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SUMMARY:

GOVERNANCE IN SAFE DELIVERY AND IMMEDIATE & EXCLUSIVE

BREASTFEEDING

Lessons Learned from USAID-KINERJA

2014

Safe Delivery and Immediate & exclusive Breastfeeding 3 www.kinerja.or.id

PREFACE

This publication is a collection of successful experiences of the USAID-KINERJA program. Kinerja aims to

improve public services in the health sector by strengthening the role of governance in safe delivery and

immediate and exclusive breastfeeding. KINERJA works to strengthen three different management pillars:

regional governments, service providers (community health centers and district health offices), and

service recipients (that is, the community) across 24 districts and cities in five Indonesian provinces.

This document presents the experiences of KINERJA in assisting regions until they produce strong

partnerships between service users, service providers, and Multi-Stakeholder Forums (MSFs) in order to

improve public services and achieve achieving health Minimum Service Standards (MSS).

Working through local implementing organizations (IOs), KINERJA has produced energetic local

community movements that are enriched by innovative practices such as partnerships between

midwives and traditional birth attendants, standard operating procedures, service standards, and service

charters, with gender mainstreaming included in each phase of activities.

In order to share experiences and to encourage implementation by the regional government, donor

agencies, civilian society, academics and others, KINERJA has developed a series of modules

containing all activities, strategies and management approaches. The modules were written based on

KINERJA’s experience in Indonesia. KINERJA expresses its deepest gratitude to staff, IOs,

consultants, district health offices, community health centres, MSFs, and all other parties that gave

their time to assist in collecting information for the development of these modules.

This series of modules was developed by KINERJA for the purpose of: (1) giving the greatest appreciation

to the achievements of KINERJA’s partner district governments, staff, IOs together with other partners in

the regions in developing institutional memory; (2) sharing knowledge on interventions implemented by

KINERJA that were able to inspire partners, so that public service delivery became more effective; and (3)

assisting donor agencies and other parties wishing to improve public service delivery to use materials

already available, through adopting, adapting and developing the ideas and trainings available in these

modules.

In order to assist decision makers in the region to understand and adopt the KINERJA program, these

modules illustrate the approaches, programs and intervention packages used as good practices in the

KINERJA partner regions.

Ringkasan Tata Kelola Persalinan Aman,

Inisiasi Menyusu Dini dan ASI Eksklusif 4 www.kinerja.or.id

It is our hope that these modules will benefit the whole community through public service improvements

in the health sector, particularly in maternal and child health.

Jakarta, 25 July 2014

Elke Rapp

USAID-KINERJA Chief of Party


FOREWORD

FROM THE MINISTRY OF HEALTH

The Ministry of Health of the Republic of Indonesia through the Directorate General for Public Health

Development expresses its deep gratitude to the USAID-KINERJA Team and the parties that have truly

enhanced the service performances of health centres and district health offices. Achievement

ofMinimum Service Standards (MSS) and strengthening management aspects from both supply and

demand sides were targeted in 24 districts and cities in five provinces.

These modules use a governance approach to improving healthcare delivery. This is a new approach in

Indonesia, but USAID-KINERJA’s experience shows that it is important to adopt, adapt and replicate this

approach throughout Indonesia with the aim of accelerating MDG achievements.

The Directorate General for Public Health Development of the Ministry of Health recommends that

donor agencies, community organizations, and educational and training institutions apply and

implement the innovations outlined in these modules, so as to develop mutual ownership over them

and accelerate public service improvements in the health sector.

Jakarta, 2014

Directorate General for

Public Health Development Ministry of Health



TABLE OF CONTENTS

PREFACE 1

TABLE OF CONTENTS 6

EXECUTIVE SUMMARY 7

CHAPTER 1 KINERJA APPROACH 11

CHAPTER 2 KINERJA Experience in Safe Delivery and Immediate & Exclusive Breastfeeding15

Background 15

How KINERJA Began Working in Partner Districts 16

Work Process 18

CHAPTER 3 Overcoming Challenges and Achieving Success 20

Success Stories 21

CHAPTER 4 Recommendations for Replication 23

Recommendations for Implementing Organizations 24

Recommendations for Education and Training Institutions 24


EXECUTIVE SUMMARY

Objectives and Successes of KINERJA

1. Primary Objective of the USAID-KINERJA Program

The primary objective of the USAID-KINERJA program is to assist regional governments in improving

governance in public services provision in Indonesia. KINERJA works in 24 districts/cities in 5

provinces:1) Aceh province (Aceh Singkil, Southeast Aceh, Bener Meriah, Simeulue, and Banda Aceh

City); 2) East Java province (Probolinggo City, Probolinggo District, Bondowoso, Jember, and

Tulungagung); 3) South Sulawesi province (Barru, Bulukumba, Luwu, North Luwu, and Makassar

City); 4) West Kalimantan province (Bengkayang, Melawi, Sambas, Sekadau, and Singkawang City);

and 5) Papua province (Mimika, Jayawijaya, Jayapura District, and Jayapura City).

