonn

el

(phy

sici

ans,

mid

wiv

es a

nd n

urse

s) w

ho

have

not

rec

eive

PO

NEK

trai

ning

s th

roug

h ap

pren

tices

hip/

in-h

ouse

tr

aini

ng

Cent

er o

f Ed

ucat

ion

and

Trai

ning

for

Hea

lth

Prof

essi

onal

s,

Min

. of H

ealt

h BP

PSD

M

3.

6.2.

Con

duct

aud

it on

all

mat

erna

l and

ne

onat

al m

orta

lity

occu

ring

in

hosp

itals

, fol

low

ed

by n

eces

sary

act

ions

(im

prov

emen

t of

hum

an re

sour

ces

com

pete

nce;

pr

ovis

ion

of

med

icin

es, b

lood

an

d eq

uipm

ent,

% o

f hos

pita

ls

cond

uctin

g au

dit

on m

ater

nal a

nd

neon

atal

m

orta

lity

In 2

014

all d

istr

ict h

ospi

tals

con

duct

au

dit o

n m

ater

nal a

nd n

eona

tal

mor

talit

y th

at is

follo

wed

by

nece

ssar

y ac

tions

.

Dir

ecto

rate

of

Mat

erna

l Hea

lth

4139

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

mod

ifica

tion

of

polic

y)

3.

6.3.

Opt

imiz

e su

perv

isio

n an

d qu

ality

ass

uran

ce in

ho

spita

ls

Supe

rvis

ion

and

qual

ity

assu

ranc

e in

ho

spita

ls a

re

cond

ucte

d re

gula

rly

In 2

014

all d

istr

ict h

ospi

tals

hav

e gu

idel

ines

and

con

duct

sup

ervi

sion

an

d qu

ality

ass

uran

ce in

hos

pita

ls

regu

larl

y

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s

Dis

tric

t/Ci

ty

Leve

l

3.

6.4.

Use

a se

rvic

e ed

ict t

o in

crea

se th

e ro

le o

f th

e so

ciet

y in

im

prov

ing

the

serv

ice

qual

ity

% o

f hos

pita

ls a

t di

stri

ct/c

ity le

vel

that

hav

e a

serv

ice

edic

t

In 2

014

all d

istr

ict h

ospi

tals

hav

e se

rvic

e ed

it

Cent

er fo

r he

alth

pr

omot

ion

3.7.

Stre

ngth

en

mat

erni

ty a

nd

neon

atal

ser

vice

sy

stem

in

hosp

itals

3.7.

1. D

evel

op/m

odify

po

licie

s in

hea

lth

care

faci

litie

s:

adm

issi

on fl

ow a

nd

hand

ling

of o

bste

tric

an

d ne

onat

al

emer

genc

y ca

ses,

av

aila

bilit

y an

d pr

oper

func

tioni

ng

of th

e em

erge

ncy

room

, etc

Polic

ies

on

hosp

ital s

ervi

ces

are

avai

labl

e,

incl

udin

g ad

mis

sion

flow

an

d ha

ndlin

g of

ob

stet

ric

and

neon

atal

em

erge

ncy

case

s,

avai

labi

lity

and

prop

er

func

tioni

ng o

f

By th

e en

d of

201

3 al

l dis

tric

t hos

pita

ls

have

and

impl

emen

t cle

ar a

nd

adeq

uate

pol

icie

s on

hos

pita

l ser

vice

s

Dir

ecto

rate

of

Mat

erna

l Hea

lth

4240

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

the

emer

genc

y ro

om, e

tc

3.

7.2.

Im

plem

ent b

ack

refe

rral

mad

e by

the

hosp

itals

for

the

refe

rrer

s, s

o th

e m

onito

ring

of t

he

post

-hos

pita

lized

pa

tient

s ca

n be

pr

ovid

ed b

y th

e re

ferr

ers

% o

f dis

tric

t ho

spita

ls m

akin

g ba

ck r

efer

ral

and

reco

rd a

nd

cond

uctin

g a

regu

lar

repo

rtin

g

By th

e en

d of

201

3 al

l dis

tric

t hos

pita

ls

mak

e ba

ck re

ferr

als

and

mak

e a

reco

rd a

nd c

ondu

ct a

regu

lar

repo

rtin

g

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s

4.

A

ssur

ance

of

the

impl

emen

tatio

n of

eff

ectiv

e re

ferr

al fo

r co

mpl

icat

ions

ca

ses

4.1.

Ens

ure

the

avai

labl

ity o

f re

ferr

al

guid

elin

es

4.1.

1. D

evel

op/e

stab

lish

clea

r ref

erra

l gu

idel

ines

at

natio

nal l

evel

Num

ber o

f pr

ovin

ces

and

dist

rict

s an

d ci

ties

that

has

gu

idel

ines

on

mat

erna

l and

ne

onat

al r

efer

ral

syst

em

Gui

delin

eon

the

refe

rral

sys

tem

(in

clud

ing

back

refe

rral

) is

com

plet

ed

by th

e M

inis

try

of H

ealth

in 2

013.

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s;

Dir

ecto

rate

of

Mat

erna

l Hea

lth

Hea

lth O

ffic

e at

Pr

ovin

cial

, D

istr

ict a

nd C

ity

Leve

l, Lo

cal

Gov

ernm

ent,

Re

gion

al

Dev

elop

men

t Pl

anni

ng B

oard

; ho

spita

ls;

prof

essi

onal

or

gani

zatio

n

4.

1.2.

