Maternal and Neonatal Survival

Year 5, Quarter 3: April – June 2016

Submitted 12 August 2016

Quarterly Report for Expanding Maternal and Neonatal Survival

TABLE OF CONTENTS I. OVERVIEW..............................................................................................................................................................................3

II. SUSTAINABILITY AND EXIT STRATEGY .....................................................................................................................4

I. OBJECTIVE 1: IMPROVED QUALITY OF EMERGENCY OBSTETRIC AND NEONATAL CARE (EmONC) SERVICES IN HOSPITALS AND PUSKESMAS .......................................................................... 13

II. OBJECTIVE 2: INCREASED EFFICIENCY AND EFFECTIVENESS OF REFERRAL SYSTEMS ......... 24

III. OBJECTIVE 3: STRENGTHENED ACCOUNTABILITY AMONGST GOVERNMENT, THE COMMUNITY AND HEALTH SYSTEM.............................................................................................................. 32

IV. SUSTAINING EMAS MENTORING APPROACHES ..................................................................................... 36

III. MONITORING AND EVALUATION ........................................................................................................................... 38

IV. DISSEMINATION AND DOCUMENTATION ......................................................................................................... 39

V. IMPLEMENTATION CHALLENGES/ISSUES............................................................................................................. 40

VI. MANAGEMENT.................................................................................................................................................................. 40

VII. EMAS COST SHARE........................................................................................................................................................ 41

ANNEX A: YEAR 5 PMP ........................................................................................................................................................ 42

ANNEX B: COST SHARE MATRIX ..................................................................................................................................... 52

ANNEX C: MEDIA SUMMARY, YEAR 5 QUARTER 3 ............................................................................................... 55

ANNEX D: MATERNAL AND NEWBORN STATISTICS, YEAR 5 QUARTER 3................................................ 59

EMAS Year 5 Quarter 3 Report 3

QUARTER 3 HIGHLIGHTS

• EMAS support ended in 11 districts, comprising the remaining Phase 1 and Phase 2 facilities. Close-out events were held in 14 districts (including some districts which closed during Quarter 2 but where close-out events were delayed until Quarter 3).

• Focused mentoring efforts in Phase 2 facilities resulted in a large jump in the percent of facilities achieving at least 80% of clinical governance standards, increasing to 76% from 64% in the previous quarter.

• Tangerang district was the recipient of the TOP 35 SINOVIK (National Public Service Innovation)

award. In the previous quarter, Tangerang, Cilacap, and Sidoarjo were honored among TOP 99 award recipients, and this quarter’s final evaluation, Tangerang was among the top award recipients.

• Whereas in the previous quarter only 43% of Phase 2 facilities conducted audits within 24 hours of

a maternal death, this quarter 87% of Phase 2 facilities performed audits within that timeframe. Seventy-three percent of Phase 3 facilities conducted audits within 24 hours of a maternal death this quarter, up from 49% in the previous quarter.

• EMAS convened a meeting with the BUK-R, KARS, facility staff, and related stakeholders, where it

was agreed that EMAS approaches will be incorporated into national accreditation tools.

• After hosting a visit of Puskomlik staff to EMAS-supported facilities in Central Java last quarter, Mediakom published articles covering EMAS activities in the province in its April issue.

• EMAS completed an analysis of ways in which EMAS interventions have been replicated across

districts, have impacted MCH regulations, and have generated funding support from the district and provincial levels.

I. OVERVIEW The USAID/Indonesia Expanding Maternal and Neonatal Survival (EMAS) Project is a five year program to support the Government of Indonesia to reduce maternal and newborn mortality. EMAS works with Indonesian government agencies at all levels, Civil Society Organizations, public and private health facilities, hospital associations, professional organizations, and the private sector. The project is expected to contribute to an overall decline in national maternal and newborn mortality, and it is focusing on two major objectives: 1) Improving the quality of emergency obstetric and neonatal care services in hospitals and community health centers; and 2) Increasing the efficiency and effectiveness of referral systems between community health centers and hospitals. EMAS works with approximately 150 hospitals (both public and private) and 300 community health centers across 30 districts and cities in six provinces—North Sumatra, Banten, West Java, Central Java, East Java, and South Sulawesi. EMAS is also emphasizing sustainability and scale up in order to impact districts and provinces outside of the EMAS target districts.


II. SUSTAINABILITY AND EXIT STRATEGY

SUSTAINABILITY EMAS continued working this quarter to ensure the sustainability and uptake of EMAS-supported approaches within and beyond EMAS areas. This section provides an overview of progress made during Quarter 3 to ensure the continuity of key EMAS-supported approaches after the program concludes. As replication within EMAS districts and provinces continues through the work of district and province based teams, work at the national level intensified to ensure sustainability and impact beyond EMAS intervention areas. This quarter, EMAS worked to document the ways in which EMAS interventions have been replicated within and outside of EMAS districts. Findings from this exercise revealed that of the 30 EMAS districts, 20 have used district funding to expand EMAS approaches outside of EMAS facilities to over 70 hospitals and 500 puskesmas. The most common interventions replicated at the hospital level have been SijariEMAS, referral system PKs, and clinical rotations, and at the puskesmas level, clinical mentoring, clinical performance tools, emergency trolleys, and referral system PKs were most common. Further examination looked at ways in which EMAS interventions were institutionalized into government MCH regulations at the district and province level, and how much funding has been allocated to sustain and/or replicate EMAS interventions across districts. All findings are currently being written up into a final report, which will be presented to USAID in the next quarter. Additional activities directed at sustainability are described in subsequent sections.