In order to assist district governments to improve public service provision, KINERJA strengthens both

the community (the demand side) and service providers (the supply side). The community, in particular

mothers and families, become more aware of their rights to receive services from public health facilities

and how to submit complaints. On the supply side, community health centers (known in Indonesian as

puskesmas) are strengthened through a governance approach based on the principles of public

participation, transparency, accountability, and responsiveness. KINERJA’s interventions focus on

improving three pillars of management: program management, service management, and puskesmas

management. This means that the improved community understanding of their rights to safe delivery

and immediate & exclusive breastfeeding (I&EBF) are in alignment with the health centers’

preparedness to fulfill these rights.

Strengthening the community and the health centers is conducted primarily by KINERJA’s

implementing organizations (IOs), who are local NGOs and CSOs provided with grants through a

transparent and accountable selection process. KINERJA conducted organizational capacity building

before the IOs began implementing KINERJA’s program.



2. Successes in Safe Delivery and Immediate & Exclusive Breastfeeding (I&EBF)

KINERJA works on the following principles: (1) work in line district and national government development

and strategic plans; (2) do not develop new innovations, and instead employ and adopt models already

tested by the national government, district/city governments, universities, or other development

partners/donor agencies; (3) implement programs through capacity building and disseminate them to

partner service units and districts; (4) ensure program continuity through working through implementing

organizations (IOs) and building local capacity; and (5) enrich public service delivery with the good

governance concepts of transparency, accountability, and participation while promoting innovation and

new incentive models.

KINERJA has had good success at the health center level in the program’s five provinces. Each district

now has a district regulation on safe delivery and immediate & exclusive childbirth (I&EBF) that is in line

with principles of good governance. Multiple regions have also financed Multi-Stakeholder Forum (MSF)

activities across many sub-districts.

Over 60 health centers have developed and displayed service flowcharts to ensure they are visible to

service users. Alongside them, service charters are displayed; these charters promise various

improvements to services, facilities and infrastructure, and are based on complaints from the community

gathered during a complaint survey. More than 30 health centers have implemented a governance-based

model of midwife-traditional birth attendant partnerships, and 45 health centers have revitalized their

pregnancy information systems to ensure that they are aware of who is pregnant and what their health

condition is.

Many partner regions have also increased the number of breastfeeding counselors and pregnancy

classes available, and have developed breastfeeding rooms or lactation corners in public facilities in

accordance with national standards and SOPs. Partnerships developed with other sectors in all

KINERJA areas, such as district education offices and the Ministry of Religious Affairs, have greatly

accelerated community behavior change. For example, at least 3 district health offices and tens of

Puskesmas have refused to cooperate with formula milk producers since making a commitment to

support immediate and exclusive breastfeeding (I&EBF); this has seen a significant increase in

breastfeeding rates in the local communities.

On the demand side, multi-stakeholder forums (MSF) including local media producers have actively

participated as supervisors, motivators, and advocators in bringing about change and improvement in

health care delivery. MSFs have worked to improve complaint management processes, and have been

actively involved by both district health offices and community health centres in planning activities, setting

priorities, and financial monitoring. MSFs have also supervised SOP and service standard implementation,

service charters, and other governance initiatives. In some districts, MSFs took part in successfully

advocating for village governments to allocate money from the village budgets to support midwife-

traditional birth attendant partnerships.


3. Program Continuity

Initiatives already implemented by KINERJA in partner districts and health centers can only be

sustainable with the full support of district governments. Changes already achieved through KINERJA’s

governance-based approach are being continued through the allocation of district government budgetary

funds. This ensures that the changes at the health center level will remain in place, allowing the centers

to become stimulants and places of learning for other health centers.