Dev

elop

/est

ablis

h cl

ear r

efer

ral

guid

elin

es a

nd

Num

ber o

f di

stri

ct/c

ities

th

at h

ave

The

guid

elin

es a

re a

dapt

ed to

the

cond

ition

s in

eac

h re

gion

. The

gu

idel

ines

are

alr

eady

ava

ilabl

e an

d

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

4341

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

oper

atio

ns a

t loc

al

leve

l, in

clud

ing

the

func

tion

and

role

of

ever

y le

vel o

f ser

vice

guid

elin

es o

n m

ater

nal a

nd

neon

atal

ref

erra

l sy

stem

impl

emen

ted

at p

rovi

ncia

l, di

stri

ct a

nd

city

leve

ls.

stan

dard

s

4.

1.3.

Dev

elop

gui

delin

es

on b

ack

refe

rral

, w

hich

ism

ade

by

hosp

itals

to th

e re

ferr

ers

Gui

delin

es o

n ba

ck r

efer

ral a

re

avai

labl

e

In 2

014

guid

elin

es o

n re

ferr

al s

yste

m,

incl

udin

g ba

ck r

efer

ral,

are

avai

labl

e an

d im

plem

ente

d in

the

regi

ons

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s

4.

1.4.

Dev

elop

gui

delin

es

on re

ferr

al s

yste

m

for

patie

nts

who

ut

ilize

the

mat

erni

ty

insu

ranc

e pr

ogra

mor

oth

er

gove

rnm

ent h

ealth

in

sura

nce

prog

ram

s

Gui

delin

es o

n re

ferr

al s

yste

m

for

patie

nts

who

ut

ilize

the

mat

erni

ty

insu

ranc

e pr

ogra

mor

oth

er

gove

rnm

ent

heal

th in

sura

nce

prog

ram

s ar

e av

aila

ble

Gui

delin

es o

n re

ferr

al s

yste

m fo

r pa

tient

s w

ho u

tiliz

e th

e m

ater

nity

in

sura

nce

prog

ram

are

com

plet

ed in

20

13

Gui

delin

es o

n re

ferr

al s

yste

m a

dapt

ed

to th

e na

tiona

l soc

ial s

ecur

ity s

ytem

pr

ogra

m is

com

plet

ed in

201

4

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s,

Cent

er fo

r H

ealth

Sec

urity

Fi

nanc

ing

4.2.

Ens

ure

the

avai

labi

lity

of

firm

refe

rral

sy

stem

4.2.

1. D

evel

op/s

tren

gthe

n a

mut

ually

agr

eed

netw

orki

ng s

yste

m,

whi

ch in

clud

es

"Ver

tical

Ref

eren

ce

Net

wor

k" b

etw

een

The

refe

rral

sy

stem

net

wor

k is

ava

ilabl

e

Gui

delin

es o

n re

ferr

al s

yste

m a

t pr

ovin

cial

, dis

tric

t and

city

leve

s ar

e co

mpl

eted

and

impl

emen

ted

in 2

014,

in

clud

ing

vert

ical

net

wor

king

sys

tem

(b

etw

een

high

er-t

ype

hosp

itals

and

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s

4442

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

basi

c se

rvic

es a

nd

serv

ices

at a

hig

her

leve

l (ho

spita

l se

rvic

es),

and

"Hor

izon

tal R

efer

ral

Net

wor

k"

low

-typ

e ho

spita

ls),

hori

zont

al

netw

orki

ng s

yste

m (b

etw

een

publ

ic

and

priv

ate

hosp

itals

) and

cro

ss-

regi

onal

net

wor

king

sys

tem

4.

2.2.

Dev

elop

/str

engt

hen

a m

utua

lly-a

gree

d re

gion

al n

etw

orki

ng

syst

em, e

spec

ially

to

han

dle

rem

ote

and

bord

er a

reas

Regi

onal

ne

twor

king

of

refe

rral

sys

tem

is

ava

ilabl

e

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

4.

2.3.

Dev

elop

a r

efer

ral

com

mun

icat

ion

syst

em th

at h

as tw

o ob

ject

ives

: to

prov

ide

guid

ance

an

d se

rvic

es fo

r ob

tain

ing

the

conf

irm

atio

n ab

out

the

avai

labi

lity

of

the

refe

rral

hos

pita

l se

rvic

es (t

he

avai

labi

lity

of

doct

or, b

ed, b

lood

, m

edic

ines

, etc

.)

The

refe

rral

co

mm

unic

atio

n sy

stem

is

esta

blis

hed

In 2

015

all d

istr

icts

/citi

es th

at h

ave

a go

od te

leco

mm

unic

atio

n ne

twor

k ha

ve d

evel

oped

and

impl

emen

ted

the

refe

rral

com

mun

icat

ion

syst

em

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s,

Cent

er o

f Dat

a an

d In

form

atio

n

4.

2.4.

Str

engt

hen

the

Adm

issi

on a

nd

By th

e en

d of

201

3 al

l dis

tric

t hos

pita

ls

Dir

ecto

rate

for

4543

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

adm

issi

on a

nd

hand

ling

syst

em fo

r ca

ses

in th

e ho

spita

ls, i

nclu

ding

ha

ndlin

g flo

w,

coor

dina

tion

with

ob

stet

rici

an o

r po

st-

grad

uate

stu

dent

s of

obs

tetr

ics,

and

co

ordi

natio

n w

ith

othe

r sp

ecia

lists

as

soci

ated

with

m

ater

nal d

eath

s du

e to

indi

rect

ca

uses

hand

ling

syst

em

for

emer

genc

y ca

ses

in

hosp

itals

are

im

plem

ente

d in

ac

cord

ance

with

th

e ho

spita

ls

accr

edita

tion

stan

dard

s.

have

and

impl

emen

ted

the

polic

y on

em

ergn

ecy

care

for

emer

genc

y ca

ses

in h

ospi

tals

acc

ordi

ng to

the

hosp

ital

accr

edita

ton

stan

dard

s

deve

lopm

ent o

f re

ferr

al

stan

dard

s

4.

2.5.

