QUALITATIVE STUDY RESULT

PERSPECTIVE OF CIVIL SOCIETY

PARTICIPATION

FOR THE SUCCESS OF

MATERNAL, CHILD, and ADOLESCENT HEALTH

PROGRAM IN 2013

Maternal and Child Health Movement J a k a r t a

2 0 1 4

QUALITATIVE STUDY RESULT PERSPECTIVE OF CIVIL SOCIETY PARTICIPATION FOR THE SUCCESS OF MATERNAL, CHILD. And ADOLESCENT HEALTH PROGRAM IN 2013

DR.dr.Brian Sriprahastuti, MPH

dr.BudhiSetiawan, MPH

AsteriaAritonang, S.Sos, M.Min, MBA

Jakarta, March, 2014

This report is developed on behalf of Indonesia Public Health Association

(Ikatan Ahli Kesehatan Masyarakat Indonesia - IAKMI) based on the study

that was implemented by civil society organizations affiliated in

Maternal and Child Health Movement, funded by World Health

Organization (WHO) through WahanaVisi Indonesia.

Parties who supported data collection process are : Aliansi Pita Putih/

White Ribbon Alliance Indonesia, Child Fund, FOPKIA – Banten, FORMAP

KIA – Sulawesi Selatan, Mercy Corps Indonesia, Micronutrient Initiative,

Muhammadiyah, Perkumpulan Keluarga Berencana Indonesia, Plan

Indonesia, Save the Children, Wahana Visi Indonesia, Yayasan

Pembangunan Cita Insani Indonesia.

iii

LIST OF CONTENT

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

EXECUTIVE SUMMARY ...................................................................................................... iv

OVERVIEW OF MATERNAL AND CHILD HEALTH MOVEMENT ................................................ v

CHAPTER 1.PREFACE ......................................................................................................... 1

1.1. Background ............................................................................................................ 1

1.2. Purpose of the Study ............................................................................................... 3

CHAPTER 2. DESIGN OF THE STUDY .................................................................................. 4

CHAPTER 3. RESULT AND DISCUSSION OF THE STUDY ....................................................... 6

3.1. Information Collection Process ................................................................................ 6

3.2. Data and Information Processing and Analysis .......................................................... 8

3.3. Involvement of NGO as Implementer of Group Discussion ......................................... 9

3.4. Characteristic of Discussion Participants .................................................................. 10

3.5. Participants Perception regarding Maternal Health Program ..................................... 11

3.5.1. Maternal Health Program Indicator .................................................................. 11

3.5.2. Maternal Health Program Policy ...................................................................... 15

3.6. Participants perception regarding Child Health Program .......................................... 25

3.6.1. Child Program Indicator .................................................................................. 25

3.6.2. Child Health Program Policy ............................................................................ 27

3.7. Participants Perception Regarding Teenagers Health Program .................................. 37

3.7.1. Teenagers Health Program Indicator ............................................................... 37

3.7.2. Teenagers Health Program Policy .................................................................... 40

CONCLUSION AND RECOMMENDATION ............................................................................ 44

A.CONCLUSION ........................................................................................................... 44

B. RECOMMENDATION ................................................................................................. 46

EXECUTIVE SUMMARY

The UN’s Commission on Information and Accountability (COIA) recommended

that each country develop an accountability framework that includes a strong role

for Civil Society Organizations (CSOs) to improve policy and accountability for

maternal and child health programmes.Since no formal mechanism is established

through which CSOs can fulfill this role, a coalition of Indonesian CSOs piloted an

initiative to obtain the needed inputs by reviewing 2013’s programme status and

offering its perspective to the GoI on MCH policy and accountability for inclusion

in the next health strategic plan.A study explored the perspective of the

participating CSOs with regard to this process.

A qualitative study was conducted through 35 focus group discussions with

representatives from CSOs, family welfare empowerment and faith-based

organisations as well as other relevant agencies.The study assessed the

participants’ experience in the development and monitoring of MCH programmes

in 12 representative provinces of Indonesia.Analysis method used for this study

was content analysis where data reduction and display were done before

formulating the conclusion

CSOs viewed that while some local governments had useful MCH policies, the

influence of civil society to ensure accountability was limited by lack of access to

data and consultation by the GoI with them.CSOs expressed the concern that local

politicians are biased towards infrastructure development as compared to

programmes with broad social benefits, while communities themselves are largely

unaware of both the obligations of government to deliver good MCH services as

well as their right to receive such services.

Civil society organisations may improve accountability for MCH programmes by

strengthening grass-root participation in advocacy and monitoring of equitable

results especially for marginalised groups.At the same time, CSOs should more

aggressively seek to obtain information on MCH policies and budgets, as is their

right under Indonesian law.Increased grassroots participation and awareness

coupled with better informed advocacy from civil society may be expected to

improve accountability.

Writer.

OVERVIEW OF MATERNAL AND CHILD HEALTH MOVEMENT

Maternal and Child Health (MCH) Movement was jointly initiated by the Government

and Non-Governmental Organizations (Civil Society Organizations, Professional

Organizations, Faith Based Organizations) in early 2010, and was launched in June

23, 2010 by the Coordinating Minister for People’s Welfare, Mr. AgungLaksono.

The launching of MCH Movement involved government and non-governmental

partners from 10 highest under-fives mortality rate provinces in Indonesia, based on

Indonesia Demographic Health Survey (Survei Demografi Kesehatan Indonesia-SDKI).

Since early 2011, MCH Movement regularly conducts coordination meeting and has

become a useful media to develop more intensive communications with decision makers

in MCH and Nutrition sectors, especially in the national level.

MCH Movement was considered and trusted to represent Indonesia Civil Society

Coalition in MCH and Nutrition sectors in Asia Pacific regional and global levels

forums, including in the meetings conducted by WHO and UNICEF.

Since UN General Secretary launched the Global Strategy for Women and Children

Health, "Every Woman, Every Child” in 2011, MCH Movement has initiated series of

cross-ministerial/institution meetings, including with Indonesia Commissioner -

Foreign Minister of Republic of Indonesia, and has guarded the follow up actions of

recommendations from Commission on Information and Accountability. MCH

Movement is even trusted to become the responsible party for Advocacy & Outreach

Working Group, and to manage funding from WHO to implement activities in form of

Journalist Training and Civil Society Discussion. This study is one of the results of

Advocacy & Outreach working group, and was presented as the material from the

National Medium-Term Development Plan (Rencana Pembangunan Jangka Menengah

Nasional – RPJMN) Background Study Seminar, conducted by Ministry of National

Development Planning (Bappenas) of Republic of Indonesia in February 2014.

Asteria Aritonang - Coordinator of GKIA’s Working Group

CHAPTER 1. PREFACE

1.1. Background

In February 2013, government and civil society groups have completed

country’s accountability framework, referring to 10 recommendations from

the information and accountability commission. Advocacy & Outreach

working group has agreed to prioritize the strengthening of civil society and

media’s participation as the important activity in 2013, to improve the

relationships of government, civil society and the media for the development

of maternal and child health accountability.

In 2012, General Directorate for Nutrition and Maternal and Child Health

performed mid-term review to confirm the achievement of program

performance that routinely and hierarchically reported from Puskesmas level

to central level. Mid-term review of MCH & N program strategic plan was

conducted through quantitative study in 16 districts of 8 provinces in

Indonesia, which was purposively selected by considering heterogeneity,

program performance report and interest of MCH & N directorate.

Facility report mentions that the targets of MCH & N’s three main indicators,

which are PN, D/S dan KN1, are almost achieved; but Mother Mortality Rate,

Infant Mortality Rate, and Under-fives Mortality Rate are still high.Result of

the mid-term review descriptively indicates the achievement of MCH & N

2010-2014 Strategic Plan indicators, which are lower compared to facility

data resulted from documentation and reporting in 2011, although there is an

increase compared to 2010. Situation Analysis discovered some facts that

include the access of MCH & N program has not achieved universal coverage,

the quality of MCH & N health services have not achieved the target, health

resources capacity is limited, Health Information System (Sistem Informasi

Kesehatan -SIK) has not functioned optimally, and MCH & N program

planning is not responsive to community’s needs. Result of that study

recommends the necessity of synergy of several factors to overcome the

challenges of weak Puskesmas management capacity, limited health human

resources, geographical problems, and family acceptability, as well as lack of

civil society participation.

This study was conducted to obtain deeper information from different

perspectives regarding the performance of Republic of Indonesia’s

government related to reproduction health, pregnant mothers, new-born,

under-fives, children and teenagers. Result of this study will be used as

supporting information for the latest Indonesia Demographic Health Survey

(SDKI 2012, Riskesdas/Basic Health Research 2013 and Risfaskes/Health

Facility Research 2011), and as information to enrich government institution

stakeholder analysis, which is currently happening in 6 selected districts.

Therefore, it is necessary to find answers for the following questions:

1) According to civil society perspective, what are the factors that determine

the achievement of Nutrition and MCH program performance?

2) As the effort to accelerate the achievement of Maternal, under-fives and

teenagers health program based on 2010-2014 strategic plan, what are

the critical policy to be recommended to the government?