4. Scope of the Document

This document consists of 4 chapters. Chapter 1 presents the general approach of KINERJA, KINERJA’s

programs in the health sector, and KINERJA’s governance principles as they relate to safe delivery and

I&EBF. Chapter 2 describes KINERJA’s experiences in supporting the inclusion of governance in safe

delivery and I&EBF, and how KINERJA’s implementation phases occurred, from start to end. Chapter 4

contains recommendations for various stakeholders on how to replicate KINERJA’s programs.

5. Recommendations

a) For District Heads

KINERJA’s governance approach – that is, supporting both the supply and demand sides – has

been proven to improve public service delivery in just two years of assistance. This approach can

then be gradually replicated and expanded to all facilities in the health service in line with regional

budgets. Expansion and development requires a number of basic elements, including:

1. High level of commitment from District Head/Mayor, legislative assembly, and District Health Office;

2. An assistance period of 2-3 years for establishing and assisting MSFs;

3. Creative innovations and incentive systems for service providers and recipients;

4. Strong coordination and monitoring between district health offices and community health centers;

5. Strong leadership by governments and the private sector in providing breastfeeding rooms,

facilities and counselors in workplaces and public places;

6. Strong contribution by local media, community health ambassadors, and MSFs to consistently

and voluntarily oversee campaigns on safe delivery and I&EBF.

b) For Future Implementing Organizations

IOs conducting advocacy on public service delivery can play a significant role in improving services and

strengthening local policy. Through KINERJA’s participatory approach, IOs are able to accelerate and

enrich the health care improvement process in their region through working closely with district health


Inisiasi Menyusu Dini dan ASI Eksklusif 10

www.kinerja.or.id

offices, health centers, and other stakeholders.

The adoption and implementation of materials already developed by KINERJA is ane option that has

been proven to make positive changes in a period of just 1 to 2 years of assistance. The key to success

of the KINERJA’s 2-year implementation was due to (1) strengthening of IO personnel using KINERJA’s

governance approach, ensuring sustainability during the implementation process, particularly if reinforced

by universities, training institutions, and local champions; and (2) choosing community movements

already rooted and active in the community.

c) For Education and Training Institutions

Training institutions and universities are recommended to incorporate KINERJA’s governance approach

into their curricula and training materials, alongside a strong gender perspective, in order to enhance the

knowledge and skills of health officers.


CHAPTER 1

KINERJA’S APPROACH

General Approach of the KINERJA Program

USAID-KINERJA is a technical assistance program for 24 districts and cities in five provinces of

Indonesia: Aceh, West Kalimantan, South Sulawesi, East Java, and Papua. Kinerja focuses on

supporting good governance in public service delivery in the health, education and business licensing

sectors. KINERJA offers packages in these sectors to regional governments through a comprehensive

approach to capacity building, assisting both the service provider side as well as service users. Working

with the two different sides, it is hoped that efforts to achieve good governance will be quicker, more

sustainable, and more easily replicable.

KINERJA supports service providers through internal capacity building on policies, program

management, and supporting active public participation. Community members, for example, were

educated on their rights to public services such as healthcare and education, and their participation was

strongly encouraged through service provider-led activities. In KINERJA’s partner districts, community

members are now more frequently and more deeply involved in policy formulation, planning,

implementation, and monitoring and evaluation.

At the health centre level, community forums were established to allow community members to carry out

supervision, advocacy, and monitoring. KINERJA worked with local stakeholders to identify potential

participants who possessed high levels of commitment, interest, and influence. Forum members were

then trained and assisted by KINERJA staff in carrying out their activities.

KINERJA implements its programs in coordination with local organizations that possess the right

experience, expertise and skills to provide technical assistance at the district/city level. These

organisations are known as implementing organisations or IOs. KINERJA developed the overall

intervention design and formulated programs, while the IOs themselves developed implementation

strategies by adpating KINERJA’s program to the local conditions, as is related in these modules. IO

facilitators were trained prior to beginning cooperation with the district governments and health offices in

order to ensure they have the ability to provide technical assistance to KINERJA partners. In the future, it

is hoped that these IOs will become the partners of district governments following the end of KINERJA’s

official implementation period, and will be able to continue to provide technical assistance to the district

governments to ensure long-term sustainability and replication.

Summary: Governance in Safe Delivery and Immediate & Exclusive Breastfeeding 12 www.kinerja.or.id

Health Sector Initiatives

Maternal and child health is one of the main mid- and long-term health priorities of the Indonesian

national government. As such, KINERJA supports the government through two programs: (1) Safe Delivery, and

(2) Immediate and Exclusive Breastfeeding (I&EBF). The national government aims to see improvements in

these areas through the achievement of minimum service standards (MSS). KINERJA’s hypothesis is that strong

relationships between the supply and demand sides will lead to sustainable and systematic improvement of

health care delivery. KINERJA’s support focuses on improving four areas: laws and regulations, management,

multi-stakeholder forums, and health promotion strategies.