Dev

elop

/str

engt

hen

a m

utua

lly-a

gree

d ne

twor

king

sys

tem

fo

r re

mot

e ar

eas

and

isla

nds

Net

wor

king

sy

stem

in

rem

ote

area

s an

d is

land

s is

av

aila

ble

Net

wor

king

sys

tem

in re

mot

e ar

eas

and

isla

nds

is e

stab

lishe

d by

the

end

of 2

013

5.

A

dole

scen

t re

prod

uctiv

e he

alth

ser

vice

s as

ear

ly

inte

rven

tion

effo

rt to

pr

even

t

5.1.

Ens

ure

avai

labi

lity

of

yout

h-fr

iend

ly

heal

th s

ervi

ces

that

focu

s on

pr

omot

ion

and

prev

entio

n

5.1.

1. In

crea

se n

umbe

r of

yo

uth-

frie

ndly

pu

skes

mas

(PKP

R)

thro

ugh

trai

ning

of

heal

th w

orke

rs a

nd

tech

nica

l as

sist

ance

s

Cove

rage

of

dist

rict

s th

at

have

min

imal

4

PKPR

pus

kesm

as

95%

of t

otal

dis

tric

ts th

at h

ave

min

imal

4 P

KPR

pusk

esm

as b

y 20

14

Dir

ecto

rate

of

Child

Hea

lth

Hea

lth O

ffic

e an

d Pu

blic

H

ospi

tal a

t Pr

ovin

cial

, D

istr

ict a

nd C

ity

Leve

l;

4644

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

adol

esce

nt

preg

nanc

y th

roug

h IE

C an

d co

unse

ling

Stra

tegy

2: E

ncha

ncin

g th

e lo

cal g

over

nmen

ts’ a

nd p

riva

te s

ecto

r’s

role

in im

prov

ingm

ater

nal h

ealth

6.

A

ssur

ance

of

the

loca

l go

vern

men

ts’e

ndor

se fo

r th

e re

gula

tions

th

an c

an

effe

ctiv

ely

supp

ort t

he

prog

ram

im

plem

enta

tion

6.1.

Regu

latio

n on

th

e pr

ocur

emen

t an

d as

sign

men

t of

hea

lth

prof

essi

onal

s

6.1.

1. S

ubm

it a

prop

osal

to

the

cent

ral a

nd lo

cal

gove

rnm

ents

to

mee

t the

man

pow

er

need

s in

hea

lth c

are

faci

litie

s at

var

ious

le

vels

, so

peop

le

have

acc

ess

24/7

to

mat

erni

ty a

nd

neon

atal

ser

vice

s w

hich

are

req

uire

d.

The

prop

osal

in

clud

es

Co

mpl

etin

g th

e m

anpo

wer

at

PON

ED a

nd P

ON

EK

faci

litie

s th

at d

o no

t ha

ve tr

aine

d pe

rson

nel

A

ssig

ning

a P

ON

ED

team

at P

ON

ED

faci

litie

s gr

adua

lly

A

ssig

ning

a P

ON

EK

team

at P

ON

EK

N

umbe

r of

PON

ED

com

mun

ity

heal

th c

ente

rs

in a

dis

tric

t an

d ci

ty th

at

has

the

requ

ired

sp

ecia

lists

Num

ber o

f PO

NEK

ho

spita

ls in

a

prov

ince

that

ha

s th

e re

quir

ed

spec

ialis

ts

By

the

end

of 2

013

all P

ON

EK

hosp

itals

hav

e be

en c

ompl

eted

w

ith th

e re

quir

ed s

peci

alis

ts, s

o th

ey c

an fu

nctio

n 24

/7

In

201

3 al

l PO

NED

com

mun

ity

heal

th c

ente

rs a

re c

ompl

eted

with

th

e re

quir

ed s

peci

alis

ts s

o th

ey c

an

func

tion

24/7

In

201

5 al

l com

mun

ity h

ealth

ce

nter

s th

at p

rovi

de e

mer

genc

y ca

re h

ave

heal

th p

erso

nnel

who

ar

e ca

pabl

e of

pro

vidi

ng P

ON

ED

24/7

BPPS

DM

(Pusreng

unakes

) H

ealth

Off

ice

at

Prov

inci

al,

Dis

tric

t and

City

Le

vel,

Loca

l G

over

nmen

t,

Regi

onal

D

evel

opm

ent

Plan

ning

Boa

rd;

hosp

itals

; pr

ofes

sion

al

orga

niza

tion

4745

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

hosp

itals

gra

dual

ly

En

suri

ngth

e av

aila

bilit

y of

sp

ecia

lists

atP

ON

EK

hosp

itals

or

publ

ic

hosp

itals

that

hav

e no

t obt

aine

d PO

NEK

st

atus

6.1.

2. S

ubm

it a

prop

osal

to

the

loca

l go

vern

men

ts to

se

cure

the

assi

gnm

ent o

f pe

rson

nel w

ho h

ave

rece

ived

PO

NED

/PO

NEK

tr

aini

ng, s

o th

ey w

ill

not b

e tr

ansf

erre

d or

repl

ace

them

with

ot

her p

erso

nnel

who

ha

ve e

qual

cap

acity

an

d ha

ve b

een

prep

ared

% o

f dis

tric

ts

and

citie

s in

a

prov

ince

that

ha

ve o

ffic

ially

ob

tain

ed P

ON

ED

stat

us th

roug

h a

decr

ee

(incl

udin

g de

cree

for

pers

onne

l) %

of d

istr

icts

an

d ci

ties

in a

pr

ovic

e th

at

have

off

icia

lly

obta

ined

PO

NEK

st

atus

thro

ugh

a de

cree

(in

clud

ing

In 2

014

all P

ON

ED c

omm

unity

hea

lth

cent

er h

ave

offic

ially

obt

aine

d PO

NED

st

atus

thro

ugh

a dc

ree

In 2

014

all P

ON

EK h

ospi

tals

hav

e of

ficia

lly o

btai

ned

PON

EK s

tatu

s th

roug

h a

decr

ee

Dir

ecto

rate

of

Basi

c H

ealth

Ca

re

Dev

elop

men

t D

irec

tora

te fo

r de

velo

pmen

t of

refe

rral

st

anda

rds

4846

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

decr

ee fo

r pe

rson

nel)

6.