A. EMAS Mentoring Approach During Quarter 3, EMAS noted progress from the district level through the national level to sustain the EMAS mentoring approaches. For example, in Banten, the Tangerang DHO facilitated a one-month clinical rotation in Tangerang hospital to build the capacity of five EMAS PONED puskesmas as “Excellence Puskesmas”. Mentor standardization activities were held for Grobogan hospital and puskesmas mentors in Central Java. Referral mentor teams have now been established in all but Wajo district. Provincial mentoring mechanisms have been finalized in Banten, Central Java, West Java, South Sulawesi, and East Java. All provinces have begun using DeKon funds to replicate EMAS approaches in new districts, and EMAS met with the Directorate General of Public Health this quarter to discuss the sustainability of the EMAS approaches with national support. Details on this quarter’s progress towards sustaining the EMAS mentoring approach are further described in this report under the following objectives and activities: Sustainability Activity Description Objective Activity

Strengthen mentors to ensure strong mentoring pool 1 1.8


Develop mentor teams for referral systems 2 2.8

Prepare PHO teams to organize and coordinate mentoring plans and activities

4 4.1

Build national commitment to and mechanisms for mentoring 4 4.3

B. Clinical Approaches

Noteworthy progress continues to be made towards achieving long-term impacts at the facility level, in order to leave in place high-functioning facilities with good clinical governance systems following the closeout of EMAS. POGI and IDAI have given EMAS their full support to establish long-term mechanisms for including external auditors in hospital-based audits, and are ready to initiate audit activities pending final approval from the MOH. A workshop was held in Quarter 3 for representatives from POGI and IDAI to plan to operationalize the mechanism. Action items from this meeting will be addressed in the next quarter. Also this quarter, EMAS convened a meeting with the BUK-R, KARS, facility staff, and related stakeholders to discuss the incorporation of EMAS approaches into national accreditation tools. EMAS will work over the next quarter to highlight areas in the existing tools where EMAS approaches can be integrated. EMAS also continued working with the Pokjas and DHOs in each district to ensure that they are requesting and reviewing hospital data; 16 of 18 Phase 2 and 3 Pokjas are now reviewing facility data in each meeting and taking follow up action when needed. Details on this quarter’s progress towards sustaining EMAS clinical approaches are further described in this report under the following objectives and activities: Sustainability Activity Description Objective Activity

Establish long-term mechanisms for including external auditors in hospital-based audits

1 1.4

Work with Pokja and DHOs to ensure they are requesting and reviewing clinical data

1,3 1.3, 3.2

Incorporate improved clinical governance practices into national accreditation standards

1 1.7

Highlight champions and high clinical performers 4 4.2, 4.3

C. Referral System Strengthening Approaches

EMAS intends to leave in place referral networks that effectively stabilize patients and support efficient referrals. With the expectation that demand for mentoring in referral system strengthening approaches will increase, EMAS set the goal of developing three complete referral mentor teams per district. As of Quarter 3, this goal has been achieved in all Phase 2 and 3 districts, with the exception


of Wajo, where mentor teams will be trained in the next quarter. Additionally, EMAS is assisting the MOH to disseminate and “socialize” the Collaborative Improvement Guidelines, developed during Year 4. West and Central Java have yet to disseminate the due Collaborative Improvement Guidelines to MOH reorganization and staff transitions. The MOH reorganization also delayed the meeting between EMAS and the MOH to review the referral system job aids and technical guidelines that were revised in the previous quarter. This meeting will now take place in Quarter 4. Details on this quarter’s progress towards sustaining EMAS referral system strengthening approaches are further described in this report under the following objectives and activities: Sustainability Activity Description Objective Activity

Disseminate Collaborative Improvement Guidelines 2 2.1

Revise referral system job aids/technical guidelines 2 2.7

Develop district-level referral mentor teams 2 2.8

D. Sustaining SijariEMAS

EMAS continues to see significant interest and commitment among DHOs and PHOs to strengthen the referral system and replicate SijariEMAS. EMAS drafted a SijariEMAS “business plan” in the previous quarter that outlines the options for handing SijariEMAS over to government or private sector entities to maintain and manage SijariEMAS. As part of the business plan development, data was collected to assess which districts have already budgeted line items to support SijariEMAS in 2017. Additionally, many PHOs, DHOs, and hospital management teams are continuing to intensify their routine monitoring and analysis of SijariEMAS data using dashboards. Several DHOs in Banten, Central Java, East Java, North Sumatra, and South Sulawesi, are demonstrating significant commitment to monitoring SijariEMAS by reviewing dashboards on a daily basis. Details on this quarter’s progress towards sustaining SijariEMAS are further described in this report under the following objectives and activities: Sustainability Activity Description Objective Activity

Build PHO, DHO and hospital capacity to monitor SijariEMAS 2 2.4

Integrate SijariEMAS into evolving national mHealth systems 2 2.5

Prepare SijariEMAS “business plan” 2 2.6

E. Sustaining Pokjas

Pokjas have become well-established, legally-supported entities in EMAS districts, with capacity in monitoring, advocacy, public consultation, planning, budgeting and legal drafting of MNH policy.