Through its implementing organizations (IOs), KINERJA worked to initiate the development of district head

regulations on safe delivery and immediate & exclusive breastfeeding. These regulations were developed with

the involvement of many different stakeholders throughout the entire process – from situational analysis through

to the formal legalization of the regulations.

KINERJA’s approach to strengthening health center management encompasses three different types of

management: institutional management, program management, and service management. Institutional

management improves planning and budgeting at the health center level. Program management supports

the safe delivery program through developing midwife-traditional birth attendant partnerships, pregnancy

classes, and pregnancy information systems. For I&EBF, program management focuses on ensuring

breastfeeding groups and ambassadors are active, and that breastfeeding rooms are available. Service

management includes developing service charters, standard operating procedures (SOPs), and creating

complaint management mechanisms.

Multi-stakeholder forums (MSFs) in the health sector act as the in-between for the supply and demand sides.

With members consisting of all parts of society – citizen journalists, local media, district/city health office staff,

health center staff, legislative members, community figures, religious leaders, and others – the MSFs are able to

play an active role as supervisors, advocators, and motivators for improvement in service delivery.

KINERJA supports the community, health sector and other government sectors to engage in promoting safe

delivery and I&EBF. KINERJA strongly encourages health service providers to allocate funds from their

budgets for promotional activities, such as awareness raising programs. The community can then become

actively involved in promoting safe delivery and I&EBF – for example, KINERJA has supported service

providers to carry out education programs for religious figures, bridal make-up artists, and vegetable sellers

so that they can use their knowledge to encourage others to breastfeed. Another success is that other

sectors such as the District Education Offices and Religious Affairs Offices now include time for health

promotion when conducting their routine activities. For instance, some district offices now run reproductive

health education programs for students, and provide maternal health information during mandatory pre-

wedding consultations to brides and grooms. In fact, in some districts, the district’s highest officeholders

(District Head and Mayor) have even become breastfeeding ambassadors.



KINERJA’s support for safe delivery and immediate and exclusive breastfeeding aligns with the five

strategies of the Indonesian Ministry of Health and the World Health Organization:

1. Improving access and quality.

2. Encouraging service providers to develop standard operating procedures through referring to

existing literature or policies and by including the community. KINERJA goes one step further and

encourages health centers to not just develop SOPs but to display them on walls and doors. This

ensures the community is better aware of their healthcare rights. SOPs thus become tools of

accountability and transparency in health care delivery.

3. Enhancing partnerships and empowering families and the community. KINERJA primarily achieved

this through establishing MSFs and supporting their involvement in supervision and advocacy for

improvements in services. KINERJA also assisted health centers in increasing the number of

pregnancy classes for women at the village level, and in developing participatory and accountable

partnerships between midwives and traditional birth attendants.

4. Improving supervision and health information systems. KINERJA here focuses on the revitalization

of pregnancy information systems which list all pregnant women in the surrounding area. The systems

are created in such a way that health center management knows the whereabouts of pregnant

women, what their risk level is, and when they will give birth. This ensures that management can

instruct midwives to stand by and be ready. The non-medical parts of this information is also shared

with the MSFs and village heads so that they can be prepared to provide help the mother in question

if required, such as through assisting with arranging transport or blood donation.

5. Increasing health funding. KINERJA here works to improve budgeting and planning, and to ensure

that adequate funding is provided and used for safe delivery and I&EBF. MSF members are

supported to act as community representatives during budget development, and are encouraged to

actively supervise its implementation.

Based on the above strategies, KINERJA designed activities to work with both the supply and demand

sides. Some principles that characterize KINERJA’s program are:

1. Not developing new innovations, but adopting models that have already been tested by the

government, universities, development partners/donor institutions, and others.

2. Technical assistance conducted by Implementing Organizations (IOs) with an emphasis on using

and building local resources.

3. Enriching public services by applying aspects of good governance, comprising the elements of

participation, transparency, responsiveness and accountability of service providers.

4. Promoting replication by regional governments (in both partner and non-partner regions).

5. KINERJA supports programs that are synchronous with the National Medium Term Development

Plan (RPJMN), Regional Medium Term Development Plan (RPJMD) and Regional Sector Strategic

Plan (Renstra), as well as achievement of Minimum Service Standard (MSS) in health.