3) What policy should be set as the success indicator and measurement

method of MCH & N 2015-2019 strategic plan?

4) What is the role of civil society to support the achievement of MCH & N

2015-2019 program indicators?

The collected, processed, and analyzed data will be used as input for policy

recommendation to improve the performance of Ministry of Health in

developing 2015-2019 strategic plan, to be more responsive to community's

needs and to become the proof of Non-Governmental Organization’s

participation in developing Maternal and Child Health in Indonesia.

3

1.2. Purpose of the Study

This study was conducted to achieve its general objective, which isto know

the perception of non-governmental organization and elements of the

community regarding MCH & N program performanceand the participation

that should be formulated. While the specific objectives of this study are:

1) Knowing in depth information regarding the problems in MCH & N

program achievement.

2) Knowing the critical policies that will be recommended to the government

as the effort to accelerate the achievement of MCH & N 2010-2014 target

indicators.

3) Knowing the policies that should be set as the success indicator and

measurement method of MCH & N 2015-2019 strategic plan

4) Formulating the role of civil society to support MCH & N program and its

indicator measurement.

This study was designed purely as qualitative study. Information collection

was done using Focus Group Discussion (FGD) method with informants who

represent the elements of civil society. The instrument in this study is the

researcher, while the measuring tools used are notes and voice recorder.

Information collection was done using a discussion guideline, which was

developed based on the key questions to answer the objective of this study.

The objectives of FGD are:

1) To discover information regarding community perception related to

government performance in achieving target indicators of health

programs for maternal, new-born, under-fives, children, and teenager.

2) To analyze root problems that were identified in the findings of mid-term

review result of the 2012 Strategic Plan, 2012 Indonesia Demographic

Health Survey, 2012 Basic Health Research, and 2010 Health Facility

Research.

3) To analyze qualitative information in determining the interests of parties

that should be considered while developing and/or implementing policy

or program. Therefore, we can map the position of stakeholders (related

to the identified problems) based on the knowledge, power/leadership,

resources, alliance and supports.

4) To formulate policy options to overcome problems identified in the

previous studies.

Participants of FGD are: Representatives of local NGOs, Empowerment of

Family Welfare (Pemberdayaan & Kesejahteraan Keluarga-PKK), child

commission, faith based organizations, tradition/culture, non-health

profession (Teacher Association of Republic of Indonesia - PGRI, Association

of Early Childhood Educator - HIMPAUDI) and other Civil Society

Organizations that are considered to be relevant to provide information as

necessary. This study covers three aspects, which are maternal health, child

health and teenager health. Purposively, the study area includes 12 provinces,

including: North Sumatera, South Sumatera, Lampung, Banten, DKI Jakarta,

West Jawa, Central Jawa, East Jawa, NTT, Papua, West Papua and South

Sulawesi.

There are 8 to 12 representatives of different organizations participated in the

each FGD, which was facilitated by one facilitator and assisted by a note-

taker.It was jointly agreed that the participants of group discussions are not

representing an individual and are not government officials. Focal point NGO

selected the facilitators and note-takers by considering their competencies to

guide an FGD. Discussion guideline design was prepared by researcher and

improved based on the input from focal point NGOs, while at the same time

aligning the perception regarding the questions and information expected

from those questions.

This study was conducted for 3 months since mid-November 2013 until

mid-February 2014. Information processing and analysis was done in

Jakarta by the researcher and research assistant. This research was funded

by WHO for Maternal and Child Health Movement through WahanaVisi

Indonesia.

CHAPTER 3. RESULT AND DISCUSSION OF THE STUDY

3.1. Information Collection Process

Representatives of focal point NGO, WHO, UNICEF and MCH Movement

attended the preparation meeting in ChildFund office on 19 November 2013, to

agree on the objectives, process, and the expected result of the FGD; finalization

of FGD guideline, implementation mechanism and time frame. This meeting

resulted some important agreements including modification of FGD guideline

as a combination with the questionnaire, so the method of the study become

quantitative-qualitative methods with bigger weigh on the qualitative study.

One of the results of the meeting is that FGD will be implemented in district

level in the 12 provinces as planned in the beginning of the study design.Three

discussion topics, including maternal health, child health, and teenager health,

can be implemented in the same or in the different districts. Focal point NGO

has the freedom to determine the sample district by considering the diversity

of Civil Society Organizations exist in that area, and the urgency of MCH and

reproduction health issues encountered by the area. Criteria of FGD

participants are:

1) Not representing the element of Government and Regional House of

Representative

2) Representing civil society, for example: Empowerment of Family

Welfare (PKK), Professionals Organization, Religious Leaders,

Community Leaders, NGO, Scholar, Youth Forum.

3) Considering aspect of representation of gender and age group

(teenagers)

4) Already involved (practitioner/observer) in Maternal and Child Health

program for at least 2 (two) years.

5) Experienced coordinating directly with Department of Health at least in

District/City level for at least 1 (one) activity.

6) Willing to fully participate (for 2 hours) in FGD on the determined day in

the Provincial/District/City levels

SanggarSuaraPerempuan (Female Voice Center) implemented the try-out of

discussion guideline in TTS District – NTT Province. Result of the try-out

indicated that the guideline is feasible to be implemented, it takes no more than

3 hours of discussion, and will be optimal to be participated by at least 8

participants from different Civil Society Organizations, feasible to involve

teenagers (child board) in the discussion, and funding support is also available

for participants, note taker and facilitator. There are some inputs for FGD

Implementation including the difficulty to programmatically segregate mother

and under-fives; facilitators' expertise to guide the discussion participants is

necessary so the discussion will stay focus to explore clear information about

the two groups.

Focus Group Discussions were conducted for 2-3 hours, facilitated by 1

facilitator and 1-2 note takers with the following discussion stages:

1) Facilitator presented the structured questionnaire about the causal-effect

description of the problems and the stakeholder analysis so the informants

could fill in the questionnaire in 30 minutes.

2) Facilitator led FGD using the prepared questionnaire-guideline with the aims

to:

a) Recognize the identified causal-effect description of the problems and

policy options, stakeholders’ position based on the knowledge,

power/leadership, resources, alliance, and supports.

b) Deeply discover the opinions of discussion participants regarding

maternal/under-fives/teenagers’ health problems, causes, and policy

options.

c) formulate result of FGD based on the causal-effect description of the

problems and policy options

3) Focal point NGO developed the summary of discussion process and

presented the summary to MCH Movement on 10-11 December 2013. This

meeting was conducted for the learning process of Focus Group Discussion

implementation and the mediation of FGD result-collection.

4) Members of Young Members Movement of Indonesia Public Health

Association moved the information from voice recorder in to a transcript

form on 11 December 2013 until the first week of January 2014.

5) Research assistant processed the transcript into information presentation

form and submit it to the main researcher in the third week of January

2014.

6) Main researcher reduced, further analyzed and reported the information.

7) Initial draft report was presented and discussed for clarification to the

members of MCH Movement in the end of January 2014.

3.2. Data and Information Processing and Analysis

Quantitative and qualitative methods were conducted to produce

comprehensive information regarding health program for maternal, new-born,

infant, under-fives and teenagers in 12 provinces within the study area.

Quantitative data was summarized through data frequency distribution resulted

from FGD questionnaire part 1 (one) that has been prepared before the

discussion in each Focus Group Discussion begins.The produced data was

formulated in form of proportion that represents characteristic of each

individuals who participated in the discussion. In the quantitative data, we can

see the characteristics including informant's age, sex, educational background,

and individual score against the indicators of mothers/child/teenagers health

program, and mother/child/teenagers health policy in district/city.

Qualitative analysis was used to get in-depth information regarding the past,

current and future program situation in district area where the discussion

participants live. This study used content analysis with the following process

stages: Facilitators and note taker record the discussion process using voice

recorder and notes and later will produce verbatim transcript that will be

reduced, and then presented and concluded based on the evidence (evidence-

based).

3.3. Involvement of NGO as Implementer of Group Discussion

Eight NGOs functioned as FGD focal point in the provincial level, and 9 NGOs and

2 coalitions as FGD guides in the district level. Focal Point NGOs averagely

guided 2 discussion groups, depending on the interests and focuses of the NGOs.

Assignment of NGOs to guide FGD was quite dynamic, and the interaction to

support each other was quite well (table 3.3.1). There were 368 people

recorded as the discussion participants; the implementation of teenagers health

FGD was disturbed in East Jawa as well as in West Jawa, which was participated

by only 3 participants (Table 3.3.2).