2. Re

gula

tion

on

the

assu

ranc

e of

th

e av

aila

bilit

y of

ne

cess

ary

med

icin

es in

ba

sic

heal

th c

are

faci

litie

s

6.2.

1. I

mpr

ove

and

stre

ngth

en

coor

dina

tion

with

na

tiona

l and

loca

l go

vern

men

t, s

o th

e av

aila

bilit

y of

the

med

icin

es re

quir

ed

is a

ssur

ed a

t all

times

, inc

ludi

ng th

e pl

anni

ng p

roce

ss,

man

agem

ent a

nd

mon

itori

ng-

eval

uatio

n

Perc

enta

ge o

f th

e av

aila

bilit

y of

ess

entia

l m

edic

ines

for

mot

hers

and

ne

wbo

rns.

In 2

014,

100

% o

f ess

entia

l med

icin

es

for

mot

hers

and

new

born

s ar

e av

aila

ble

acco

rdin

g to

the

type

and

am

ount

of t

he m

edic

ies.

Dir

ecto

rate

of

Publ

ic

Med

icin

esan

d H

ealth

Supp

lies

Nat

iona

l, H

ealth

O

ffic

e at

pr

ovin

cial

, di

stri

ct/c

ity

leve

l

6.

2.2.

Im

prov

e an

d st

reng

then

co

ordi

natio

n w

ith

the

Indo

nesi

an R

ed

Cros

s re

gard

ing

the

bloo

d pr

ovis

ion,

if

nece

ssar

y th

roug

h a

Mem

oran

dum

of

Und

erst

andi

ng a

t lo

cal l

evel

MO

U o

n bl

ood

prov

isio

n be

twee

n he

alth

of

fice

and

the

Indo

nesi

an R

ed

Cros

s is

es

tabl

ishe

d

In 2

014,

MO

U b

etw

een

all h

ealth

of

fices

at p

rovi

ncia

l, di

stri

ct/c

ity le

vels

an

d th

e In

done

sian

Red

Cro

ss is

es

tabl

ishe

d

Dir

ecto

rate

of

Basi

c H

ealth

Ca

re

Dev

elop

men

t

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

6.

2.3.

Im

prov

e an

d M

OU

on

bloo

d In

201

4, M

OU

bet

wee

n al

l hos

pita

ls

Dir

ecto

rate

of

Prov

inci

al,

4947

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

stre

ngth

en

coor

dina

tion

betw

een

hosp

itals

, pu

blic

and

and

pr

ivat

e, b

oth

with

in

the

regi

on a

nd

outs

ide

the

regi

on

(pro

vinc

ial h

ospi

tals

or

the

near

est

hosp

ital),

in th

e pr

ovis

ion

of

equi

pmen

t,

med

icin

es a

nd

bloo

d, if

nec

essa

ry

thro

ugh

a M

emor

andu

m o

f U

nder

stan

ding

at

loca

l lev

el

prov

isio

n be

twee

n ho

spita

ls a

nd

the

Indo

nesi

an

Red

Cros

s is

es

tabl

ishe

d

and

the

Indo

nesi

an R

ed C

ross

is

esta

blis

hed

Basi

c H

ealth

Ca

re

Dev

elop

men

t,

Dir

ecto

rate

for

deve

lopm

ent o

f re

ferr

al

stan

dard

s

Dis

tric

t/Ci

ty

Leve

l

6.3.

Regu

latio

n on

ad

min

istr

ativ

e an

d fin

anci

al

gove

rnan

ce

6.3.

1. S

ubm

it a

prop

osal

to

the

loca

l go

vern

men

ts to

in

crea

se th

e re

gion

al

budg

et a

lloca

tion

to

supp

ort h

ealth

ac

tiviti

es th

at h

ave

a hi

gh le

vera

ge to

ac

hiev

e th

e M

DG

5:

Loca

l bud

get

allo

catio

n fo

r th

e ac

tiviti

es

that

hav

e hi

gh

leve

rage

to

achi

eve

MD

G 5

in

crea

ses

as

need

ed

Serv

ices

pro

vide

d by

PO

NEK

hos

pita

ls

for

24/7

and

by

at le

ast 4

PO

NED

co

mm

unity

hea

lth c

ente

rs fo

r 24

/7

per d

istr

ict a

nd b

y tr

aine

d m

idw

ives

ar

e pe

rfor

med

eve

ry y

ear

The

num

ber

of c

omm

unity

hea

lth

cent

ers

prov

idin

g em

erge

ncy

care

that

Loca

l G

over

nmen

t,

Loca

l Par

liam

ent

5048

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

PON

EK h

ospi

tals

, re

ferr

ed h

ospi

tals

, PO

NED

com

mun

ity

heal

th c

ente

rs a

nd

com

pete

nt

mid

wiv

es

are

conv

erte

d in

to c

omm

unity

hea

lth

cent

ers

prov

idin

g PO

NED

24/

7 in

crea

se to

4 p

er d

istr

ict i

n 20

14

6.

3.2.