6. At national level, KINERJA coordinates with relevant ministries: the National Planning Body

(BAPPENAS), the Directorate General for Regional Autonomy, and the Directorate General of

General Government. A Coordinating Team was established based on need, involving the National

Planning Body (Bappenas), Ministry of Health, Ministry of Internal Affairs, Ministry of Education,

Ministry of State Administrative and Bureaucratic Reform, and others.



CHAPTER 2

KINERJA’S EXPERIENCE IN

GOVERNANCE IN SAFE DELIVERY

AND IMMEDIATE & EXCLUSIVE

BREASTFEEDING

Background

1. Safe Delivery

Due to the high maternal mortality ratio (MMR) and neonatal mortality rate (NMR) in Indonesia, the

government has declared reducing maternal and neonatal deaths as national and regional

priorites. Achievement of health minimum service standards (MSS) is low – indicators that require

improvement include the percentage of women who receive their first and fourth antenatal check-

ups, the percentage of deliveries assisted by trained medical personnel, and the percentage of

deliveries that take place in health facilities. Indonesian health data from 2010 reports that only

61% of women underwent antenatal checkups and only 82% of deliveries were assisted by trained

health workers. Services continue to vary significantly between regions in Indonesia, and gaps are

particularly large in rural areas, which lag far behind urban areas.

Pregnant women in Indonesia are at high risk of dying during childbirth due to the poor quality of

antenatal care and the fact that almost 20% of deliveries are still not assisted by skilled personnel.

Even when women do get antenatal care and are assisted by skilled personnel when their children

is born, the lack of service standards and standard operating procedures, inadequate facilities and

poor infrastructure all contribute to poor health outcomes.

Poor community understanding of women’s health and women’s health rights further complicates

matters. Some communities distrust midwives and prefer to rely on traditional birth attendants, for

example.


2. Immediate & Exclusive Breastfeeding

Although national government policy (Government Regulation No 33/2012) recognises the

importance of the role of the community in supporting breastfeeding, individuals, groups, and

organizations in Indonesia face three main challenges. Firstly, challenges from health personnel.

Many health personnel have become the promotional mouthpieces for formula milk, and many fail to

provide adequate and accurate information on breastfeeding to mothers and pregnant women.

KINERJA’s research has found that many government and private hospitals, government health

centers, and private midwifery clinics continue to work together with formula milk sponsors and

regularly receive promotional items in the form of formula milk samples, calendars, stationary,

posters, and even assistance to go on the pilgrimage to Mecca.

The second challenge is from the community. A part of the community still does not believe that

breastfeeding can provide sufficient nutrition, mostly due to the influence of formula milk promotion.

Many women also do not breastfeed their babies due to work commitments or pressure from their

family, with infants receiving formula milk from birth. Although exclusive breastfeeding has been a

priority program in Indonesia for a number of years now, only 33.6% of babies in Indonesia are

exclusively breastfed (Susenas, 2010). In fact, the Indonesian Demography and Health Survey

indicates that this percentage is actually falling.

Finally, national and local governments have not been strong actors in supervising formula milk promotion

and distribution. Few governments have allocated adequate funds to increase community understanding

of the importance of breastfeeding.

How KINERJA Began Working in Partner Districts

1. Building commitment of districts heads, legislative members, and other stakeholders

The first phase of KINERJA’s program was to hold provincial consultations to ensure transparency,

accountability, and public participation. These consultations were attended by the provincial

government and the district governments of each of KINERJA’s partner districts. Attendees included

district government managers, the heads of the Local Planning Body (Bappeda), members of the

budget, health and education commissions from the local legislatures, the district health offices, the

district education offices, and the district business offices. At the consultations, districts each chose

one priority from the three KINERJA support sectors (health, education, and business enabling

environment) to implement in the first year. The district governments also demonstrated their

commitment through signing Memoranda of Understanding between district heads and KINERJA



management.

The next phase involved holding district-level consultations for all KINERJA partner regions. These

consultations were in the form of Focus Group Discussions (FGD).

Consultations were held at the District Health Offices or District Planning Offices, with participants

consisting of health office staff, heads of community health centers, midwives, community health

volunteers, community organizations working on health issues, professional health workers’

organizations, media, and religious figures, traditional figures, and women.