Province Maternal Health

Under-fives Health

Teenagers Health

Focal Point NGO

1 North Sumatra

Forum Percepatan KIA

Forum Percepatan KIA

Forum Percepatan KIA

Muhammadiyah

2 South Sumatra

PKBI PKBI PKBI PKBI

3 Lampung PKBI PKBI PKBI PKBI 4 DKI Jakarta Mercy Corps Mercy Corps WahanaVisi Mercy Corps 5 Banten Forum

Komunikasi KIA

Forum Komunikasi KIA

Micronutrient Initiative

Muhammadiyah

6 West Jawa ChildFund Save the Children

Save the Children

Save the Children

7 Central Jawa

ChildFund ChildFund ChildFund ChildFund

8 East Jawa APPI APPI WahanaVisi APPI 9 NTT APPI Plan Plan Plan 10 Papua YPCII YPCII/ World

Vision

WahanaVisi YPCII

11 West Papua PKBI PKBI PKBI PKBI

Table 3.3.1 Distribution of NGOs FGD Implementer on Provincial Based.

No. Province Maternal Health

Under-fives Health

Teenagers Health

Focal Point NGO

12 South Sulawesi

USAID - EMAS USAID - EMAS PKBI Muhammadiyah

Table 3.3.2 Distribution of FGD Participants on Provincial Based

No. Province Total FGD Participants:

Mothers

Total FGD Participants:

Children

Total FGD Participants:

Teenagers

1 North Sumatra 9 11 12 2 South Sumatra 12 11 12 3 Lampung 12 12 13 4 Banten 9 10 9 5 DKI Jakarta 12 11 14 6 West Jawa 14 13 3 7 Central Jawa 13 10 13 8 East Jawa 11 10 NA 9 NTT 8 11 9 10 Papua 9 10 8 11 West Papua 10 13 11 12 South Sulawesi 9 9 9

Total 115 140 113

3.4. Characteristic of Discussion Participants

Civil society participation in this study was quite variable based on the age

group, sex, and educational background.The youngest discussion participant

was 12 years old and the oldest was 77 years old.FGD was dominated by

female participants, except in the teenager FGD where the proportion of male

and female was almost equal. The education of most of the participants (89%)

is at least high-school graduates, so we can assume that they have good

education to give their opinions related to MCH programs in their areas.

Maternal Health FGD

Child Health FGD

Teenagers Health FGD

Female

Male

Image 3.4.1. Graph of Discussion Participants Proportion Based on Sex

Mother FGD Children FGD Teenagers FGD Did not graduate from Elementary School At least Junior-high school graduates At least High school graduates At least bachelor graduates At least master degree graduates Image 3.4.2. Graph of Discussion Participants Proportion Based on Education

3.5. Participants perception regarding Maternal Health Program

3.5.1 Maternal Health Program Indicator

The success of Maternal Health Program is measured from the achievement

of indicator. There are 6 indicators measured in this study, which are

categorized into 2 groups: access indicator and quality indicator. Access

indicator sees the coverage of first pregnancy check up in the first trimester

(K1), fourth pregnancy check-up in the third trimester (K4) and labor with

the assistance of health workers (PN); while quality indicator considers the

implementation of 7T during the post-natal check-up, pregnancy check-up

(ANC) with the right timing (1:1:2) and labor support performed in health

facilities.

Table 3.5.1. Distribution of the Frequency of Participants Behavior toward Maternal Health

Indicator

Strongly Disagree (%)

Disagree (%)

Agree (%)

Strongly Agree (%)

Not Answering (%)

K1 0.87 1.75 43.85 52.63 0.9

7T 0 0.85 40.35 58.8 0

K4 0.87 1.75 43.85 52.63 0

Pure K4 0 4.38 60.52 33.3 1.8

PN 0.87 0 35.08 64.05 0

PNF 0 0 42.98 43.85 13.7

Quantitative data analysis showed that for all indicators, around 86.83%-

99.15% participants agreed with the access and quality indicators that were

determined by the government and that are currently applied. The most

agreed indicator was the service quality indicator ANC 7T (99.15%) followed

by PN (99.13%).Indicator with the lowest frequency of approval is labor in

health facilities. For all of those indicators, 81% of participants think that the

district indicators have been achieved.

Discussion participants think that those indicators cannot measure the

equality of maternal health service. There are locus and target groups that

still face difficulties to access health services. Such things happen because

there are some areas with difficult geographical condition, or because not all

villages have health facilities and workers, and diffable mothers are treated

the same way with others when they have different needs.

Indicator regarding male participation in family planning is already available,

which is number of husbands using condom (or vasectomy).This indicator is

adopted as National Family Planning Coordination Body (Badan Koordinasi

Keluarga Berencana Nasional – BKKBN) performance.FGD participants think

that male participation indicator is important as the indicator of maternal

program success indicator because now husbands/fathers are often involved

in support meetings and socialization for mothers.

Other than the indicators that directly measure maternal health service, we

also need measurement for the female teenagers target group because

prospective mothers can prepare healthy pregnancy and safe labor early.

Distribution of blood booster tablet to pregnant mothers is ANC quality

indicator that does not automatically overcome anemic issues on pregnant

mothers. Maternal health program should also able to make sure that all

female teenagers do not have anemic. We should think of counseling and

efforts for female teenagers’ health as integrated indicators with maternal

program.

“when we think of mother’s health, we should start from prospective mothers. ... They are the female teenagers, who since the beginning should be well prepared to become future qualified mothers. Therefore, it is necessary for the government to prepare well all female teenagers through measureable and focused efforts.”

We need to think of civil society participation indicator for maternal health

program. That indicator should be sensitive and strategic. Civil society

participation indicator should be measured hierarchically from the village,

sub-district, district, and provincial to the national levels. Participation in the

village level can be measured from the availability and function of

Community Based Health Efforts (Usaha Kesehatan Berbasis Masyarakat -

UKBM) relevant with maternal health. Alert Village and Posyandu become

the strategic vehicles of Community Based Health Effort, including the

partnership among Cadres and Village Midwives/Nurse in Village Health

Post (PosKesehatanDesa– Poskedes).

“... there are maternal-based Community Based Health Effort; tabupas, pregnant mothers’ savings.On-going pregnant mother program.In the community, voluntary donor awareness has started (Voluntary Donor Community – Komunitas Donor Sukarela – KDS)MCH motivator has started...”

Civil society participation can be in the form of monitoring implementation of

maternal health program, and evaluating the impact of the program, such as

mortality of mothers.The quotes below represent the opinion:

“... Program monitoring has not yet existed.There are mothers who receive P4K (Delivery Planning and Complication Prevention Program – Program PerencanaanPersalinandanPencegahanKomplikasi) sticker, ... they used it to patch broken bucket".

"In Central Jawa (there are) 635 maternal deaths.This data should be exposed to make us more aware.”

Availability of service becomes an important input in achieving target of

maternal health program indicators.We need to dig deeper the indicator of

health workers availability.By considering the equal distribution aspect, we

need to discuss further whether the availability of that service should use

village unit or ratio against the population?

From 6 maternal health program indicators used as FGD topic, the fulfillment

of 7T in K1 is considered as important indicator for most of the discussion

participants.It aligns with the result of FGD, that the quality of provision of

maternal health service is not only seen from the technical capacity of the

health workers/facilities, but also the compliance of the health workers to

guideline/SOP (Standard Operations Procedure) and good communications

with the served community.

Generally, the discussion participants welcome government’s initiative

through Maternity Benefit policy, because it is proven to improve community

access to health facilities.However, the government needs to manage the

policy more strictly so it will not impact on the increase of number of

pregnancy and labor.Most of the participants worry that free pregnancy

check-up and labor will increase pregnancy without considering the

difficulties and death risks that mother will deal with.The tendency of

increase of pregnancy and labor check-up in health facilities, as the

consequence of Maternity Benefit policy, has not been anticipated by adding

the number of health workers who serve in health facilities.

”... The objective of Maternity Benefit is to reduce mortality rate, but it still high anyway, maybe it is related to the ongoing mortality report.Free pregnancy check-up...The result is long queue...”

3.5.2. Maternal Health Program Policy

Quantitative data analysis indicated that 74% of the discussion participants

agreed that the prevailing policies in the district benefit their

organizations.The biggest benefit is the health effort and health resources

aspects, while the smallest is the health information.Most of the discussion

participants agreed that there are parties outside of the health sector who

support maternal health program policy.Those parties are the Non-

Governmental Organizations and Government Institutions, while profit

companies give the least support.Most of the discussion participants did not

agree that there are parties outside of the health sector who do not support

district maternal health program policy.Even when there are such parties, the

proportion is almost the same between non-health government institutions,

profit companies, NGOs, etc.

Most of the districts that are part of the assessment in this discussion already

have policies related to maternal health.Most of those policies are in form of

regional regulation, governor regulation, or district regulation regarding

health of mothers, new-born, infant, under-fives (KesehatanIbu,

BayiBaruLahirdanBalita-KIBBLA).There are also regulations regarding health

covering wider issues such as on Health Jakarta Card or Healthy Magelang

Health Insurance (JKMS).In South Sumatra HIV Regional Regulation is

available.Three provinces, East Jawa, Papua and West Papua, did not

specifically mention any written regulation regarding maternal

health,although there are policies in forms of program, such as cadres

incentives and supplementary feeding in Posyandu.According to FGD

participants, the other six provinces, which are NTT, Central Jawa, West Jawa,

Banteng, Lampung, North Sumatra, South Sulawesi, already have written

regulations that regulate the policies regarding Health of Mother, New-born,

Infant, Under-fives (KIBBLA).

