Indonesia Country Profile

Jhpiego in Indonesia
Quick Facts
Estimated total population:1 238.2 million Maternal mortality ratio:2 228/100,000 live births Infant mortality rate:2 34/1,000 live births Under-five mortality rate:2 44/1,000 live births

Background The Republic of Indonesia, the fourth most-populated country in the world, comprises more than 17,500 islands. Despite a long history of social programs and a strong policy environment in support of maternal, newborn and child health, Indonesias health indicators remain poor. To improve health in the country, the Government of Indonesia has taken a number of key steps, including development of a national strategy to address maternal mortality, development of a national child health policy and national action plan to improve newborn health, and devolution of authority to local governments.

Jhpiego has been working in Indonesia since the early 1980s, initially with funding from the U.S. Agency for International Development (USAID), supporting competencybased training in reproductive health (RH) with the Department of Obstetrics and Gynecology at the School of Medicine at the University of Indonesia. Jhpiego also Total fertility rate:1 worked to strengthen the RH training system by training trainers and establishing a 2.3 National Clinical Training Network for RH at provincial and district levels, and a Contraceptive prevalence:2 National Resource Center at the national level. In 1991, Jhpiego began to work with the 54% (modern methods) Ministry of Health (MOH) to provide IUD and Norplant implant services, including a 61% (all methods) field assessment of the arm model for Norplant training and overseeing training of more than 6,000 providers in IUD and/or Norplant services. By 1995, this experience HIV prevalence:3 culminated in the development of the U technique for Norplant removal, proven to 0.2% be more easily learned by clinicians, as well as being an improvement over the standard technique in terms of speed and safety. From 2000 to 2006, Jhpiego, along with the Births with skilled Johns Hopkins Center for Communication Programs, led the USAID-funded provider:4 75% Sustaining Technical Achievements in Reproductive Health/Family Planning (STARH) Project, which focused on improving quality and choice of family planning (FP) and Sources: RH services in Indonesia. Following the December 2004 earthquake and tsunami that 1 Population Reference Bureau 2011 devastated parts of the country, Jhpiego also provided immediate assistance in the Population Data Sheet; 2 Indonesia Demographic and Health disaster situation. From 2007 to 2011, under a Ford Foundation-supported initiative in Survey 2007; the Karawang District, Jhpiego built the capacity of 17 community health centers, or 3 UNAIDS Report on the Global AIDS Puskesmas, and health care providers to identify and treat cervical cancer, and worked Epidemic 2010; 4 UNICEF Information by Country with local groups to build awareness and increase demand for cervical cancer prevention Program services. In addition, Jhpiego has collaborated and is continuing to collaborate with corporations (e.g., Exxon, Chevron, BP) to strengthen demand for and quality of primary health care services in their worksites. Currently, Jhpiego manages a mix of programs funded by a variety of donors as described under Current Program Highlights. From developing training systems, to strengthening medical and midwifery schools, to re-establishing health care services in a time of crisis, Jhpiegos collaboration with the Indonesian government has resulted in establishment of tools and approaches that are now used as models for organizations and partners worldwide. Over the past decade, Jhpiego has provided technical leadership to address the following MOH priorities:
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Strengthening the Quality of Maternal and Newborn Health (MNH) and RH Services: Jhpiego works to ensure that essential MNH and RH services are functioning and that an effective system for referrals exists. Jhpiego utilizes a proven quality improvement approach whereby standards for performance are defined, and then each staff member works toward achieving those standards. As improvements are made and standards are achieved, the health centers are recognized or rewarded by the District Health Office, peers and others. Building Training Capacity for MNH and RH: Jhpiego expands training capacity of the National Clinical Training Network by developing new classroom training sites, identifying and improving clinical practice sites, and developing classroom and clinical trainers. Jhpiego also serves as a national leader with this network in the development of new training curricula. Strengthening Midwifery Training: Jhpiego works to re-establish and strengthen midwifery education in support of the Government of Indonesias national strategy for strengthening pre-service education of nurses and midwives. As midwives graduate from these schools with stronger skills, they are able to contribute more fully to high-quality service provision for mothers and families, thereby promoting maternal and child survival. Jhpiegos technical assistance helps improve the quality of midwifery education by strengthening classroom teaching, laboratory practice and clinical practice. Cervical Cancer Prevention: The Cervical Cancer Prevention Initiative in Indonesia has laid the foundation for a national cervical cancer prevention program by: 1) working at national level on policy, guidelines, advocacy and management issues to ensure that the proper systems are in place to support delivery of a single visit approach; and 2) implementing and evaluating a cervical cancer screening and treatment service delivery model in selected districts so that best practices from this intervention can be shared and scaled up to other districts throughout Indonesia. Infection Prevention Practices: Jhpiego supports efforts to strengthen infection prevention and control (IPC) practices at health facilities, in line with the national strategy. Initiatives to date include: development of IPC guidelines and standards, development of a training strategy and plan, adaptation of training packages, training of trainers, development of job aids to support best practices, development of a supervision model/tools and development of an IPC management package for health office staff at district and provincial levels. Jhpiego has also adapted the IPC model to avian influenza. Community Mobilization: To increase skilled attendance and facility births, Jhpiego is implementing community-based approaches such as Desa SIAGA and Midwifery TBA partnership. Desa SIAGA (or ALERT village) is a community-mobilization strategy developed by Jhpiegos MNH Program funded by the USAID. Currently being scaled up nationwide by a variety of donors and partners, this strategy promotes community readiness for childbirth: 1) pregnancy notification and referral to a midwife; 2) organization of transport; 3) organization of blood donors; and 4) family and village savings for birth emergencies. Additionally, Jhpiego is promoting partnerships between traditional birth attendants (TBAs) and midwives by clarifying roles, agreeing on mutual compensation and providing recognition Community gathering for the Desa SIAGA (ALERT Village) for strong partnerships to increase skilled attendance and facility births. Program in Indonesia.