The meetings explored priority maternal and child health issues, including breastfeeding and safe

delivery, and identified the community health centers that would be assisted by KINERJA during the

initial phase. The health centers chosen were based on three indicators: health centers that needed

service improvements, that were isolated, or that were providing adequate services.

Informal discussions in KINERJA’s partner districts were also held. Members of the media,

government, legislature, and professional organizations were invited to attend in order to obtain a true

idea of the condition of KINERJA’s partner districts. This information was analysed alongside

secondary data related to social, economic, education, and health conditions in the partner districts.

KINERJA staff and IOs worked as initiators, motivators, and facilitators to approach and gain the

support of the legislatures, Local Planning Bodies, and decision-makers at the District Health Offices,

as well as community leaders and professional organizations. The MSFs later emerged from these

efforts.

The main indicator that measured the commitment of district governments was their willingness to

allocate a portion of the district budget to support KINERJA’s program. The funds allocated are used

for activities that support public participation in health care delivery. This creates feelings of local

ownership over the programs and encourages sustainability.

2. Working Arrangements

The main duty of Kinerja’s local staff – called Local Public Service Specialists – is to coordinate the

program at the district level, and to facilitate IOs to be able to optimally conduct activities with the

health office, MSFs, and regional government. LPSS, together with IOs, are responsible for program

achievement at the district level. IOs work at both the district and health center levels, in addition to

assisting the community and MSFs in their advocacy and supervision efforts.

KINERJA conducted regular IO capacity building, so as to ensure adequate capability in providing

technical assistance for KINERJA’s partner districts. For strengthening the supply side on safe delivery,

KINERJA worked to empower local champions with health backgrounds to support the work of IOs in


the region.

3. Development of Work Plan Upon issuance of the District Head’s decision letter, the district technical team developed work plans in

conjunction with IO work plans. This work plan was required to conform to the district planning and

budgeting process.

Work Process

1. Role of Partners

Actively involving partners outside of the immediate KINERJA staff is essential to good implementation.

The District Health Offices are involved as resource persons, participants and policy makers in implementing

KINERJA’s program. The technical team that was established became the steering team when field

implementation encountered challenges. The technical teams hold meetings on a regular basis in order to

monitor progress and solve implementing issues. Individuals and representatives of religious organizations

and other civil society groups joined together to establish a forum with government representatives, which

came to be known as the district-level multi-stakeholder forum (MSF). This MSF runs entirely separately to

the health center-level MSFs, and provides more of an oversight role.

Legislative members also play a role in monitoring KINERJA’s program implementation. In several districts,

parliamentarians became members or chairpeople of MSFs, and worked as internal advocators to the

legislature and executive branch (such as the District Head and the budget committee) to facilitate approval

for the budget required to support breastfeeding programs. In regions where the district head had higher

commitment than the parliament, their role was to perform budget advocacy to the legislature to push

through the budget.

2. Work Plan Implementation

The Immediate & Exclusive Breastfeeding (I&EBF) program was implemented through the following phases:

1. Synchronizing perceptions and building commitment

Kinerja staff assisted IOs in an initial round of awareness raising campigns on I&EBF. This

process is an important phase, as it has the objective of creating understanding, ensuring

similar perceptions, and building mutual commitment to program implementation.

2. Establishing and capacity building of MSFs

Kinerja staff, together with IOs, facilitated several meetings to establish MSFs and to develop



MSF capacity to begin motivating the community to support I&EBF. The meetings aimed to

increase MSF members’ understanding of the importance breastfeeding for child nutrition.

3. Sharing experiences and problem solving

MSF capacity building was done through holding periodic meetings to share experiences in the

community and seek mutual solutions to problems identified in the field. This was continued with

the development of action plans on how to better support breastfeeding mothers.

4. Advocacy

MSFs, assisted by IOs, advocated to the District Health Offices and the health centers to integrate

MSF activity into their plans and budgets in order to ensure the MSF’s oversight role would

continue. The advocacy strategy included visiting health centers for discussions with center

management. With intensive assistance from the District Health Offices, the MSFs successfully

advocated to the districts governments to develop regional laws on maternal and child health and

budgets that would support their implementation.

5. Institutionalization of MSFs

Several districts chose to formalize their MSFs into legal entities. This makes the activities carried

out by MSFs more powerful and sustainable.

3. Process of Change and Benefits

Changes in KINERJA’s partner districts were witnessed from multiple sides.