Most of the district government has good commitment to safe mothers,

especially in the district that has Regional Regulations regarding KIBBLA,

because Regional Regulations have the implications to Regional Budgetary

Revenue and Expenditure (AnggaranPenerimaanBelanja Daerah – APBD)

allocation.Civil society concerns about some issues that can be concluded

from the result of this discussion:

1) Authority to approve budget is not only in the hand of the Regional

Government, but there are other actors, such as members of the board

who have not seen the efforts to safe mothers as a priority.

“...Health of mothers and pregnant mothers are not yet a priority.The important people are usually males who do not consider that issue as their priority.They still take patriarchy with them.That is why they tend not to think about how to safe mothers when they develop policies...”.

2) Development still prioritizes physical and infrastructure

development.This affects the realization of results from series of

Development Planning Consultation as well as village plan for

National Program for Community Empowerment.

“National Program for Community Empowerment is also discussed in Development Planning Consultation; the meeting discussed more physical issues, while health issues stayundiscussed.

3) The publication of Regional Regulation/District Regulation was not

followed with socialization activity, so there are a lot of community

members who do not understand the existence of the regulation that

oblige regional government to fulfill the regulation and community’s

right to receive that.

“One cadre was trained, so the message does not reach the

destination.I see at least in the village.It is better to invite them

in one meeting and socialize it to the community.It should be

socialized and everyone should involve.”

There is bottom-up planning process for development plan.Development

Planning Consultation mechanism from village to the district/city is aimed to

ensure the development process based on the needs of community.However,

in reality, maternal health issues has not become the main agenda in the

Development Planning Consultation.This also happens in National Program

for Community Empowerment that has not fully allocated 15% of its funding

for maternal health. MDG is linked more with poverty alleviationthat is why

the development priority is mainly for physical development.

Government's commitment is also visible from the implemented program

strategy. Alert Village is seen as the form of regional government’s

commitment for maternal health.Further discussion is necessary to explore

whether alert village is a program of top-down movement it aligns with

community's needs.Government's commitment should not stop at the

discourse level and formal document level, but it should also be

operationalized.

“...The problem is how to translate commitment into action, for instance, to overcome maternal health problem we cannot only see the achievement in the open area, but should also see the implementation in the remote areas, that are still far from adequate.”

Central Government Policy, for instance the policy regarding National Social

Security System (SistemJaminanSosialNasional– SJSN), which is Law No.40

year 2004, or government regulations regarding Breastfeeding, which is

Government Regulation No. 33 Year 2012, become the guideline for regional

government; however that central policy may not be applied by Regional

Government.In decentralization era, authority to determine program strategy

and priority is fully in the hand of regional government.The fact is, not all area

leaders have good understanding about MCH.

“...Health of mothers and pregnant mothers are not yet a priority.The important people are usually males who do not consider that issue as their priority.That is why they tend not to think about how to safe mothers when they develop policies...”.

In the districts that are included in this study, the availability of health facility

is considered good enough.The weakness is in the service quality that has not

follow all standard/Standard Operating Procedure, and unequal distribution

of health workers, as well as health workers’ lack of interpersonal

communication skill.Some group discussions give the example about attitude

of health workers who treat participants of National Health

Insurance/Regional Health Insurance differently in Puskesmas as well as in

regional hospital.Discussion participants considers the service in Government

Hospital is not good enough due to the heavy workload (especially following

the policy about health insurance), and service lower than the previous fee,

especially there is an obligation to payretribution deduction to regional

government as the Original Regional Income (PendapatanAsli Daerah – PAD).

“We still have a lot of problems... Comprehensive Emergency Obstetric and Newborn Care-CEMONC (Pelayananobstetradan Neonatal EmergensiKomprehensif-PONEK) should open in 24 hours in a week, but in reality, mortality rate in the hospital is high...Regional Government service is 60%and 40% by the service provider...that is why the health workers are lazy to help.”

Not all health facilities have community complaint mechanism as an

implemented policy to improve health service.Central Jawais the only

province that stated that they have implemented complaint mechanism

through the Mayor’s Short Text Message center; howeverwithout any

confirmation about the actual condition this system may cause reactive

actions.The other form of information transparency between the service

provider and user is the availability of information regarding service hour

(service mandate).Some parties said that the previous service mandate policy

has already been applied in Puskesmas, but then it was not continued because

the new Mayor’s policy is different from the old policy.

“Our assessment result showed that almost all Puskesmas do not have adequate complaint system; most of the beneficiaries report to Tribun Newspaper or to the Mayor, and sometimes the Mayor directly dismissed the staff, so the system is not working.

In general, we can say that maternal health information system has not run

optimally.There are 2 sub-indicators to notice the fact, they are:1) accuracy

of the data, 2) accessibility of the data.The improvement of program coverage

does not followed by the decrease of Maternal Mortality Rate.It indicates

problem with data validity.Besides that, the available data is not updated and

the public cannot easily access it.Civil society organizations consider

obtaining data is not easy.This phenomenon can be interpreted that

governance of the government, in this case the management of information

system, still needs improvement.

“The government is still too careful in usingthe data, especially since the Information Law. ... They are very stingy (to give information) about maternal and child health, it is possible that the related department will get a bad name.”

Information system is also understood as the availability of communication

media and forum.Some of the available good examples are village

communication forum in Bogor District, and Short Text Message notification

initiative as the reference for pregnant mothers in East Flores.Participants

expect the discussions like the FGDs can be implemented more often in

sustainable manner, because it also functions as communications forum.

“I hope health information can be communicated through the Friday Sermon (in the Mosque for Moslems), mass media, electronic media, website, call-center, pocket book, pamphlets, etc., so all levels of community could access information regarding maternal health."

In general, government’s efforts to meetsome requirements for health

resourcesare already good, although there are some things that still require

improvements related to quality, equal distribution and efficiency. Expired

medicine was found in the health facilities, which indicates not-optimal

medicine logistic management.Disparity adequacy of health workers can be

seen from the fact that there are areas still complaining about the lack of

midwives in their village; on the other hand, there are a lot of midwives in the

Puskesmas, who have not been empowered,because the understanding is

midwives who do not have Normal Child-birth Care (AsuhanPersalinan

Normal - APN) certificate cannot provide help during labor.

Information gathered from the result of the FGD indicated that not all

hospitals have specialist in obstetrics/gynecology, but on the other hand

there are a lot of General Practitioners.Result of the discussion concludes the

necessity of seeing the clarity about policy regarding more realistic health

workers assignment based on the types of the health facilities.It is necessary

to align the availability of health workers based on the profession,

qualifications, and authority against the service capacity that should be

provided in that health facility.It should also link with the mechanism and the

hierarchical reference system.

“..whyspecialist in obstetrics/gynecology does not empower General Practitioners? In reality when talking about high risk, we need golden time; should we wait for the specialist to get labor emergency management? ...”

Implementation of the new Community Based Health Effort (Unit

KesehatanBerbasisMasyarakat-UKBM) involves Empowerment of Family

Welfare (PKK) as the community's motivator.The available health cadres

among the community are usually cadres of Empowerment of Family

Welfare, because the current UKBM (Community Based Health Efforts) that

can operatesnationally is posyandu.Unfortunately, even thoughposyandu

does not belong to the health sector, but currently Department of Health

givesserious attention for Posyandu.Participants think that the involvement

of the related sector can be improved through the wives of agency heads,

joined in the Empowerment of Family Welfare motivator team.Committee of

Empowerment of Family Welfare is hierarchical from the central to the

village and bounds the wives of the officials in the Ministry of Home Affairs

and Local Government.It makes posyandu politically a strategic vehicle for

Community Based Health Efforts.

Cadres work voluntarily, willing to work and willing to change.Posyandu

cadre became the implementer of Community Based Health Efforts and

source of health information for community, but the cadres cannot yet be

positioned as health partners.Currently the cadres are treated as health

helper in Community Based Health Efforts.

“All these times the cadres are not humanized...cadres are not given the welfare.Give recommendation to Family Planning Field Officer (PetugasLapanganKeluargaBerencana-PLKB)or Community Empowerment Body (BadanPemberdayaanMasyarakat-bapermas)to give awards to cadres, but not salary... Cadres are underestimated.How to develop skillful posyandu cadres?

Civil Society Organization also has networks until the village level, but this

strength has not been used optimally.As the change agent, Civil

SocityOrganizations has the resources to expand posyandu's service coverage,

to make it functions more than just weighing and supplementary feeding

post.FGD participants emphasized that posyandu can be integrated with

medical service in the village and become the network of Village Health

Post.Regulations of Ministry of Home Affairs number 19/2013 rules posyandu

as the center of basic social service; therefore, as social change agent in the

community, posyandu cadres should not be synonymous with female,

although posyandu is synonymous with Empowerment of Family Welfare

(PKK).With that understanding, males should also participate in posyandu

activities and become cadres.