Across provinces, Pokjas are demonstrating significant commitment to maternal and newborn health issues. Fifteen of 18 Phase 2 and 3 district Pokjas have achieved the highest level of development, with the remaining three Pokjas at the second highest level of development. At the provincial level, Banten, East Java, and North Sumatra provincial Pokjas held meetings this quarter to support PHOs to strategize and coordinate mentoring activities and budgets following the end of EMAS. Details on this quarter’s progress towards sustaining Pokjas are further described in this report under the following objectives and activities: Sustainability Activity Description Objective Activity

Support Pokja through local regulations 3 3.1

Build capacity of Pokja to review assessment results, MPA results, and SijariEMAS data

3 3.2

F. Sustaining Civic Forums

Many civic forums are now self-sustaining, requiring no further EMAS financial support. Civic forums from across EMAS districts engaged in advocacy for funding and policies supportive of MNH activities. Among their activities this quarter, civic forums held maternal mortality advocacy events in Brebes and Nganjuk districts, conducted community-level socialization of maternal health best practices in Labuhan Batu, and reviewed citizen feedback on the health services they received in Madaling Natal and Wajo. EMAS is also seeing several examples of civic forums facilitating establishment of new civic forums and MKIA networks in replication districts or sub-districts. By the end of Quarter 3, 15 out of 18 Phase 2 and 3 civic forums reached either the highest or second highest level of development, with the remaining Phase 3 civic forums currently in the “developing” stage. Details on this quarter’s progress towards sustaining Civic Forums are further described in this report under the following objectives and activities: Sustainability Activity Description Objective Activity

Build capacity of Civic Forums to generate financial resources and mentor less-developed Civic Forums

3 3.3

CLOSE OUT Since districts began closing out in Year 5 Quarter 1, EMAS has focused on ensuring streamlined, transparent systems are in place in order to close out EMAS activities in a way that complies with USAID rules and regulations. During Quarter 1, EMAS support in three districts came to a close: Pinrang in South Sulawesi, Bandung in West Java and Blitar in East Java. In Quarter 2, eight


additional districts closed: Serang in Banten, Banyumas and Tegal in Central Java, Malang, Pasuruan and Sidoarjo in East Java and Asahan and Deli Serdang in North Sumatra. This quarter, eleven districts closed (Bogor, Cirebon, and Karawang in West Java, Kota Semarang, Brebes, and Cilacap in Central Java, Jombang in East Java, Bulukumba and Gowa in South Sulawesi, and Labuhan Batu and Langkat in North Sumatra); these comprise the remainder of the Phase 1 and Phase 2 districts. However, it is important to note that some of these districts have Phase 3 facilities which will continue to receive support from EMAS through December 2016. In addition, if the need arises and on a case-by-case basis, EMAS will consider requests to provide targeted technical support to DHOs after the official close date. With these closings, a total of 22 EMAS districts are now considered closed. The below summary of close out events includes districts which closed in Quarter 3, as well as districts which closed during Quarter 2 but had delayed official closing ceremonies. A summary of close out activities by district are as follows:

• Cirebon, West Java: Over 100 participants from professional organizations, the media, and EMAS staff joined together to ceremonially close out Cirebon district. The district Bupati praised EMAS for establishing mentors to strengthen clinical and referral performance and accountability in the district. The close-out event presented an opportunity to review the accomplishments of Cirebon district; facilities who met referral performance standards, for example, increased from 33% to 85% over the 4 years that EMAS was active in the district. Clinical performance in hospitals increased from 35% to 85%, and in puskesmas from 3% to 89%. Health providers present at the event said they now felt more confidence in their services after technical assistance from EMAS. The Bupati then committed to continue EMAS program interventions in the district.

• Banyumas, Central Java: The Banyumas close-out event was held in April for 70 participants from health facilities, SKPD, EMAS, USAID, and the PHO. EMAS presented the Banyumas Bupati with an award recognizing his contributions to the success of EMAS in the district.

• Tegal, Central Java: The Bupati of Tegal district hosted a close-out meeting in April, attended by government staff, civic forums, health facility staff and mentors. The Bupati emphasized his support for continuing EMAS activities in the district, and EMAS mentors were given an award for their part in strengthening maternal and newborn health in the district.

• Cilacap, Central Java: Cilacap district held a close out meeting at the office of the Bupati, attended by government staff, civic forums, health facility staff, EMAS PTL, mentors, and the head of the Central Java PHO. Awards were distributed to individuals who are supporting the implementation and sustainability of EMAS in Cilacap.

• Brebes, Central Java: Brebes district held a close out meeting in June at the office of the Bupati. In addition to representatives from EMAS, PHO, health facilities, mentors, and civic forums, the wife of the Central Javanese Governor, Mrs. Atikoh Ganjar Pranowo, also attended and gave a thank you speech for EMAS. She spoke on ways to continue building upon the success of EMAS in Brebes district, including using SMSBunda to support maternal and newborn health.

• Semarang, Central Java: The Semarang close out event was held at Dr. Kariadi Hospital, attended by the head of the PHO, the Semarang Vice-Mayor, EMAS leadership, facility representatives, and mentors. The meeting took the form of a seminar, in which EMAS


representatives from Tegal, Cilacap, and Semarang presented the latest on EMAS activities and how those activities will be implemented moving forward. Awards were given to staff from Semarang facilities that exhibited strong commitment to the EMAS program.

• Malang, East Java: Malang district held a handover Pokja meeting at the DHO. Invited guests included Pokja members, health facility directors, and DHO. The DHO presented on the latest achievements of EMAS and progress made since the start of the program. EMAS staff then spoke about the importance of Pokja and how their role can be carried forward after EMAS.

• Sidoarjo, East Java: A close out ceremony was held during a Pokja meeting at the DHO. EMAS staff spoke about program’s progress and achievements. They also presented local government representatives with a summary book that included pertinent program documentation (i.e. SK, Perda, photos, etc.) to use as a reference to continue EMAS activities in the district.

• Jombang, East Java: A small close out event was held during a Pokja meeting at the DHO. The DHO presented a comprehensive slide show on EMAS achievements in the district, and local government members then had a strategy session for continuing EMAS approaches.

• Labuhan Batu, North Sumatra: The DHO held a close out ceremony for EMAS, attended by the Vice-Bupati, PHO, health facility staff and civic forum representatives. During the meeting, participants expressed their commitment to continue the EMAS movement, signing a declaration to continue decreasing maternal and newborn mortality in the district.