1. From the district government side: KINERJA’s partner district governments slowly began

to see the benefit of increased public participation as the program progressed. The

community helped the government to identify areas for action, such as the need to

establish District Head Regulations on safe delivery and I&EBF and the necessity of

allocating part of the district budget for program replication to other health centers in the

district. In general, government commitment to improving maternal health services was

notably higher after one year of assistance.

2. From the supply side: Changes have been seen in how service providers think about

community participation, especially with regards to user complaints, which are now being

increasingly heard and responded to. As a result, health results improved, meeting MSS

indicators. One example of the breastfeeding program’s impact was the prohibition of formula

milk promotion and sales in all puskesmas of Probolinggo District and Makassar City; this

caused a dramatic increase in the rates of exclusive breastfeeding.

3. From the demand side: The community in general but particularly members of the MSFs

became more aware of their role in monitoring health care. MSFs have brought many changes

to health care, to the point that health centers now regularly take into account input from MSFs.

MSFs have also been included in the development of health care policies at sub-district and

district levels. Community members in some districts also formed action groups such as the

Kelompok Peduli ASI (Breastfeeding Concern Group) and Ayah Peduli ASI (Fathers who

Support Breastfeeding) to support their communities and encourage breastfeeding. Partnerships

between midwives and traditional birth attendants also run better due to MSF supervision.



CHAPTER 3

OVERCOMING

CHALLENGES AND

ACHIEVING SUCCESS

KINERJA’s experience shows that there are several challenges that must be faced when

implementing maternal health programs.

At District Government Level: • KINERJA’s implementation required changes to be made to some district plans and

policies. This was not easy to achieve, and meant that some program activities either

could not be carried out or were poorly implemented due to a lack of support from the

districts.

• Frequent senior staff changes in the health sector – such as district health

office heads or heads of health centers – were a major obstacle to

sustainability.

At District Health Office and Health Center Level: • Difficulty in synchronizing schedules between district health offices and health centers.

• Personnel at decision-making levels in district health offices and health centers

sometimes provided insufficient support.

• Several health centers refused to or were unwilling to accept the results of the community complaint surveys, primarily because they were unfamiliar with complaints as tools for improvement.

At MSF and Community Level:

• Difficulty in ensuring the participation of MSF members in meetings and activities without

expecting reimbursement for transport.

• A tendency in some communities and amongst some women to distrust midwives.

At IO Level:



• Despite capacity building, limited knowledge of good governance, safe delivery, I&EBF, and

facilitation techniques restricted the assistance IOs could provide to district health offices, health

centers, and MSFs.

• Isolated geography and long distances between health centers meant it was harder to

schedule and carry out multiple activities over a short period of time.

Success Stories

1. Midwife and Traditional Birth Attendant (TBA)

Partnerships in Singkil Health Center, Aceh Singkil

District, Aceh Province

• Partnership commenced in April 2012. During the first phase, partnership was

implemented in 2 villages, which later on expanded to a total of 31 villages.

• Childbirth assisted by TBAs decreased to 0% within two years at the first health centre

to implement the program. In 2011, there were 18 deliveries assisted by TBAs, which

decreased to 8 childbirths in 2012, and 0 in 2013. The number remained at 0 in 2014.

• Some health centres now involve TBAs in promoting health in the community as Village

Health Motivators.

• The District Health Office has committed to replicating the partnerships across the

whole district.

• Creation of Emergency Childbirth Assistance Card and Health Care Hotline in all health centers.

2. Immediate Breastfeeding in South Singkawang

Health Center, Singkawang City, West Kalimantan

Province

• Patients now feel more comfortable in asking for the healthcare they are supposed to

receive.

• Families of patients now complain to midwives when mothers are not assisted in carrying

out immediate breastfeeding after childbirth.

• Requests for breastfeeding counseling have increased.

• Exclusive breastfeeding rates in Singkawang City have increased. In 2011 when

KINERJA entered the region, the percentage of infants exclusively breastfed was only

22.2%. The coverage increased to 38.1% after 1 year of assistance (2012), and rose

again to 48.7% in 2013.

• All childbirths assisted by health personnel are required to include immediate

breastfeeding in the South Singkawang area.



3. Supporting Exclusive Breastfeeding, Probolinggo District, East

Java Province

• The District Head of Probolinggo became the Breastfeeding Ambassador for

Probolinggo District and has issued a District Head Regulation on ensuring safe delivery

and I&EBF for all mothers, developed in cooperation with MSFs.

• The District Head published a prohibition letter forbidding the supply of formula milk to

health facilities and private midwife practices throughout Probolinggo District.