“Almost all of the cadres are mothers. Males are rare. How to initiate male cadres and make it a movement in the district. How to develop alert-cadres, to balance the role of cadres and males?So it is not only female’s responsibility.”

There are not so many civil society organizations exist, especially in maternal

and child health sector. Health problems are not much explored by Civil

Society Organizations because they do not consideredit “sexy”. Some of the

existing civil society organizations participate more in program

implementation level, filling the gap of public services that should have been

the responsibility of the government, or developing sample project, which

was intended to improve community's access tohealth services.Some civil

society organizations said that they support the activity to improve capacity

of cadres in posyanduand the village community organizing, so that the

community have the independence to identify problems and the capacity to

solve the problem, including to change the behavior (social action) to bring

the service closer (resources mobilization).

Some civil society organizations start to play the role in political actions,

which is being critical toward the prevailing policies and have the intention

to ensure better government's policy.Those actions are implemented from

the lowest level, which is the village, district until the national level.The

limited number of civil society organizationsworking for maternal health

issues becomes the obstacle for successful advocacyif it is implemented

separately.Civil society organization network becomes a crucial and

important thing to do.That fact was raised in focus group discussion and

produced a recommendation regarding the importance of having a forum in

provincial and district levels similar to the one that is already developed in

national level (Mother and child Health Movement).

“The role of civil society organizations can be improved if they are given the space for participation and partnering, where they can do skill and funding sharing for the improvement of maternal health quality.Civil society organizations can also play the role as the watch-dog or guard for health budgeting process in the Development Planning Consultation level to the budgeting in legislative level.”

Civil society organizations forum becomes very important, not only as the

media for sharing, but also to raise greater strength for better bargaining

position with the government.This forum should be managed professionally

and have 5 years plan, but not by forcing the same vision and mission for all

different civil society organizations involve in the forum.The basic issue is the

need for motivator and funding support.Is it possible to get funding from the

government?Community Development Welfare and Protection (Kesejahteraan

Pembangunan danPerlindunganMasyarakat –Kesbanglinmas) is one of the

institutions that are recommended as umbrella-agency, however the

independency of civil society organization should be discussed further, so that

the controlling function attached to the role of external agent can still be

implemented.The controlling role does not always mean that civil society

organization cannot synergize with the government, but how the government

can be familiar with civil society organization, able to involve in each strategic

opportunity and to negotiate for good governance.

“There are joint forums and secretary where the civil society organizations synergize to support the improvement of maternal health program directly to the executive as well as through legislative institution.”

“Network is necessary, but currently there are so many networks already, now how the role and functions can be comprehensively optimized.It is better to have monitoring team from civil society starting from the implementation, planning, until evaluation processes.”

Networking with civil society organizations has its own uniqueness.Informality becomes one of the characteristics that ease the process to maintain communication, but the working scope of civil society organizations activists can be so different, and it becomes difficult to find the right schedule to meet.Aside from that, the fact that civil society organization is close with wider community, but it cannot deny another fact that the activities of civil society organizations are not well organized.It causes the impression as if civil society organizations create parallel and segmented systems.Civil society organizations network can also triggers innovations to find catalytic and with leveraging solutions

“able to provide best practices from the implemented initiatives in form of pilot program as evidence baseto mobilize the government to replicate or adopt models pioneered by civil society organizations”.

The readiness of regions to form forum and capacity of civil society

organizations are different between one region to another.Related to the best

strategy, we need to think about these differences together, to avoid big gaps

between the well-developed district/provinces withthe least developed ones.

Gaps in the skills of civil society organizations in each area should be

identified, including the negotiation skill, participation in every opportunity,

advocacy, critical thinking and partnering.The established network/forum

should be able to strengthen the civil society organizations although it does

not close any opportunity for competition and institution-ego because

dynamic is another characteristic of civil society organizations.The

expectation is to constructively manage this dynamic for wider benefit of the

nation and country.

2 5

“Through this meeting we can work together, not to bring down each other but to walk hand in hand.

“It is necessary to have inter-agency quarterly meeting in one place to maintain mothers’ health/support each other in wellness."

3.6. Participants perception regarding Maternal Health Program

3.6.1 Maternal Health Program Indicator

In this study, the success of Child Health Program is measured based on the

information of the achievement of 5 indicators, which are KN1, infant health

service, under-fives health service, Ante-Natal Care, infant and under-fives

growth and development check-up.Quantitative data analysis showed that

for all indicators, around 75%-91.6% participants agreed with the access

and quality indicators that were determined by the government and that are

currently prevailing.The most approved indicator is KN1 (91.57%), while

the lowest approval frequency is under-five health service (74.99%).For all

of those indicators, 48.07% of participants think that the district indicators

have been achieved.

Table 3.6.1. Distribution of the Frequency of Participants Behavior toward Maternal Health

Indicator

Strongly Disagree

(%)

Disagree (%)

Agree (%)

Strongly Agree (%)

Not Answering (%)

KN1 1.28 12.8 46.7 44.87 0.5

Infant Health Service 1.56 4.48 53.8 25.64 14.52

Under-five Health Service 1.28 8.97 55.76 19.23 14.76

ENC 1.56 4.48 44.87 39.74 9.35

Growth and Development 4

times, A vit., complete

immunization

1.56 4.48 39.74 44.87 9.35

Growth and Development 2 times, A vit.,

1.56 4.48 44.87 39.6 9.49

MTBS

In general, discussion participants’ understanding regarding Child Health

Program is limited to the programs in posyandu.Almost all discussion groups

know the growth indicator (D/S) as child health program

indicator.Representatives of civil society organizations that own programs

related to Early Childhood Education and Development of Families with

Children Under-five (BinaKeluargaBalita-BKB), who participated in the group

discussions stated the development status as child health program indicator.

“...we need to give attention to infants’ psycho-motoric.At the age of 1-3

months infants are able to hear voices, they will respond when they hear

sounds..."

According to the discussion participants, government’s benchmark in the

success of child health program is seen from:1) the achievement of target in

service accessibility, meaning that more children can access health and

nutrition services, meaning that the program achievement is better; 2) the

increase of regional budget allocation for child health program funding; 3)

non-occurance of under-fives mortality and more healthy children and good

nutrition status; and 4) mothers of under-fives have the right understanding

about the benefit of health services and child nutrition, so they can

participate to make sure their children receive such services.Discussion

participants also stated that the above benchmark achievement report

should be verified with observation result to see the reality in the field, as

stated in one of the quotes below:

“...some still see from the health report only, they can only make notes; reality in the field is there are still a lot of children who has not develop and grow well, not as expected..."

Government should optimally involve civil society organizations and cadres

to make sure the implementation of the benchmark.Civil society organization

can be partners of the governmentto give technical facilitation, funding and

goods; therefore, good coordination and communicationbetween the

government and civil society organizations become the key success of this

partnership. Also, there are thousands of posyandu cadres spread out in the

neighborhood, sub-village, and village, and they are valuable resource asset.

Therefore improving cadres' capacities is an important and necessary

strategy, so that cadres will have good skills as government's development

partner in health sector.

"...article 28 of Indonesian 1945Constitutionregarding rights for

health...all community members should receive health services, but

unfortunately it has not reached the village level. ... no regional

regulations...so how can we reach Indonesia Sehat 2015 (Healthy

Indonesia 2015), I am sure we will not achieve it if we do not

implement it optimally ... at least we should develop legal umbrella

for posyandu cadres... so if we develop Authorization Letter (for

cadres), we can be more optimal towards Indonesia Sehat 2015"

3.6.2. Child Health Program Policy

Quantitative data analysis indicated that 84.61% of the discussion

participants agreed that the prevailing policies in their districts give benefits

for their individual organization.The most benefit gained is the health effort

aspect (58%) and the lowest is health information system (2%).Most of the

discussion participants (47%-60%) did not answer when they were asked

whether there are parties outside the health sector who support/do not

support maternal health program policy.It indicated that the coordination

regarding child health among Civil Society Organizations and other

stakeholders is still weak.

In general, the discussion result concluded that the commitment of central

government is already good, because the child health program target is

linked with the efforts to achieve Millennium Development Goal (MDG)

target.That commitment was measured from the availability, implementation

and usage of the program that can be directly perceived by the

community.Provision of free basic immunization service for infants

(Hepatitis, BCG, polio, DPT and measles), TT immunization for future bride

and groom and pregnant mothers, and also vitamin A supplement for

pregnant mother in posyandu are the examples of central government’s

commitment.Maternity Benefit and National Health Insurance policies are

also the proofs of government’s commitment to overcome financial barriers

in accessing health service.Unfortunately in some regions, the program

implementations are still facing some obstacles.

“...commitment for child health. We refer to what has already exist.Maternity Benefit, National Health Insurance are (central) government programs, even those are not optimal (the implementation)...there are hospitals that are not ready due to limited

budget... it seems like this is just a dream because we developed it then abandon it...it means that the government has not think about this, especially the district government.