Current Program Highlights Expanding Maternal and Newborn Survival: Jhpiego is leading a five-year, $55 million, USAID cooperative agreement to implement the Expanding Maternal and Neonatal Survival (EMAS) project in Indonesia. The EMAS objectives are twofold: 1) to improve the quality of MNH health services at 150 hospitals; and 2) to increase efficiency and effectiveness in referral systems between 300 Puskesmas and the 150 hospitals. In addition, EMAS seeks to improve governance and increase the use of communication technology to improve referral efficiency and quality of health services. Partners in the Jhpiego-led team include Budi Kemuliaan Maternal and Child Health Hospital (RSIABK), Muhammadiyah, Save the Children and RTI International. All three international partners will leverage corporate partnerships with sponsors such as ExxonMobil, Chevron, General Electric (GE) Healthcare, Starbucks, Kraft, Coca-Cola, Project Cure, Laerdal and AT&T to maximize and extend results. Each partner has complementary roles as follows: Jhpiego leads the team, providing technical leadership in maternal health and quality improvement and contributing to referral system strengthening. RSIABK serves as the EMAS lead for on-the-job mentoring in high-quality clinical practices and governance practices in both public and private facilities. Muhammadiyah leads all quality improvement efforts within the 57 Muhammadiyah and Aisyiyah hospitals located in the EMAS target provinces. Their womens organization, Aisyiyah, is a key partner in promoting the use of facilities for births, raising public awareness of insurance opportunities and demanding accountability for quality services and good governance. Save the Children provides technical leadership in newborn health and contributes to referral system strengthening. RTI International leads the integration of cross-cutting interventions in governance and information and communication technology.
Maternal and Child Health Integrated Program: MCHIP in Indonesia is a USAID-funded, $9.8 million, three-year program (January 2010 to December 2012) being implemented by Jhpiego in collaboration with Save the Children and John Snow, Inc. In support of the MOH Road Map to the 2015 Millennium Development Goals (MDGs), MCHIP/Indonesia is being implemented in three districts classified as Health Problem Areas (Serang District in Banten Province, Kutai Timur District in East Kalimantan Province and Bireuen District in Aceh Province). MCHIPs goal is to catalyze implementation of existing policies that promote key, evidence-based, lifesaving interventions at scale in remote areas. More specifically, MCHIP is working to: Ensure effective implementation of the MDG Roadmap for scaling up lifesaving interventions to achieve MNH impact at scale within three remote provinces Improve maternal and newborn care in the three target districts Improve quality of clinical services at all levels of care Improve management of district health systems Strengthening Midwifery and Primary Care Services: In collaboration with ExxonMobil, Jhpiego has been working in the Bojonegoro Regency and Tuban District of the East Java Province since August 2010. The program has improved midwifery services in 15 communities in the targeted subdistricts in Bojonegoro. In addition, the program revitalized TBA and midwifery partnerships in the community to increase births at facilities. The program is also strengthening the Puskesmas that serve as referral sites and improving MNH reporting and recording. The program will replicate the Bojonegoro primary care services model in Tuban. Strenthening Utilization of Health Services through Effective Community Engagement: In collaboration with Chevron, Jhpiego has been working in Riau and Kalimantan Provinces since January 2011. Jhpiego is strengthening the Puskesmas in the community to provide high-quality MNH services. To increase the demand for services and facility births, Jhpiego is facilitating partnerships between TBAs and midwives, and revitalizing Desa SIAGA, a partnership at the community level to support birth preparedness and complication readiness. Strengthening Pre-Service Midwifery Education: Jhpiego is providing technical assistance to GITEC, a German consulting company, to improve the quality of midwifery education on MNH practices at the Midwifery Academy of Langsa District in Nanggroe Aceh Darussalam Province and the University of Syah Kuala in Banda Aceh.