• The District Head, together with the District Health Office, actively conducted surprise

supervisory visits to all health facilities and midwife practices to check whether formula

milk was still promoted or sold, and issued sanctions to violators.

• Implemented the katuk leaf planting movement, whose leaves are beneficial for

improving lactation, and ensured that katuk leaves were part of the menu for all women

giving birth at health centers and hospitals.

• Cooperation with the private sector to ensure breastfeeding rooms are provided in the work place.



CHAPTER 4

RECOMMENDATIONS FOR REPLICATION

Recommendations for the Government

These recommendations are intended for the national government (Ministry of Health), provincial

governments, district governments, and district health offices.

a) Commitment

High commitment is required from the District Head, legislature and district health office, through

creating district legislation, providing financial support, supporting local champions, and training

human resources.

b) Ensuring Community Participation

Provide local resources for establishing MSFs and ensuring complaint mechanisms are available to

encourage a visible form of active participation on the demand side, and to support transparency as

well as accountability on the supply side that will improve health care performance and meet

minimum service standards and goals.

c) Individual and Community Supervision

MSFs should work together with local governments to perform monitoring and supervision in order

to ensure district regulations are implemented appropriately.

d) Materials for Health Centers

Support district health offices to adopt and adapt KINERJA’s model at the health center level,

with the assistance of materials and equipment from the KINERJA Learning Series and

guidance from former KINERJA staff, IOs, and partner health centers.

e) Health personnel

Support the health service to provide health personnel with the knowledge and skills required

according to national standards and SOPs. Support is required from parties such as MSF, the

legislature, and provincial and national governments to perform advocacy in order for health centers



and district health officers to ensure their health workers are professionally competent.

f) Incentives and Sanctions

Creative innovations are required in providing incentives and sanctions for service providers and

recipients. Such innovations act as stimulants in supporting movements for change within both the

community and the service provider.

g) Protection

District heads must protect organisations and officials who are responsible for enforcing prohibitions

and handing out sanctions as the law requires.

h) Motivation for Service Providers

Promote the role of government and private sector in providing breastfeeding rooms and

counselors at health centers, in the work place, and at public facilities.

i) Motivation for Media

Promote the role of local media to become voluntary supporters of movements to improve public service

provision.

j) Motivation for the Community

Simultaneously develop incentive models for community participation in MSFs so as to make a

space for sustainable community participation, control, and partnership. Enhance the role of men in

promoting breastfeeding.

Recommendations for Implementing Organizations

For NGOs with a mission of bringing about change through strengthening community movements, the

recommendations below will accelerate and enrich the movement for public service improvements.

a. IOs should become an agent of adoption and replication.

b. Elements of governance such as participation, transparency, accountability, and responsiveness are

the spirit of governance and should be applied by IOs to their work in non-governance sectors, such as

health and education.

c. Strengthening of IO personnel may be required, so that personnel are able to comfortably and

effectively facilitate activities.

d. Ensure the assistance period aligns with the district/city planning and budgeting cycle.



e. Select community movements already rooted and active in the community and provide creative

incentives that encourage people to take part, such as developing a sense of pride in being able to

assist others through choosing an innovation that is also cost effective and sustainable.

f. Adopt and adapt materials, tools, and supplies already developed by KINERJA in other fields as

an economical approach, as these materials have already been proven to make positive

changes in just 1 to 2 years assistance.

g. Improve methods of approaching private sector entities to seek corporate social responsibility

funding sources for improving public services in company districts.

Recommendations for Education and Training Institutions

Education and training institutions, both government and non-government, have strategic roles to play in

encouraging productive stakeholder participation in how safe delivery and I&EBF programs are managed.

It is recommended for the relevant institutions to:

a. Include KINERJA’s approach through incorpoating three sides of governance (regional

government, supply side, and demand side) into the curriculum.

b. Adopt and adapt supplies, tools, and materials already developed by KINERJA and incorporate

them into existing teaching materials.

c. For the Health Training Body, an immediate priority should be to enhance the knowledge and

skills of health personnel so that they are in line with national standards and SOPs.

d. For universities, use KINERJA’s materials as literature for student learning.

IMPLEMENTED BY RTI INTERNATIONAL AND PARTNERS

USAID - KINERJA

Sampoerna Strategic Square,

South Tower, 18th Floor, Jl. Jend.

Sudirman Kav 25-26, 12930.

[email protected]

www.kinerja.or.id

mailto:[email protected]

http://www.kinerja.or.id/

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