Regional government is responsible to conduct those program policies, by

ensuring that all under-fives receive optimal program benefit.To ensure

equal distribution of health service than can be fully used by childrenwill

require adequate resource and funding support.That support does not only

come from the central, but also from the regional government.Discussion

participants assessed that regional government commitment to achieve

child health program target indicator is seen based on political support in

form of regulations regarding regional health program policy and the size of

allocation of regional budget (Regional Budgetary Revenue and

Expenditure).Both issues are strongly related to each other because the

application of Regional Regulation will have implications on the funding

allocation of Regional Budgetary Revenue and Expenditure and

mobilization of other resources, including the fulfillment of the needs for

health worker and the empowerment of cadres/community.However, in

reality there are unsuitable facts between the funding availability for child

health program and the program impact.

“Indonesia is rich, but does not reach the ones in the bottom.It was said that the Ministry of Health has disbursed a lot of fundbut why does the mortality rate is still high? The core of the problem is the log government’s commitment.”

In district level, as known by the discussion participants, there are only four

districts, including Deli Serdang, Bogor, TTS and TTUthat informed the

availability of District Regional Regulation arranging child health in forms of

KIBBLA Regional Regulation.Mothers’ FGD showed that three of from 6

provinces that own written regulation on KIBBLAare NTT, West Jawa, and

North Sumatra Provinces.Therefore, it is obvious that provincial government

commitment can be the motivation for district government commitment for

KIBBLA.

“There are Regional Regulations that require mothers to perform routine check-up to Posyandu, to getimmunization, giving birth in health facilities, Pustu does not have support for mothers who are giving birth and Traditional Birth Attendant (dukun)could only help midwives for delivery.

Just like the child health program, the existence and content of Regional

Regulation is not adequately socialized to the community and the discussion

participants consider that as obstacles.Even when the socialization is

conducted, it is usually limited to the Working Units for Regional Operations

or Empowerment of Family Welfare.

“...That legal product was socialized in the Working Units for Regional Operations and Empowerment of Family Welfare levels only but not equally distributed to the community... having no Forum and good communication channel between Working Units for Regional Operations with the community/civil society organizations is the reason for this problem.”

Besides the Regional Regulation, Regional Government Policies are also

availablein form of formation of District Team Problem Solving (DTPS),

KIBBLA, etc., through the Authorization Letter of Head of Health Department;

or program policy that favors the fulfillment of child health service, such as To

Love Mothers Movement (GerakanSayangIbu), alert village, supplementary

feeding, etc..From the evolving conversation during the discussion process, we

obtained information regarding unequal socialization about the existence of

the team or the program, and socialization usually conducted only

momentarily, so the program was not sustainably implemented.The

information was revealed in one of the following statements:

“The government has budgeted funding for To Love Mother Movement activities by preparing all requirements related to the activities.It was implemented in RW (hamlet) 2, but did not last long...because the government did not do any socialization”.

The amount of program fund from Regional Budgetary Revenue and

Expenditure is determined by the Regional Medium Term Development Plan

and annual Recommended Activities by Working Units for Regional

Operations. Result of this discussion highlighted the problems about low

community participation through civil society organizations in Development

Planning Consultation (Musrenbang).The level of participation varies in one

area to the other so there is an impression that the involvement of Civil

Society Organizations only to fill in the representatives qualificationsand not

for the essence of listening to people's aspirations.That phenomenon occurs

in the lowest level, which is village/neighborhood or district:

“... The Participation of discussion participants in planning or policy is only formality and to meet participants’ quota.”

“Development Planning Consultation is a planning for an area...but there was something strange from Development Planning Consultation in RW 2; every year since 1992, none of the result of Development Planning Consultation has been implemented.”

If civil society is involved in the appropriate ways, the result of village

planning consultation would have produced programs that are suitable with

the needs of the community, and the funding will be allocated to ensure the

implementation of the program.One of the successes was shared based on the

following experience:

“Development Plan Discussion activities in RW 04 accommodate Maternal and Child Health because all elements/parties of communities are involved in determining 10 priorities.The result was RW 4RawaBuaya Village achieved funding around IDR 40 million for Maternal and Child Health through Supporting Group for Mother program.

We gained information that often the involvement of civil society

organizations in the Development Planning Consultation is not-

comprehensive.Whereas the participants were sure that community has the

capacity to participate actively in the process.Community capacity to actively

involved in planning include the capacity for situation analysis, problems

identification, solution finding, plan development as necessary, monitoring of

the implementation of program plan and evaluation of program target

achievement based on the plan.

“Each organization or community is able to involveactively in making child health program plan; community should also encouragedtoparticipatein expressing their opinion regarding child health program,which is needed by the community instead of the government.

Discussion participants also believed that health cadres have good and precise

information regarding the health condition of under-fives, they should be

involved in Development Planning Consultation in RT/sub-village/village

levels to sharpen analysis regarding health and under-fives mortality issues.

“situation analysis for planning does not use any data or routine report.. female cadres are the ones who know about the efforts to improve maternal and child health, while fathers never know about it.So the recommendations for Mother and Child Health have never been included in the Development Planning Consultation recommendations because the cadres (mothers) have never been involved in Program Planning or Development Planning Consultation.

Male domination that represents civil society makes child health program left

undiscussed in Development Planning Consultation and in the end, the issue

has never become the priority of the development plan.

“In several areas in RawaBuaya, participants of Development Planning Consultation are only dominated by fathers who are not sensitive about maternal and child health so it has never been accommodated.

“Development Planning Consultation process does not begin with problem analysis, usually only based on physical needs.”Government has not being assertive about the policy to assign officers, including to supportthe provision of supporting infrastructure."

There is an impression that child health issues can be represented by having

posyandu program, so more detail discussion about child mortality and

morbidity in the sub-village and village levels are not considered as

priority.Similar with the findings from maternal health FGD, the development

priority of FGD participants still focus on the physical infrastructure

development.

“Through Development Planning Consultation activities, the initial recommendations from the RT (neighborhood) regarding Mother and Child Health are not included as priorities because they prioritize public facilities (road renovations, culverts, flowerpot, garbage cart, and streetlight)”

Individually, civil society may not have any voice in Development Planning

Consultation process, but civil society who are part of an organization may

become the force that determine the policy direction for country’s

development.Coordination forum between the Civil Society Organizations

and the regional government is a good media to develop constructive

partnership, so the government will not make development planning on their

own and civil society participation will not be assumed only as

representation of community’s element, but it is done truly to make sure that

the development plan aligns with the community needs.

“Having routine activity forum from Regional Government such as Civil Society Organizations that concern about health in health program evaluation, especially health budget as the form of accountability of regional government."There are valuable experiences in development planning process by optimally involving civil society.One of the successes in TTU District is when Civil Society Organizations were informed to involve in monitoring and evaluation of results of Development Planning Consultation.

“..government also involves civil society organizations in discussing annual plan with Working Units for Regional Operations (Annual SKPD Forum).Department of Health of TTU District has allocated monitoring and evaluation funding through the Authorization Letter of Head of District.”

Management for child health efforts are already good, although according to

the discussion participants, they still found discriminative treatment toward

poor community in the hospital who are known for having National Health

Insurance and to the solvent community, and the unavailability of specific

facility for community groups with special needs.

“Doctors or health workers for child health should try to provide routine similar/equal service for children, not only for children from the high/middle levels, but also from the low level, those children should also get attention and services.”

“City government do not have specific policy, the group with the special needs are abandoned."

Beside the managerial aspect, service quality for child health efforts still

needs improvement.One of the examples is the medical service quality.

According to the discussion participants in two different provinces, under-

fives who are suffering from diarrhea are not always given zinc due to the

limited stock; they only receive ORS in posyandu.Meanwhile the neo-natal

emergency health service, both Comprehensive Emergency Obstetric and

Newborn Care in the hospitals (CEmOnc) or Basic Emergency Obstetric and

Newborn Care – BEmOnc (PelayananObstetridan Neonatal EmergensiDasar-

PONED) in the Puskesmas should always available because emergency cases

could happen any time.

“CEmOnkservice in Regional Public Hospital and BEmOncin Puskesmas for children’s health is not optimally implemented although it is said available for 24 hours/7 days.”

According to the discussion participants, qualified health servicesalso reflected from the friendly attitude of the hospital staff to the patients, their responsiveness to the needs of the community, including the need to get explanation.Discussion participants stated that patients should consult to the health workers, so health workers should have skills to communicate and to provide counseling.

“.... Usually some health services do not take a long time... they register and that’s it...community becomes lazy to come.”

“Communications between officers (midwife) with community members

in Posyandu is very good.But in Puskesmas the response is not so good,

maybe because the midwives are busy.”

Other managerial aspects related to the health efforts are the availability of

health workers.Generally the discussion participants highlight unequal

distribution of health workers and their unreadiness.These two things

happen almost in all area, although with different problem backgrounds.

“Now we need to pay attention to the medics, we regret that although government has developed a very good program, the realization in the field is absolutely different from our expectation; for instance, midwives who signed study letter should come back to their initial location; however, after they become smarter, they do not go back to serve in their original places, he/she is called to the cities and the village is left without health officer, this is what causes the mortality.He/she is pulled to the city because the human resource is getting better, but no one wants to be assigned to replace them in the village.”