Key Accomplishments Under the MNH Program, Jhpiego provided technical assistance to local organizations to adapt the World Health Organization (WHO) manual, Managing Complications in Pregnancy and Childbirth, for use in Indonesia. This adaptation serves as the national standard for MNH care. In addition, the Performance and Quality Improvement approach was used in Indonesia to develop high-quality service delivery and training sites that serve as models for scale-up. At these sites, the percentage of trained providers practicing specified skills increased from 35% in 2001 to 85% in 2003. Also under the MNH Program, Jhpiego established the Desa SIAGA program based upon the concept of birth preparedness and complication readiness. By the end of the program, all districts in West Java had successfully adapted the Desa SIAGA framework and the MOH later established Desa SIAGA as a national decree. Currently, 166 communities have functioning ALERT villages able to respond to obstetric emergencies. In the aftermath of the tsunami, Jhpiego re-established, equipped and renovated 20 midwife practices and two midwifery schools, established and equipped the obstetric unit of one provincial hospital, equipped 50 village midwives with delivery and suturing kits, and equipped two midwifery schools. It also recruited and deployed 127 midwives to fill the gap in RH services at health facilities and camps for displaced persons. Services provided by these midwives covered an estimated 1,504 children and 3,852 women. Jhpiego also helped provide counseling to 141 midwives who lost their practices and/or family members. Three hospitals, 16 Puskesmas and 50 midwifery clinical sites in Aceh have become models of high-quality MNH services and IPC practices. One provincial training center has been strengthened and two district training centers have been established in Aceh to train 240 midwives and doctors per year. A model for quality midwifery education has been developed in four academies in Aceh that follow national standards of midwifery education. More than 50,000 women have been screened and treated, as needed, for cervical cancer using the single visit approach. Jhpiego materials (clinical guidelines, training package and training plans) are now used nationally for the prevention of avian influenza and other emerging diseases. Jhpiego also trained five national and 30 regional trainers to conduct avian influenza training. Partners and Donors Jhpiego has formed multi-level partnerships in Indonesia with communities, community-based providers, health care facilities, nongovernmental organizations, government institutions and policymakers, private sector corporations (e.g., ExxonMobil, Johnson & Johnson, GlaxoSmithKline, BP Rio Tinto, Chevron), and international agencies and foundations such as USAID, AusAID, UNICEF, Ford Foundation and the German company GITEC Consult GmbH. References
Statistics Indonesia (Badan Pusat StatistikBPS) and Macro International. 2008. Indonesia Demographic and Health Survey 2007. Calverton, Maryland. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2010. Global Report: UNAIDS Report on the Global AIDS Epidemic 2010. At: http://www.unaids.org/globalreport/Global_report.htm Population Reference Bureau. 2011 World Population Data Sheet. Washington, D.C. World Health Organization (WHO) Statistical Information System. At: http://www.who.int/whosis/en/