Sub

mit

a pr

opos

al to

th

e lo

cal

gove

rnm

ents

abo

ut

the

need

for

brea

kthr

ough

eff

orts

re

late

d to

mat

erna

l an

d ne

onat

al c

are,

in

clud

ing

cons

ider

ing

the

emer

genc

y as

pect

s in

ser

vice

del

iver

y (a

fter

wor

king

ho

urs)

Regi

onal

re

gula

tion

on

brea

kthr

ough

ef

fort

s fo

r m

ater

nal a

nd

neon

atal

car

e,

incl

udin

g pr

ovis

ion

of

serv

ices

by

spec

ialis

ts, i

s de

velo

ped

In 2

013

the

regi

onal

reg

ulat

ion

rega

rdin

g m

ater

nal a

nd n

eona

tal c

are

is m

odifi

ed

Dir

ecto

rate

of

Mat

erna

l H

ealth

, D

irec

tora

te o

f Ch

ild H

ealth

6.

3.3.

Sub

mit

a pr

opos

al to

th

e lo

cal

gove

rnm

ents

to

mak

e cl

ear

regu

latio

ns fo

r bo

rder

and

rem

ote

area

s, in

clud

ing

the

regu

latio

n go

vern

ing

Polic

ies/

loca

l re

gula

tions

on

refe

rral

sys

tem

fo

r bo

rder

and

re

mot

e ar

eas

In 2

014

polic

ies/

loca

l reg

ulat

ions

on

refe

rral

sys

tem

for b

orde

r an

d re

mot

e ar

eas

are

effe

ctiv

e

Dir

ecto

rate

of

Basi

c H

ealth

Ca

re

Dev

elop

men

t

5149

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

the

refe

rral

sys

tem

of

obs

tetr

ic a

nd

neon

atal

cas

es to

fa

cilit

ate

the

peop

le

in th

ese

area

s to

ac

cess

the

heal

th

care

ser

vice

s ne

arby

6.

4. Re

gula

tion

on

impr

oved

qu

ality

/ski

lls o

f he

alth

pr

ofes

sion

als

6.4.

1. S

ubm

it a

prop

osal

to

the

loca

l go

vern

men

ts to

im

prov

e th

e qu

ality

an

d cl

inic

al s

kills

of

heal

th p

rofe

ssio

nals

th

roug

h tr

aini

ng,

appr

entic

eshi

p or

ot

her

trai

ning

pr

ogra

ms

Ann

ual p

lan

on

clin

ical

trai

ning

fo

r he

alth

pe

rson

nel i

s av

aila

ble

In 2

013

a cl

inic

al tr

aini

ng p

lann

ing

is

deve

lope

d fo

r 20

14 a

nd 2

015

Cent

er o

f Ed

ucat

ion

and

Trai

ning

for

Hea

lth

Prof

essi

onal

s

6.

4.2.

Reg

ulat

e th

e pe

rmit

for e

stab

lishi

ng

scho

ols

or a

cade

my

in th

e re

gion

s to

re

fer

to th

e cu

rren

t pr

ofes

sion

al

stan

dard

of

com

pete

nce

Pust

anse

rdik

BP

PSD

M

6.

4.3.

Con

duct

so

cial

izat

ion

of th

e

BP

PSD

M

5250

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

Hea

lth M

inis

ter

Dec

ree

of 2

009

on

heal

th tr

aini

ng

thro

ugh

the

PPSD

M

6.5.

Regu

latio

n on

m

ater

nal a

nd

neon

atal

hea

lth

info

rmat

ion

syst

ems

6.5.

1.

Dev

elop

gui

delin

es

for

inte

grat

ed

reco

rdin

g an

d re

port

ing

syst

em

(ver

tical

ly a

nd

hori

zont

ally

)

An

inte

grat

ed

mot

her a

nd

child

hea

lth

info

rmat

ion

syst

em is

av

aila

ble

In 2

013

the

inte

grat

ed m

othe

r an

d ch

ild h

ealth

info

rmat

ion

syst

em is

av

aila

ble

Cent

er fo

r D

ata

and

Info

rmat

ion

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

6.

5.2.

Es

tabl

ish

key

indi

cato

rs fo

r m

onito

ring

and

ev

alua

tion

purp

oses

Key

indi

cato

rs

for

mon

itori

ng

and

eval

uatio

ns

are

agre

ed

upon

: O

utco

me

Indi

cato

rs:

mat

erna

l m

orta

lity

rate

,,del

iver

y as

sist

ed b

y he

alth

pr

ofes

sion

als,

de

liver

y at

he

alth

faci

litie

s (w

ith d

etai

ls o

f

Dis

tric

ts a

nd c

ities

rec

ord

and

repo

rt

the

key

indi

cato

rs re

gula

rly

usin

g th

e va

lid d

ata

star

ting

in 2

013

Cent

er fo

r D

ata

and

Info

rmat

ion

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

5351

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

faci

litie

s ty

pe),

obst

etri

c co

mpl

icat

ions

re

ceiv

ing

trea

tmen

t at

PON

EK

hosp

itals

, tee

n bi

rth

rate

, 4-

time

visi

t

6.5.

3.

Cond

uct a

n an

alys

is

and

utili

zatio

n of

in

form

atio

n as

a

basi

s fo

r de

term

inin

g po

licie

s an

d pr

ogra

ms

Polic

ies

on

prog

ram

im

plem

enta

tion

base

d on

in

form

atio

n/da

ta

anal

ysis

are

av

aila

ble

In 2

013

polic

ies

on p

rogr

am

impl

emen

tatio

n ba

sed

on th

e an

nual

in

form

atio

n/da

ta a

naly

sis

are

avai

labl

e.

Balit

bang

kes

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

6.6.

Ass

uran

ce o

f su

ppor

t for

oth

er

requ

ired

re

gula

tion

6.6.