• Langkat, North Sumatra: The DHO office held a close out ceremony for Langkat district in June.

• Gowa, South Sulawesi: An EMAS close out ceremony was held in May, in which the Bupati announced an EMAS program continuation called APPASALAMA (Aksi Penyelamatan Amma na Ana, or Saving Lives of Mothers and Children). Stakeholders from the government and NGOs came to declare their support and commitment to the movement. Activities that have already been budgeted under APPASALAMA include AMP, Pokja, self-assessments and skills updates in hospitals and puskesmas, and civic forum and MKIA activities.

• Bulukumba, South Sulawesi: The close out event in Bulukumba was led by the head of Bappeda, also the chief of the district Pokja. As in Gowa, the district has committed to building off of the progress of EMAS. They announced that AMP, Pokja, provider self-assessments and skills updates, and facility upgrades are now budgeted in the district plan. USAID representative Eddie Rahmat addressed the meeting and acknowledged the achievements of EMAS in the district.

Also this quarter, Muhammadiyah, an EMAS consortium partner, ended activities. Muhammadiyah’s work over the past five years helped to introduce EMAS approaches to Muhammadiyah hospitals, recruit networks of community-level MKIAs to support pregnant women, and strengthen citizen feedback mechanisms and health system accountability through establishment of civic forums.


II. PROGRAM ACTIVITIES AND RESULTS SUMMARY In this quarter, EMAS collected data on 48,961 deliveries and associated data, including the number of live births, stillbirths, newborn deaths and maternal deaths across all facilities. Annex D includes a summary of this data, for the last four quarters, disaggregated by Phase. As EMAS closes support to a district, it also ends data collection activities at the facility level. By the end of Quarter 3, EMAS ended support to Phase 1 and 2 facilities. Data from these districts/facilities are no longer included in quarterly reporting. Some Phase 1 and 2 districts have Phase 3 facilities, however, and data will continue to be reported from Phase 3 facilities through December 2016. The number of facilities included in routine data collection and in reports will continue to decrease as districts close out and facilities continue to be handed over to the district. Data reported in Quarter 3 includes data from the following districts and facilities, unless otherwise noted:

Phase District Total # of Hospitals

Total # of Puskesmas

2 Banten: Tangerang West Java: Bogor, Karawang Central Java: Cilacap, Brebes, Kota Semarang East Java: Jombang South Sulawesi: Bulukumba, Gowa North Sumatra: Labuhan Batu, Langkat

39 Hospitals 96 Puskesmas

3 West Java: Bogor*, Karawang*, Cirebon*, Indramayu Central Java: Banyumas*, Grobogan, Pekalongan East Java: Kota Semarang*, Malang*, Nganjuk, Tuban South Sulawesi: Wajo North Sumatra: Labuhan Batu*, Mandaling Natal

60 Hospitals 72 Puskesmas

*Only Phase 3 facilities MATERNAL AND NEWBORN HEALTH INTERVENTIONS EMAS tracks progress in providing life-saving interventions to women and newborns. Coverage of maternal health interventions in Phase 2 and 3 facilities continued on an upward trajectory this quarter (Figure 1). As seen in previous quarters, coverage across all phases is between 90-100% for provision of magnesium sulfate (MgS04) for women with pre-eclampsia/eclampsia (PE/E), as well as uterotonic in the third stage of labor to prevent post-partum hemorrhage (PPH). Both Phase 2 and 3 facilities have achieved significant improvement in coverage of at least one dose of MgS04 for women with severe PE/E before referral, and other indicators assessing stabilization before referral (Figure 1). While still less than optimal, Phase 2 facilities have increased coverage from


44% to 61% over the past four quarters, and Phase 2 facilities have nearly doubled their coverage, going from 32% in Year 4 Quarter 4 to 61% in Year 5 Quarter 3. This intervention is tracked at the hospital level and measures the percentage of woman who arrive at the hospital who have already received at least one dose of this medication. Since this indicator tracks stabilization at the point of referral, regardless of whether the referral point is an EMAS mentored facility, it is possible that EMAS’s efforts to have total coverage across districts is boosting performance on this measure. Figure 1: Coverage of maternal interventions, Phases 2 and 3

Newborn interventions in Phase 2 and 3 facilities have also shown upward coverage trends over the past four quarters (Figure 2). Percentage of newborns breastfed within an hour of delivery and provision of antenatal corticosteroids (ACS) to women who delivered pre-term increased slightly among Phase 2 and 3 facilities. Notably, between Year 4 Quarter 4 and Year 5 Quarter 3, provision of ACS to women delivering pre-term jumped from 81% a year ago to 91% Phase 2 facilities, and from 65% to 80% in Phase 3 facilities. EMAS placed strong focus on increasing performance of pre-referral indicators, as coverage of this interventions tended to lag behind others. The percent of newborns with suspected severe infection who received an antibiotic prior to referral continues to be lower than desired, and there is varied performance across quarters. This inconsistency is most clearly seen in Phase 3 facilities, which increased coverage of this intervention from 10% to 26% as of Quarter 3, but saw a sharp decline in the previous quarter. EMAS continues to explore strategies that will support Phase 2 and 3 facilities to make progress on this referral intervention as they have with percent of newborns breastfed within one hour of delivery and percent of pre-term newborns whose mothers received ACS.