The unequal distribution of health workers availability is not only a problem

in the provinces with challenging geographical condition such as NTT, Papua

and West Papua, but also in certain areas such as KampungLaut,

CilacapDistric, and Central Jawa Province.

“In Cilacap where I come from, the Posyandu opens from 8 am to 1 pm... midwife comes only for 1 hour.Doctor only comes when there is an assessment.So we need to have more human resources and improvement in arranging visit schedule.”This study collected variousinformation regarding the availability of health information system.For instance it was informed that in TTS and TTU Districts, health information system has been implemented through Regional Health Information System (SistemInformasiKesehatan Daerah-SIKDA), both manually and electronically, facilitated by a donor agency.Specific health information system using software, which is PWS-KIA or CHISis implemented in several districts due to the support of certain projects.There are also some statement regarding imbalance information flow between the government and the community, because in reality the emphasis is more on the

documentation and reporting flow from Posyandu/Village to Puskesmas/government, than spreading information from the government to the community.

“It’s the opposite; the available information comes from the bottom to the top, it is in form of data.Information regarding the reported child health.So the government’s way to find information is upside-down; instead of giving information, they ask for information from us.It is similar with the government that looks for data in Posyandu, while the ones who enjoy the results are heads of village, sub-district and district.So, specific information system is not available.In reality, it is us from social institutions that provide information to the government.”

For instance, the information regarding mortality and morbidity of

infants/under-fives should have come from the documentation from the

grass-roots, validated, then informed back to the community.If the

government do this, community will be aware about infants and under-fives

health problems in their own areas.Of course sending the information to the

community should be done with appropriate communication strategy.

Information channel should be chosen by considering the type of media that is

most commonly owned by the community.According to the participants, the

most strategic media to send information these days is through short text

messages (SMS), information center for health services (call center), and

village communication forum and coordination meeting of the posyandu

cadres.Health information should be disseminated by someone who has

appropriate credibility, for instance doctors and religious leaders who have

been trained about health messages.The availability of facility to express

community’s complaints and to communicate both ways areno less important

communication media. They will help to build the development of good

communication climate between the community/client and health

officers/provider.

Community has already involved in some activities related to health

information system.Cadres have already involved in documentation and

reporting of under-fives health situation.Documentation,which is done by

cadres, helped village midwives and Puskesmas to know the number of target

under-fives in their working area.Cadres record under-fives’ development

status every month in Posyandu and Early Childhood Education.

“Through the data collection regarding the total number of under-fives and their problems in an area we know the development of children in that area.Cadres are used to collecting data..there are reporting, monitoring and evaluation at the end of the activity."

Based on the correct reporting flow, responsible person for village health

worker will collect report from posyandu/PAUD to be recapitulated in village

level.In practice, there are areas that oblige cadres to develop formal report

to Puskesmas as result of the documentation.It of course depends on the

program policies in each area, which surely have different

implications.Hierarchically, posyandu cadres are not included as health

workers under the Puskesmas/Department of Health; instead they are part of

Empowerment of Family Welfare under the managerial responsibility of

Posyandu's working groups(Pokja)/Operational Working Group (Pokjanal).

“Posyandu’s documentation and reporting mechanism includes: filling in a form from Puskesmas, stamping the form and then sending the data about mothers and under-fives to Puskesmas.Besides that it is also reported to the village.”

The most common and equally distributed Community Based Health Effort is

Posyandu; that is why Posyandu cadres are the most easily met health

service provider.Related to child health, the other form of Community Based

Health Effort is the partnership of midwives and traditional birth attendant;

MTBS-M and alert village. The partnership between professional health

workers and health providers within the community is already

good.Midwives and traditional birth attendant have developed partnership

for labor support service function and partnership between officers and

cadres for documenting cases target and reference regarding labor

emergency, neo-natal and ill under-fives.In several places, these

partnerships have already been put in writing for the agreement of

traditional birth attendant and midwives partnership or regulations

regarding alert village.There is even a partnership between private practice

mid-wives and local posyandu.

“There are working partners between traditional birth attendant (paraji) and village mid-wives... they have the agreement letter. The arrangement is traditional birth attendant takes and accompanies the pregnant mother to mid-wives ... traditional birth attendant helps to take care of the child... Midwives support the labor."

3.7. Participants Perception Regarding Teenagers Health

Program 3.7.1. Teenager Health Program Indicator

The success of Teenagers Health Program within this study is measured from

the achievement of 5 indicators (table 3.7.1). Quantitative data analysis

showed that around 60%-71% participants agreed with all indicators that

were determined by the government and that are currently applied.

“We need indicator from social relationship side, because children social factor can copy the attitudes of their peers.To measure that indicator, we can see from the number of early marriage cases, drug abuse and parenting style.”

Table 3.7.1. Distribution of the Frequency of Participants Behavior toward Maternal

Health Indicator

Strongly Disagree

(%)

Disagree (%)

Agree (%)

Strongly Agree (%)

Not Answering (%)

Age of firt marriage (M/F) 2.85 26.6 57.14 2.85 10.56

Age of the first pregnancy 2.85 19.04 67.6 3.8 6.71

Knowledge about contraception method, UPP, 2.85 19.04 57.14 2.85 18.12

UKP, HIV transmission prevention method

Not smoking, consume alcohol, pre-marriage

sex.

2.85 19.04 67.6 3.8 6.71

Youth Friendly Health Care Puskesmas 2.85 26.6 57.14 2.85 10.56

The most agreed indicator is the quality of service for first pregnancy age

and the non-smoking, non-alcohol and pre-marriage sex.For all of those

indicators, 52.81% of participants disagreed that the district targets are

already achieved. Result of the group discussions concludes that

performance of district/city government for teenagers health program is not

yet optimal because there are a lot of problems regarding accessibility of

care for teenager service (Youth Friendly Health Service), the environment

that do not support teenagers’ (health) behavior, and parents’ knowledge or

role that are lacking regarding (health of) teenagers.

Besides that, the number of health facilities that provide health service for

teenagers is still lacking, and the utilization of the existing facilities by

teenagers is still low.Besides feeling embarrassed and lack of knowledge,

social peer pressure also influences the choices for seeking for juvenile

reproduction health information and services. This study recommends

formalizing education regarding juvenile reproduction health through school

curriculum.

“.. what if we include reproduction health into school curriculum. I do not think that with just a couple of hours of Biology class is enough. Therefore, there will be better knowledge regarding teenagers' health."

“Teenager’s health is not touched too much, the recommendation is to give juvenile reproduction health service formally, or include it in the school curriculum or in the local content; informal education only is not enough.”

The risk for teenagers to have reproduction health problem is bigger. It is

caused by the influence of internet media and the trend for teenagers to live

in rented-rooms without enough supervision. The limitation of available

information regarding reproduction health and healthy dating style, and

parents are too busy to supervise their children's relationships may lead to

the practice of living together without being married (kumpulkebo) or free

sex behavior.

Two important indicators that are used for Coordination Body for National

Family Planning (BKKBN) performance are the age of the first marriage and

the age of the first pregnancy. Discussion participants consider both

indicators important, but they admitted that the age of the first pregnancy is

a better indicator and more sensitive to measure the success of juvenile

health program. Meanwhile, the term first marriage may be mistakenly

understood with the 2nd, 3rd marriage, and so on.

“I do not agree with the term age of first marriage because the

connotation is there will be the second, third, and so on marriage, it is

better to use ideal age marriage."

"Life skill (education) should be disseminated to students and college students, so we will know the age of their first time having sexual intercourse, and it is more important than the information on first marriage.”

Besides the unwanted/unplanned pregnancy, based on the information

gathered from the group discussion, in several areas whenever a proposal

comes, parents tend to wed their children eventhough the age is still not

adequate. The implication is teenagers' pregnancy with bigger death risks for

mothers.

“...There is a tendency for parents in this district to wed their children not based on their age, but based on the proposal.”

“Yes, there are a lot of cases where elementary students are sent into marriage...”

Besides the indicators that were determined by the government, we also

need indicator about teenagers' morbidity (for instance HIV-AIDS on

teenagers) and prostitution on teenagers.

“...when dating... it leads to free sex... they do not realize they can get infected with diseases such as HIV-AIDS. ...this afternoon I received the information that a lot of teenagers are infected with AIDS.”

3.7.2. Teenagers Health Program Policy

Quantitative data analysis indicates that 64.61% of the discussion

participants agree that the applying policies in the district give benefits for

their individual organization. The biggest benefit is the health effort aspect

and funding (4.5%) while the lowest is health information (2%).Most of the

discussion participants (62.85%) agreed that there are parties outside of the

health sector who support teenagers health program policy. Those parties

are the Religious Institutions (4.5%) and Non-Health sector Government

Institutions (4.3%), while profit companies give the least support

(2.5%).Most of the discussion participants (70.8%) did not answer the

statement that says there are parties outside the health sector who do not

support district’s teenagers health program policy.