1. D

evel

op m

acro

and

fu

ndam

enta

l po

licie

s re

late

d to

co

mm

unity

hea

lth

cent

er. T

hese

po

licie

s in

clud

e th

e co

ncep

t of

com

mun

ity h

ealth

ce

nter

, spe

cific

w

orkf

orce

and

fin

anci

al

Polic

ies

on

com

mun

ity

heal

th c

ente

rs

whi

ch in

clud

es

the

conc

ept o

f co

mm

unity

he

alth

cen

ter,

sp

ecifi

c w

orkf

orce

and

fin

anci

al

gove

rnan

ce a

re

Star

ting

in 2

014

com

mun

ity h

ealth

ce

nter

s ha

ve m

acro

and

fund

amen

tal

polic

ies

whi

ch in

clud

e th

e co

ncep

t of

com

mun

ity h

ealth

cen

ter,

spe

cific

w

orkf

orce

and

fina

ncia

l gov

erna

nce

Dir

ecto

rate

of

Basi

c H

ealth

Ca

re

Dev

elop

men

t,

Fina

ncia

l Off

ice

and

BMN

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

5452

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

gove

rnan

ce

avai

labl

e

6.6.

2. D

evel

op re

gula

tions

to

det

erm

ine

prio

rity

hea

lth c

are

area

s

Regu

latio

ns to

de

term

ine

prio

rity

are

as fo

r m

ater

nal a

nd

neon

atal

car

e ar

e av

aila

ble

In 2

013

the

regu

latio

ns o

n th

e de

term

inat

ion

of p

rior

ity h

ealth

car

e ar

eas

are

avai

labl

e

Dir

ecto

rate

of

Mat

erna

l Hea

lth

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

6.

6.3.

Con

duct

so

cial

izat

ion

of th

e na

tiona

l ref

erra

l gu

idel

ines

(Hea

lth

Min

iste

r Re

gula

tion

No.

1/2

012)

Soci

aliz

atio

n of

th

e re

gula

tions

on

the

dete

rmin

atio

n of

hea

lth c

are

prio

rity

are

as is

co

nduc

ted

In 2

013

the

regu

latio

n is

dis

sem

inat

ed

Dir

ecto

rate

of

Mat

erna

l Hea

lth

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

6.

6.4.

Dev

elop

regu

latio

ns

on th

e re

ferr

al

syst

em fo

r m

ater

nal

and

neon

atal

hea

lth

at d

istr

ict/

city

leve

l

Gui

delin

es fo

r m

ater

nal a

nd

neon

atal

hea

lth

refe

rral

are

av

aila

ble

In 2

013

guid

elin

es fo

r m

ater

nal a

nd

neon

atal

hea

lth r

efer

ral a

re a

vaila

ble

Dir

ecto

rate

of

Mat

erna

l Hea

lth

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

6.

6.5.

Con

duct

adv

ocac

y on

del

ayed

mar

riag

e ba

sed

on h

ealth

co

nsid

erat

ions

th

roug

h va

riou

s ap

proa

ches

, in

clud

ing

diss

emin

atio

n of

Adv

ocac

y m

ater

ials

/mes

sage

s ab

out

biol

ogic

al a

nd

psyc

holo

gica

l re

adin

es o

f te

ens

for

preg

nanc

y ar

e

In 2

013c

omm

unic

atio

n, in

form

atio

n an

d ed

ucat

ion

mat

eria

ls a

bout

te

enag

e m

arri

age

are

avai

labl

e an

d re

ady

for

dist

ribu

tion

Dir

ecto

rate

of

Child

Hea

lth

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

5553

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

com

mun

icat

ion,

in

form

atio

n an

d ed

ucat

ion

mat

eria

ls

abou

t bio

logi

cal a

nd

psyc

holo

gica

l re

adin

ess

of te

ens

for

preg

nanc

y

avai

labl

e

7.

Im

prov

ed

Cros

s-Se

ctor

al

and

Priv

ate

Part

ners

hip

W

ork

with

oth

er s

ecto

rs

othe

r tha

n lo

cal

gove

rnm

ent:

1.

Med

ical

edu

catio

n in

stitu

tions

to w

ork

in

loca

l hos

pita

ls to

en

sure

the

avai

labi

lity

of a

dequ

ate

serv

ice

24

hour

s/7

days

, suc

h as

th

roug

h th

e as

sign

men

t of

pos

t-gr

adua

te

stud

ents

of o

bste

tric

s pr

ogra

m

2.

Pri

vate

sec

tor

whi

ch

dire

ctly

pro

vide

s ob

stet

ric

care

(m

ater

nity

hos

pita

ls,

clin

ics,

gen

eral

MoU

on

any

form

of

coop

erat

ion

is

esta

blis

hed

In 2

013,

201

4 an

d 20

15 th

e nu

mbe

r of

M

oU o

n co

oper

atio

n at

pro

vinc

ial,

dist

rict

and

city

leve

l, bo

th w

ith

gove

rnm

ent a

nd p

riva

te s

ecto

r in

crea

ses

Dir

ecto

rate

of

Mat

erna

l Hea

lth

Hea

lth O

ffic

e at

Pr

ovin

cial

, D

istr

ict a

nd C

ity

Leve

l, Lo

cal

Gov

ernm

ent,

Re

gion

al

Dev

elop

men

t Pl

anni

ng B

oard

; ho

spita

ls;

prof

essi

onal

or

gani

zatio

n,

Educ

atio

nal

Inst

itutio

n,

Relig

ious

In

situ

tion,

Pr

ivat

e Se

ctor

5654

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

hosp

itals

) is

expe

cted

to

bui

ld c

oord

inat

ion

for p

rovi

ding

mid

wife

ry

serv

ices

to th

e co

mm

unity

, inc

ludi

ng

the

refe

rral

sys

tem

, th

roug

h a

Mem

oran

dum

of

Und

erst

andi

ng (M

oU)

on C

oope

ratio

n 3.