100% 100% 95%

98%

88% 91%

44%

32%

61%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Y4 Q4 Y5 Q1 Y5 Q2 Y5 Q3

Phase 2: % of hospital deliveries with uterotonic in the 3rd stage of laborPhase 3: % of hospital deliveries with uterotonic in the 3rd stage of laborPhase 2: % of PE/E cases treated with MgSO4Phase 3: % of PE/E cases treated with MgSO4Phase 2: % of referred PE/E cases treated with MgSO4 before referralPhase 3: % of referred PE/E cases treated with MgSO4 before referral


However, similar to the pre-referral indicator for MgS04, this indicator is collected at the hospital and includes referrals from any referral point. Previously reported data show that coverage of this intervention is much higher when referrals are initiated from EMAS-supported facilities. EMAS does not expect to be able to be able to make significant progress in provision of newborn antibiotics before referral as a large proportion of newborns are being referred from private midwives, who are not legally allowed to administer antibiotics (as documented in the EMAS Origins of Referral Brief and discussed in Year 4, Quarter 2 report). Figure 2: Coverage of newborn interventions, Phases 2 and 3

74% 77%

63%

68%

81%

91%

65%

80%

15% 22% 20% 26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Y4 Q4 Y5 Q1 Y5 Q2 Y5 Q3

Phase 2: % of newborns breastfed within 1 hour of deliveryPhase 3: % of newborns breastfed within 1 hour of deliveryPhase 2: % of newborns delivered between 24-34 weeks whose mothers received antenatal corticosteroidsPhase 3: % of newborns delivered between 24-34 weeks whose mothers received antenatal corticosteroidsPhase 2: % of newborns referred with infection, given antibiotic before referralPhase 3: % of newborns referred with infection, given antibiotic before referral


OBJECTIVE 1: IMPROVED QUALITY OF EMERGENCY OBSTETRIC AND NEONATAL CARE (EmONC) SERVICES IN HOSPITALS AND PUSKESMAS

A. PROGRESS TOWARD YEAR 5 PERFORMANCE MEASURES

Table 1: Progress towards Year 5, Objective 1 indicators

Performance Measure End of Year 5 Target

Progress Summary

Phase 2 Phase 3 Year 5 Outcomes (EMAS PMP Indicators)

% of EMAS facilities that achieve at least 80% of EmONC standards achieved

Phase 1 & 2: 80% Phase 3: 60%

ACHIEVED ACHIEVED Maternal, IP

Neonatal 53%

Clinical Governance 45%

% of severe pre-eclampsia/eclampsia cases managed with MgSO4 at EMAS facilities

100% 98% 92%

% of deliveries that receive at least one dose of uterotonic postpartum during 3rd stage of labor at EMAS facilities

100% ACHIEVED ACHIEVED

% of live births who are breastfed within 1 hour of birth at EMAS facilities

90% 86% 76%

% of newborns delivered in EMAS hospitals between 24 and 34 weeks gestation whose mothers received one or more doses of antenatal corticosteroids


% of EMAS facilities that conduct regularly scheduled death reviews on fresh stillbirths (IPUD) > 2000 grams*


% of EMAS facilities that conduct regularly scheduled death reviews on neonatal deaths > 2000 grams*


% of EMAS facilities that conduct deaths reviews on all maternal deaths within 24 hours of occurrence*

100% 87% 73%



Progress Summary

Phase 2 Phase 3 Year 5 Outcomes (EMAS PMP Indicators)

% of EMAS hospitals that conduct regularly scheduled near miss reviews*


Year 5 Program Implementation Indicators (EMAS Input, Process and Output Indicators)

% of EMAS-supported health facilities that are functioning as mentors

80% Phase 1 and 2 30% of Phase3

ACHIEVED 17%

*Assessed among the subset of facilities who reported a related death

B. NARRATIVE DESCRIPTION 1.1 Continue to strengthen Phase 1 and Phase 2 facilities through targeted mentoring As of Quarter 3, EMAS is currently providing direct support to 39 hospitals and 96 puskesmas in Phase 2 districts to improve clinical governance and the quality of care. Significant progress has already been achieved in reaching high coverage of life-saving interventions, as well as in reaching indicators related to improved clinical governance within facilities. With support having ended to Phase 1 facilities, EMAS continued to provide targeted support to Phase 2 facilities this quarter and to prepare them to transition off of EMAS support. This quarter, facility mentors at both the hospital and puskesmas level led mentoring activities, with periodic supplemental support from LKBK and EMAS clinical mentors as needed. For example, in Banten, EMAS clinical mentors visited 13 PONED puskesmas and provided a refresher training on the use of the MamaNatalie anatomical model. In Central Java, clinical mentors visited 10 mentor puskesmas in Cilacap to provide a refresher on the DST and referrals. Clinical mentors in Kota Semarang visited Telogorejo Hospital to socialize the simplified audit form. EMAS mentors also supported RSUD Kajen and RSI Pekajangan in Pekalongan to successfully become accredited. LKBK supported a regional hospital in South Sulawesi to review their maternal death and near-miss audit data. The mentoring process continues to be more and more driven by local mentors. Hospital and puskesmas mentors from Jombang district successfully led P2 mentoring in Jombang district on their own, with no additional support from EMAS mentors. PKM Tanjung Langkat in Langkat district of North Sumatra independently arranged for 2 non-EMAS puskesmas to visit their site to initiate a mentor relationship. To further bolster mentoring sustainability, EMAS has encouraged DHOs to hold quarterly meetings for hospital directors/boards to share clinical governance successes and lessons learned from each hospital in the district. DHOs continue to be supportive of this endeavor; this quarter, DHOs from 14 districts held meetings to increase communication, improve coordination, and share progress in mentoring and clinical governance. Overall support for the mentoring process and other activities to boost hospital performance remains strong. For example, this quarter, all districts reported that they


continued to review and follow up on RTL recommendations, and most have allocated funds for clinical rotations to take place. Cirebon district allocated funding for 35 teams from PONED puskesmas to participate in clinical rotations at RSUD Arjawinangun and RSUD Waled between June and December 2016. Mentoring support from EMAS and commitment from the DHOs in monitoring facility performance contributed to improved performance this quarter. Figure 3 shows the percentage of Phase 2 hospitals that are achieving less than 50%, 51 – 79%, or 80% or more of EmONC performance standards. At least 80% of Phase 2 hospitals achieved 80%-100% of maternal care, newborn care, and infection prevention this quarter. Improving performance in clinical governance has proved to be the most challenging among all standards. Over the previous three quarters, Phase 2 performance in this area was stagnating at around 65%. This quarter saw a large jump in clinical governance achievement, however; 76% of Phase 2 hospitals achieved between 80%-100% this quarter. Figure 3: Percent of Phase 2 hospitals that achieve EmONC Performance Standards (Y4Q4-Y5Q3)