Except in Papua Province that already has Regional Regulation no. 4 year

2011 regarding Education (article 37 verse C) that mandates local content for

HIV-AIDS; generally other districts do not have any specific policy regarding

teenagers health in form of local products, although they have it in program

level, which is in form of Adolescent Health Care Service (Youth Friendly

Health Services -PKPR) Puskesmas, Health Information Center (Pusat

Informasi Kesehatan-PIK) for teenagers in the villages and Adolescent Family

Development (Bina Keluarga Remaja –BKR) etc.. Various obstacles were

faced during the implementation of the programs due to the lack of trained

implementation officers, limited facilities, low utilization by the teenagers,

etc..

“PIK (Health Information Center) for teenagers are already formed in the village level. However mostly the Health Information Center is just exist. They do not seem to care to provide further guidance. Committee and the existence of Teenagers PIK are not specifically and intensely prepared, so without the continuous guidance and supervision, it will ‘die’.”

"...although I haven’t seen it directly, but I have heard the government’s effort to improve teenagers’ health through life skill education etc.”

In the village level, the development programs for teenagers’ health are

implemented through PIK (Health Information Center) and BKR (Adolescent

Family Development) programs. This is also understandable because the

situation analysis of teenagers' health process was not conducted, although

there are discussion groups that said that village Development Planning

Consultation process has involved the teenagers.

“...Reproduction health became the problem for adults, while the

teenagers do not see it as a problem. Therefore, Development Planning

Consultation should involve children. The consultation that has occurred

never involved children to develop programs in the village.”

Although village planning was conducted as the attempt to overcome

teenagers’ health issues, the discussion participants were not sure that the

village plan is approved, because nobody guard the village plan to the district.

Based on our experience in TTU, village plan was not used by Working

Units for Regional Operations. Working Units for Regional Operations

discussions, village plans were not used. They discuss about Working

Units for Regional Operations Program. Therefore, it is better if we

directly approach Working Units for Regional Operations at the time of

budget development.

Although it has become the national program, some teenagers’ health

programs are recently applied only in several areas, and the programs are

often not sustainable. Furthermore, the service utilization factor of teenagers’

health service is low due to the lack of socialization or the time for service,

the unfriendly attitude of health officers and uncomfortable counseling room

for teenagers. Counseling schedule, which is at the same time with

Puskesmas working hour is also an obstacle for the teenagers, because it is

conducted during school time. Maybe we need to consider other type of

counseling methods, for instance through consultation via Short Text

Messages or letter.

“types of socialization regarding teenagers’ reproduction health in junior high schools, high schools, and in community environment in the village. But that program is not conducted annually. It is only conducted when there are new cases, then preventive actions are implemented through socialization.”

The unsuitable service schedule with the time owned by teenagers who

need it. Consultation in the Puskesmas is usually conducted on

Saturdays, between 10.00-11.00, when the teenagers who need the

service are still at schools.”

“Forget about the remote areas, even the cities do not get the

attention."

Documentation and reporting related to teenagers’ health program are

manually conducted and not by a specifically assigned officers. Computer

based data base is not available, where data can be regularly updated, so the

discussion participants can communicate the obstacles in accessing

teenagers health data. The available information system is for Maternal and

Child Health.

“To increase the performance of teenagers’ health program in this district, government still has no accurate and good information system in planning and managing teenagers’ reproduction health program that is easily accessed by all community and teenagers.”

Service utilization by teenagers is also a problem. Socialization to the

community about the existence of teenagers' health service is not well

communicated. The role of civil society organization is necessary to monitor

the implementation of teenagers' health program and to monitor no

deviation.

“The role of Civil Society Organizations is necessary to control government in implementing teenagers’ health program to avoid deviation in the implementation.

To reach more teenagers to receive services.Community Based Health Effort

is one of the solutions.Adolescent Family Development, PIK-KRR and

SakaPramuka are the form of Community Based Health Effort for teenagers’

health. Expansion of School Health Unit program in middle school can be

implemented in form of teenage-doctor. Regulations of Ministry of Home

Affairs No.19 year 2013 indicates the development of Posyandu as the center

of integrated basic social service. Adolescent Family Development and PIK-

KRR are enabled to enrich the activities of Posyandu. Although the next idea

is to provide private counseling room that does not make people suspicious.

“Actually, posyandu is the Integrated Health Post.Posyandu does not focus only to certain diseases because the system is integrated.The form is cadres’ capacity so they have the ability in all sectors.”

“Posyandu is crowded.If it is crowded, the teenagers will not come to

check on their reproduction health.Therefore, there should be a specific

time for teenagers’ reproduction check-up."

CONCLUSION AND RECOMMENDATION

A.CONCLUSION

1) Generally around 40%-80% of the discussion participants

stated that the government is already successful in achieving

the target of maternal, child and teenager health indicators.

Bearing in mind that in general the discussion participants do

not have health specialist background, they think that the

government has set the right indicators for maternal, child and

teenagers’ health, especially by covering the accessibility and

quality of health service aspects.Among the existing indicators,

discussion participants identified some indicators that they

consider sensitive, including:

a) 7 T service on the first pregnancy (K1)

b) Labor supported by health workers (PN)

c) Essential newborn care is performed during the new-born

visit between the first 6 hours - 3 days (KN1)

c) Age of the first pregnancy

Beside the existing indicators, the discussion participants also

highlights the necessity of having indicators that can measure the

equal service distribution, including population with special

needs (different ability - diffable), and the involvement of

teenagers in program planning and implementation related to

reproduction health.

2) In general, the regions already have policies in forms of legal

products for maternal and child health, but not for reproduction

health. While at the program level, all districts have completed

maternal and child health program, but the region is still dealing

with issues regarding unequal service utilization. Result of this

discussion identified that Civil Society Organizations agreed with

maternal, child and teenagers health program because they feel

the benefit from those programs, both from the health effort

aspects as well as other aspects. Civil Society Organizations

viewed themselves as government supporters for the three

programs, together with other government institutions other

than health and religious institutions. Civil Society Organizations

sensed the lack of availability and access to accurate and up-to-

date information as a weakness. Civil Society Organizations felt it

was difficult to get information, and also when they have the

information, they found it difficult to ensure the government

about the validity of the information.

3) Role of Civil Society Organizations in supporting the success of

maternal, child and teenagers health program:

- Civil Society Organizations as the facilitator to improve village

community capacity, form the social change agent in the

community, mobilize the community and improve the capacity

of civil society in the village to advocate policies related to

maternal, child and teenagers health.

- Strengthen village planning process to sharpen the maternal,

infants and teenagers health component by emphasizing on the

accurate and up to date analysis. It includes ensuring posyandu

cadres as the actors in village Development Planning

Consultation.

- Monitor the implementation of maternal, child and teenagers

health program by giving more attention to the aspects that

may not be covered by government service, which is for equal

service distribution in the areas with limited health

workers/facilities and geographical accessibility, health

service/facility for target groups with special needs and the

improvement of civil society participation with gender

balance, both in Development Planning Consultation process

as well as program implementation in village, district,

province, and central levels.

- Evaluate the impact of maternal, child and teenagers health

program by focusing on valid maternal mortality and child

mortality and inform it correctly to the community.

B. RECOMMENDATION

a) It is necessary to form a coalition of civil society organizations for

Maternal and Child Health Movement in district/city

level.Coalition of Maternal and Child Health Movement becomes

government's partner in guarding Maternal and Child Health in

order to achieve MDG target and equity. Civil Society

Organizations coalition involves local NGOs, traditional leaders,

religious leaders, youth/child forum in district level with the

agenda of routine meeting at least once a month.Focal point of

the coalition in district/city level is Civil Society Organizations

that already exist in maternal, child and teenagers health sector.

b) Maternal and Child Health Movement Coalition in district/city

level has five years strategic plan with clear funding/budget

guarantee. Funding may come from the government, donor

agency, one of the civil society organization as well as budget

sharing, as long as the utilization is jointly agreed.

c) Strategic plan of Maternal and Child Health Movement coalition

does not take over the role of government, but it synergizes with

the government’s program, by focusing on the inequity service

and partisanship issues to the target group with special needs,

and to build participation of civil society and capacity of

professional members of Maternal and Child Health Movement

coalition.

d) The objective of improving capacity of the professional members

of Maternal and Child Health Movement coalition is to make sure

they have the right understanding regarding program strategy

and its implementation, and the skill to develop network, to do

coordination and to advocate.

e) Strategic plan, advocacy, and improvement of capacity are

developed based on data base and assessment according to the

situation in each area. It supports the Maternal and Child Health

Movement coalition to have good database with correct data

collection methodology, so the validation and its reliability can be

accounted for.This database should not overlap with the data

collected by the government through routine report, as well as

routine survey, but it will be complementary and more

explanatory, and can be used as reference for data/information

triangulation.

f) The government is expected to seriously support civil society

organizations and support this network to exist and able to help

the government to achieve success in health development sector,

and still appreciate the independence and dynamic that

characterizes the civil society organization.

GERAKAN KESEHATAN IBU DAN ANAK

CIVIL SOCIETY ORGANIZATIONS

SUPORTING THE STUDY