The

Nat

iona

l Fam

ily

Plan

ning

Coo

rdin

atin

g Bo

ard,

to im

prov

e ac

cess

for

all w

omen

of

child

bear

ing

age

to

info

rmat

ion

on

repr

oduc

tive

heal

th a

nd

acce

ss to

fam

ily

plan

ning

met

hods

4.

Rel

igio

us s

ecto

r, to

im

prov

e ac

cess

for

all

girl

s in

relig

ion-

base

d sc

hool

s,

mad

rasah(

scho

ol

heal

th u

nit)

and

all

5755

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

brid

es-t

o-be

who

re

gist

er th

eir

mar

riag

e at

the

offic

e of

relig

ious

af

fair

s, to

info

rmat

ion

on r

epro

duct

ive

heal

th,

incl

udin

g bo

dy

read

ines

s fo

r fir

st

preg

nanc

y 5.

Pri

mar

y an

d se

cond

ary

educ

atio

n se

ctor

s, to

in

crea

se a

cces

s fo

r all

adol

esce

nts,

esp

ecia

lly

girl

s, in

sch

ools

(sch

ool

heal

th u

nit)

to

info

rmat

ion

on

repr

oduc

tive

heal

th.

The

impl

emen

tatio

n of

12

-yea

r co

mpu

lsor

y ed

ucat

ion

is e

xpec

ted

to b

e ut

ilize

d by

the

heal

th s

ecto

r to

con

vey

the

info

rmat

ion

rela

ted

to re

prod

uctiv

e he

alth

an

d ot

her h

ealth

-re

late

d in

form

atio

n

% o

f pri

vate

co

mpa

nies

that

ha

ve C

SR

prog

ram

on

mat

erna

l hea

lth

5856

No

Stra

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/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

6. P

riva

te s

ecto

r w

hich

ha

s in

dire

ct

role

s(ed

ucat

iona

l in

stitu

tions

for h

ealth

pe

rson

nel,

com

pani

es’

CSR)

is e

xpec

ted

to

wor

k to

geth

er to

im

prov

e m

idw

ifery

co

vera

ge a

nd s

ervi

ces,

ei

ther

thro

ugh

the

impr

oved

qua

lity

of

stud

ents

of h

ealth

-re

late

d pr

ogra

m b

ased

on

the

natio

nal

stan

dard

s, o

r th

roug

h th

e ut

iliza

tion

of C

SR

fund

s 7.

Pro

fess

iona

l or

gani

zatio

n, to

in

crea

se it

s ro

le in

im

prov

ing

the

qual

ity o

f se

rvic

es o

f its

mem

bers

, su

ch a

s th

roug

h tr

aini

ng,

appr

entic

eshi

p,

coac

hing

and

5957

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

arra

ngem

ent o

f pr

ofes

sion

al

licen

cere

gist

ratio

n. T

he

loca

l gov

ernm

ents

and

th

e lo

cal h

ealth

off

ices

ar

e ex

pect

ed to

wor

k w

ith th

e pr

ofes

sion

al

orga

niza

tions

in

acco

rdan

ce w

ith th

eir

resp

ectiv

e ro

les

as

agre

ed u

pon

8. R

elig

ious

org

aniz

atio

ns

can

play

a ro

le in

at

leas

t tw

o as

pect

s

Del

iver

y of

hea

lth

info

rmat

ion,

suc

h as

info

rmat

ion

on

repr

oduc

tive

heal

th

and

heal

th in

sura

nce

(mat

erni

ty

insu

ranc

e, n

atio

nal

soci

al s

ecur

ity

syst

em),

thro

ugh

the

exis

ting

orga

niza

tion

netw

orks

, and

6058

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

A

s pa

rt o

f the

Loc

al

Hea

lth S

ervi

ce

Net

wor

k 9.

Dev

elop

/im

prov

e ot

her

part

ners

hips

acc

ordi

ng

to th

e ci

rcum

stan

ces

and

cond

ition

s of

the

regi

ons

Stra

tegy

3: E

mpo

wer

ing

fam

ily a

nd c

omm

unity

8.

Im

prov

ed

Und

erst

andi

ng

and

Impl

emen

tatio

n of

Del

iver

y Pl

anni

ng a

nd

Com

plic

atio

ns

Prev

entio

n in

the

Com

mun

ity

8.1.

Reo

rien

tatio

n fo

r al

l rel

evan

t he

alth

per

sonn

el

rega

rdin

g th

e de

liver

y pl

anni

ng

and

com

plic

atio

ns

prev

entio

n pr

ogra

m to

cr

eate

the

sam

e ap

prop

riat

e un

ders

tand

ing

abou

t the

pr

ogra

m

conc

ept,

in

clud

ing

the

8.1.

1. R

eori

enta

tion

for a

ll re

leva

nt h

ealth

pe

rson

nel r

egar

ding

th

e de

liver

y pl

anni

ng a

nd

com

plic

atio

ns

prev

entio

n pr

ogra

m

to c

reat

e th

e sa

me

appr

opri

ate

unde

rsta

ndin

g ab

out t

he p

rogr

am

conc

ept,

incl

udin

g th

e pu

rpos

e an

d be

nefit

s of

the

prog

ram

, and

the

mea

sure

s th

at m

ust

Num

ber o

f co

mm

unity

he

alth

cen

ters

co

nduc

ting

reor

ient

atio

n ab

out t

he

deliv

ery

plan

ning

and

co

mpi

licat

ions

pr

even

tion

for

heal

th p

erso

nnel

In 2

014,

90%

of c

omm

unity

hea

lth

cent

ers

have

con

duct

ed o

rien

tatio

n ab

out t

he d

eliv

ery

plan

ning

and

co

mpl

icat

ions

pre

vent

ion

prog

ram

for

heal

th p

erso

nnel

.