PHASE 2

Phase 2 puskesmas also achieved higher percentages of MNH and infection prevention standards this quarter, as seen in Figure 4. Close to 100% of Phase 2 puskesmas achieved 80%-100% of MNH standards. Over the past four quarters, the percentage of Phase 2 puskesmas meeting 80%-100% of infection prevention standards has risen from 65% to over 90%.

2% 0% 2% 0% 0% 2% 2% 3% 0% 2% 2% 0% 11% 7% 10% 5% 2% 9%

14% 8%

23% 23% 14% 11% 16%

21% 14% 11%

25% 28% 24% 18%

96% 91% 83%

92% 77% 74%

83% 87% 84% 77%

83% 89%

64% 65% 67% 76%

Y4Q4 Y5Q1 Y5Q2 Y5Q3 Y4Q4 Y5Q1 Y5Q2 Y5Q3 Y4Q4 Y5Q1 Y5Q2 Y5Q3 Y4Q4 Y5Q1 Y5Q2 Y5Q3

Maternal Neonatal Infection Prevention Clinical Governance

% of hospitals that achieved <50% of standards% of hospitals that achieved 50-79% of standards% of hospitals that achieved 80-100% of standards


Figure 4: Percent of Phase 2 puskesmas that achieve EmONC Performance Standards (Y4Q4-Y5Q3)

PHASE 2

In Year 5, EMAS has prioritized ensuring that dashboards and the referral decision-support tool (DST) are fully utilized to boost rates of pre-referral stabilization. Nearly all Phase 2 hospitals actively used clinical dashboards this quarter, and all Phase 2 puskesmas reported as regularly using DST. EMAS will continue to work with DHOs and hospital management teams to instruct puskesmas and hospital staff to reinforce and maximize utilization of dashboards and the referral DST. 1.2 Complete mentoring cycle in Phase 2 and Phase 3 facilities EMAS mentoring continued this quarter to build the capacity of Phase 2 and 3 facilities. Mentoring for Phase 2 facilities focused largely on mentoring standardization, as most Phase 2 facilities have already begun or are preparing to begin mentoring. Most Phase 3 facilities are now mid-way through their mentoring cycle. Visits conducted relied primarily on mentors from Phase 1 and Phase 2 districts to conduct mentoring visits. Among the visits that took place:

• Banten: RSUD Serang provided an on-the-job PONED training for 4 EMAS puskesmas in Tangerang. This was funded by Banten PHO. Two new hospitals in Banten began mentoring this quarter.

• Central Java: Mentor standardization took plan for 4 hospitals and 10 puskesmas in Grobogan district. A Phase 3 hospital in Kota Semarang, Bhakti Wira Tamtama, completed P2 mentoring and improved their clinical performance score by 80%. Three new hospitals and 10 puskesmas in Central Java began mentoring this quarter.

• East Java: Hospital and puskesmas mentors from Jombang district conducted P2 mentoring for Nganjuk district facilities. One new puskesmas in East Java began mentoring this quarter.

• North Sumatra: Vertical hospital mentors from Labuhan Batu supported a Phase 2 hospital with their audit review process. One new puskesmas from North Sumatra began mentoring this quarter.

4% 2% 1% 2% 4% 2% 1% 1%

21%

5% 4% 2%

31% 30% 19%

7%

75% 93% 95% 96%

65% 68% 80%

92%

Y4Q4 Y5Q1 Y5Q2 Y5Q3 Y4Q4 Y5Q1 Y5Q2 Y5Q3

MNH Infection Prevention

% of puskesmas that achieved <50% of standards% of puskesmas that achieved 50-79% of standards% of puskesmas that achieved 80-100% of standards


• South Sulawesi: LKBK and provincial mentors led P3 mentoring for RSUD Bone. Five new puskesmas in South Sulawesi began mentoring this quarter.

• West Java: RSUD Karawang hosted a clinical rotation for 22 puskesmas staff. P3 mentoring visits were held for RSUD Proklamasi and 6 PONED puskesmas from Karawang.

A number of vertical hospitals were actively involved this quarter in mentoring within and beyond EMAS target facilities. In Central Java, RS Kariadi conducted the P2 mentoring visits at 4 hospitals in Kudus, a replication district. RS Kariadi also did P1 mentoring for Telogorejo hospitals in Semarang, and conducted mentor standardization at 4 interfaith network hospitals and 2 puskesmas in Semarang, as well as an additional 2 hospitals in Pekalongan. Vertical hospital mentors from Labuhan Batu district in North Sumatra assisted with the audit process at RSUD Rantau Prapat this quarter. They also advocated to other specialists in EMAS districts to encourage their involvement in the audit process. In South Sulawesi, vertical hospital RSUP Dr. Wahidin Sudirohusodo Makassar mentored regional hospitals in Makassar, Bulukumba, Bone, Palopo, and Pare-pare on analyzing death audit reports. Vertical hospital specialists from South Sulawesi also sent mentors from maternal and neonatal units and facility management to RS Bone to introduce best practices in clinical governance. EMAS has continued to see success in the uptake and replication of mentoring this quarter. In Tangerang, the EMAS Banten team organized a visit for DHO Tangerang Selatan to DHO Tangerang and the Tangerang district hospital. The team from DHO Tangerang Selatan called the visit “inspirational”, and said it will help accelerate the finalization of their local regulations on maternal and newborn emergency care, SijariEMAS, call centers, and SPGDT. In Central Java, puskesmas mentors from Grobogan began initial mentoring activities in 20 replication puskesmas. Mentors from RSUD Rantau Prapat provided technical assistance to Labuhan Batu Utara, a replication district, to introduce EMAS approaches in their facilities and the MPA process. West Java mentors from across EMAS districts have been actively providing mentoring to 5 replication districts. These visits are managed by the Satgas team and funded through APBD. Phase 3 facilities continue to improve performance over baseline, with increases seen among both hospitals and puskesmas across all areas this quarter, including clinical governance. As seen in Phase 1 and 2 facilities, ensuring strong clinical governance involves changing behaviors and processes within facilities, which often results in slower achievement of standards in these areas compared to others. Figure 5 shows that more Phase 3 hospitals are achieving at least 80 percent of standards and are increasingly meeting higher percentages of standards. This quarter saw notable achievements in the number of hospitals meeting maternal care and infection prevention standards. Each quarter, fewer Phase 3 facilities are meeting less than 50% of standards; in Year 4 Quarter 4, 67% of Phase 3 facilities met less than 50% of infection prevention standards, but as of this quarter, that has been reduced to only 5%. EMAS will continue to work with DHOs and Phase 3 facilities over the next quarter to build their capacity to adhere to EmONC performance standards.


Figure 5: Percent of Phase 3 hospitals that achieved EmONC Performance Standards (Y4Q3-Y5Q2)

PHASE 3

As seen in Figure 6, achievement in Phase 3 puskesmas is still less than desired, although this quarter saw 10% more Phase 3 puskesmas meeting at least 80% of MNH and infection prevention standards. Gradually, more puskesmas are achieving high percentages of standards. For example, as of this quarter, only 1% of Phase 3 puskesmas met less than 50% of MNH standards, compared to 60% one year ago. Figure 6: Percent of Phase 3 puskesmas that achieved EmONC Performance Standards (Y4Q4-Y5Q3)

47% 48%

30% 14%

70% 56%

41% 31%

67% 64%

19% 5%

77%

43%

61% 46%

40% 30%

33%

34%

20%

26%

28% 37%

13% 21%

42%

44%

13%

28%

22%

27%

13% 22%

37% 53%

10% 19%

31% 32% 20% 15%

40% 51%

10%

30% 17%

27%

Y4Q4 Y5Q1 Y5Q2 Y5Q3 Y4Q4 Y5Q1 Y5Q2 Y5Q3 Y4Q4 Y5Q1 Y5Q2 Y5Q3 Y4Q4 Y5Q1 Y5Q2 Y5Q3

Maternal Neonatal Infection Prevention Clinical Governance

% of hospitals that achieved <50% of standards% of hospitals that achieved 50-79% of standards% of hospitals that achieved 80-100% of standards

60%

36%

14% 1%

39% 33%

13% 6%

29%

38%

28%

31%

50% 44%

35% 31%

11% 26%

58% 68%

11% 23%

53% 63%

Y4Q4 Y5Q1 Y5Q2 Y5Q3 Y4Q4 Y5Q1 Y5Q2 Y5Q3

MNH Infection Prevention

% of puskesmas that achieved <50% of standards% of puskesmas that achieved 50-79% of standards% of puskesmas that achieved 80-100% of standards


1.3 Strengthen and expand data for decision-making in facilities EMAS continues to place strong emphasis on the importance of data, working with facilities to increase their availability to effectively use and analyze data in order to track trends in service delivery and to make informed management decisions. In addition to routine support to facilities in this regard, data for decision-making (D4D) workshops were conducted for Phase 3 facilities in Bogor, Karawang, Cirebon, Grobogan, Kota Semarang, Nganjuk, Pekalongan, and Wajo. As in prior quarters, separate workshops were held for puskesmas or hospital staff with facility leadership and DHO staff included. The workshops were conducted as a joint activity between M&E and the Component 1 clinical team. As of this quarter, 59 Phase 3 and Muhammadiyah hospitals have participated in D4D workshops. The remaining hospitals are scheduled to participate in D4D workshops next quarter. Significant progress continues to be seen each quarter in the use of data for decision making in EMAS facilities. Clinical dashboards, e-registers, and other data reviews have supported puskesmas to make improvements within the facility and in quality of care. As of Quarter 3, all Phase 3 hospitals are now using standardized registers, and after clinical dashboards were introduced to most Phase 3 facilities in the previous quarter, all but a few Phase 3 hospitals are routinely using dashboards to make decisions. With the right tools and understanding of how to use data, EMAS is continuing to see good examples across a number of districts demonstrating the utility of dashboards and how data can be used to make decisions to improve the quality of care. In a facility in Tangerang, data helped facility staff recognize that the number of NICU beds was insufficient to meet the number of neonatal cases who needed NICU. As a result, the facility management purchased a new CPAP and ventilator for the neonatal ward. Some puskesmas in Madaling Natal district of North Sumatra recognized the need for a clean water well in order to meet infection prevention standards, and used their data to advocate for funding to construct the wells. Mentor puskesmas in Gowa and Bulukumba present their data during mentoring visits to limited support puskesmas in order to demonstrate how data impacts clinical performance. As a result, almost all limited support puskesmas have very strong data use practices. Other facilities across districts reported using data to hire additional staff, move or renovate rooms in the facilities, make management decisions, and ensure adequate supply of equipment and commodities needed for safe deliveries. Use of dashboards for effective decision making is a process that takes time and support. Phase 3 facilities ramped up use of dashboards this quarter, with a majority of facilities now routinely using dashboards as a tool for decision-making. In Tangerang, the DHO consistently emphases to puskesmas during supervision or on-the-job training that dashboards need to be prioritized and regularly updated. Hospitals in Brebes, in Central Java, have integrated dashboard use with patient monitoring; staff are using dashboards to monitor the conditions of patients and easily report any changes or problems to their supervisor. Dashboards also helped Pekalongan hospitals to become accredited; staff used dashboards to demonstrate their performance against their indicator targets. Several facilities reported that although they are actively using dashboards and analyzing dashboard data, they have not yet begun meeting with facility management to review data. As use of dashboards becomes more institutionalized, EMAS expects that facility staff will become more comfortable presenting dashboard data to management and other decision makers.