Cent

er fo

r H

ealth

Pr

omot

ion,

D

irec

tora

te o

f M

ater

nal H

ealth

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

6159

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

purp

ose

and

bene

fits

of th

e pr

ogra

m, a

nd

the

mea

sure

s th

at m

ust b

e ta

ken

be ta

ken

8.

1.2.

Con

duct

ori

enta

tion

for h

ealth

cad

res

and

soci

ety

abou

t th

e da

nger

sig

ns o

f pr

egna

ncy

and

child

birt

h as

wel

l as

thei

r ro

le in

the

deliv

ery

plan

ning

an

d co

mpl

icat

ions

pr

even

tion

prog

ram

Num

ber o

f co

mm

unity

he

alth

cen

ters

co

nduc

ting

orie

ntat

ion

for

heal

th c

adre

s ab

out t

he

bene

fits

and

step

s of

the

deliv

ery

plan

ning

and

co

mpl

icat

ions

pr

even

tion

prog

ram

In 2

014,

90%

of c

omm

unity

hea

lth

cent

ers

cond

uct o

rien

tatio

n ab

out t

he

deliv

ery

plan

ning

and

com

plic

atio

ns

prev

entio

n pr

ogra

m t

o he

alth

cad

res

Cent

er fo

r H

ealth

Pr

omot

ion,

D

irec

tora

te o

f M

ater

nal H

ealth

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l and

cro

ss-

sect

or (P

KK,

PMD

)

8.2.

Reo

rien

tatio

n ab

out t

he

impo

rtan

ce o

f ne

cess

ary

mea

sure

s du

ring

8.2.

1. C

ondu

ct m

ater

nal

clas

s us

ing

mot

her

and

child

hea

lth

guid

e bo

ok

Num

ber o

f co

mm

unity

he

alth

cen

ters

co

nduc

ting

mat

erna

l cla

ss

usin

g m

othe

r

Num

ber o

f com

mun

ity h

ealth

cen

ters

co

nduc

ting

mat

erna

l cla

ss in

crea

ses

ever

y ye

ar a

nd b

y th

e en

d of

201

3 50

% o

f pub

lich

heal

th c

ente

rs h

ave

cond

ucte

d m

ater

nal c

lass

usi

ng

Dir

ecto

rate

of

Mat

erna

l Hea

lth

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

6260

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

preg

nanc

y an

d ch

ildbi

rth

and

child

hea

lth

Gui

delin

e m

othe

r and

chi

ld h

ealth

Gui

delin

e

8.

2.2.

Soc

ializ

e th

e da

nger

si

gns

of p

regn

ancy

an

d ch

ildbi

rth

thro

ugh

appr

opri

ate

med

ia to

eve

ry

segm

ent o

f soc

iety

in

acc

orda

nce

with

th

e ac

cept

able

cu

lture

and

nor

ms

% o

f pre

gnan

t m

othe

rs w

ho

unde

rsta

nd th

e da

nger

sig

ns o

f pr

egna

ncy

In 2

015

, 70

% o

f pre

gnan

t mot

hers

un

ders

tand

the

dang

er s

igns

of

preg

nanc

y, c

hild

birt

h an

d pu

erpe

rium

Cent

er fo

r H

ealth

Pr

omot

ion,

D

irec

tora

te o

f M

ater

nal H

ealth

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

8.

2.3.

Con

duct

so

cial

izat

ion

abou

t th

e im

port

ance

of

anem

ia p

reve

ntio

n th

roug

h he

alth

y lif

esty

le, c

onsu

min

g bl

ood

supp

lem

ent

pills

, and

con

sum

ing

nutr

itiou

s ba

lanc

ed

food

dur

ing

preg

nanc

y

Soci

aliz

atio

n ab

out t

he

impo

rtan

ce o

f an

emia

pr

even

tion

for

preg

nant

m

othe

rs is

co

nduc

ted

thro

ugh

suita

ble

med

ia fo

r al

l pu

blic

seg

men

ts:

preg

nant

m

othe

rs w

ho

com

e to

hea

lth

care

faci

litie

s,

By th

e en

d of

201

3 co

mm

unic

atio

n,

info

rmat

ion

and

educ

atio

n m

ater

ials

ab

out a

nem

ia o

n pr

egna

nt m

othe

rs

are

avai

labl

e fo

r va

riou

s se

gmen

ts o

f so

ciet

y at

nat

iona

l lev

el

At t

he b

egin

ning

of 2

014

com

mun

icat

ion,

info

rmat

ion

and

educ

atio

n m

ater

ials

abo

ut a

nem

ia o

n pr

egna

nt m

othe

rs a

re a

vaila

ble

for

vari

ous

segm

ents

of s

ocie

ty a

t dis

tric

t an

d ci

ty le

vel a

nd in

com

mun

ity h

ealth

ce

nter

s

Cent

er fo

r H

ealth

Pr

omot

ion,

D

irec

tora

te o

f M

ater

nal H

ealth

Prov

inci

al,

Dis

tric

t/Ci

ty

Leve

l

6361

No

Stra

tegy

/Mai

n Pr

ogra

m

Sub

Prog

ram

A

ctiv

ity

In

dica

tor

Targ

et

RESP

ON

SIBL

E U

NIT

Exec

utor

: at

nati

onal

, pr

ovin

cial

, di

stri

ct/c

ity

leve

l

2012

(Bas

elin

e) -

2015

brid

es-t

o-be

, te

enag

e st

uden

ts a

t pu

blic

sc

hool

s/m

adra

s ah

In 2

015

100%

of c

omm

unity

hea

lth

cent

ers

cond

uct s

ocia

lizat

ion

abou

t an

emia

, eith

er d

irec

tly o

r th

roug

h co

oper

atio

n w

ith o

ther

sec

tors

.