Since Year 5 Quarter 1, EMAS has been working to pilot an e-dashboard for monitoring clinical indicators in Banten province. An electronic database was developed where the health facility service statistics can be manually input into an electronic version of the standard register using Microsoft Excel (e-register). The main principle behind the development of the e-registers is to allow for real-time recording and reporting. E-registers help to reduce printing costs for the facility, standardize records, ensure completeness of data, and prevent miscalculations of entries thanks to computerized calculation formulas. Once data is input into an e-register, dashboards can then be generated and customized based on the needs of the user. In addition to using the dashboard for routine data monitoring, facilities can extract formal reports from this dashboard and present them to the DHO or MOH. In Quarter 3, pilot districts in Banten continued to regularly use the e-register and e-dashboard, and to send reports to hospital management and DHOs. After noting the success of the pilots in Serang and Tangerang, the province has decided to scale up use of the e-register to Kota Cilegon, Kota Tangerang, and Tangerang Selatan district. The use of e-registers in these new sites is supported by a Bupati-issued Peraturan that says the need for reliable data justifies the use of information and technology systems, such as the e-register. 1.4 Improve quality and frequency of maternal and neonatal death audits within 24 hours in

hospitals EMAS continues to underscore the importance of maternal and neonatal death and near-miss audits in health facilities in improving clinical governance and practice. EMAS has placed a strong emphasis on these processes and has implemented several activities to improve the quality and frequency of audits, including the introduction of a simplified audit form, preliminary death review form, and a mechanism to increase external participation in audits. Encouraging frequency of audits by simplifying the form The simplified audit format has been introduced in all EMAS facilities. By the end of Quarter 3, 72 Phase 3 hospitals were using the simplified audit tool. This quarter saw significant improvements in Phase 2 and 3 hospitals’ capacity to conduct death audits within 24 hours of their occurrence (data presented below). However, some hospitals still have difficulty with conducting audits within 24 hours, usually due to limited resources or heavy caseloads. Using audit information to immediately solve problems EMAS developed a simple preliminary death review form targeted at the hospital director that will alert him/her within 24 hours to gaps that need immediate action. After being tested and refined during Quarter 2, the preliminary death review form was introduced to remaining facilities in Quarter 3. Phase 1 and 2 mentor facilities trained Phase 2 and 3 facilities in the use of the form during routine mentoring visits. At the national level, EMAS facilitated a workshop this quarter with POGI and IDAI representatives from the 6 EMAS provinces. POGI and IDAI representatives agreed to use this form moving forward. POGI is making some modifications to simplify the form. Its current status is with the MOH for approval, after which the preliminary death review form will be circulated to facilities nationwide. Improving the quality of audits by using external auditors To boost the quality of audits, this year EMAS is collaborating with POGI and IDAI to develop a feasible mechanism that will enable external auditors from professional organizations to participate


in audits. The participation of external auditors will increase the objectivity of the audit process as they will be able to facilitate difficult discussions as “objective outsiders.” EMAS has finalized the development of a guideline that will be promoted by professional organizations and is in the process of being taken up by the MOH. The guideline, which provides overall instruction on how to conduct audits, also outlines a process and defines the circumstances in which hospitals should seek expertise from specialists outside of the facility (i.e professional organizations). For example, in the event that there is internal disagreement within a facility regarding the need for an external auditor, the facility can draw upon the process outlined in the guidelines to ensure facility staff comply with the external audit process. Both POGI and IDAI have given their full support to this mechanism and are prepared to initiate audit activities. A workshop was held in Quarter 3 for representatives from POGI and IDAI to discuss the need for facility-based audits and near-miss and death reviews. Outcomes of that meeting included:

• POGI agreed to adopt the preliminary death review form because it directs reviewers to identify gaps along the pathway of care of near-miss or death cases.

• IDAI/UKK Perina agreed to test the RMP form from the National AMP system, discuss it with peers and at the facility-level, and develop recommendations from there.

• POGI and IDAI agreed to develop technical guidelines to mandate the performance of facility-based death reviews, but stated that these guidelines should be endorsed by the MOH in order to ensure compliance and strong clinical governance.

Figure 7 shows trends in audits conducted in Phase 2 and 3 hospitals over the past four quarters. This quarter, both Phase 2 and 3 hospitals showed improvement in the percentage of maternal and neonatal cases (≥2000 grams) audited. Phase 2 facilities had a marked increase in percentage of neonatal deaths audited, jumping from 56% in the previous quarter to 70% in Quarter 3. While still lower, Phase 3 facilities have demonstrated significant improvement over the past four quarters in neonatal audits conducted; from only 14% in Year 4 Quarter 4, they are now auditing 57% of neonatal deaths. As discussed with USAID previously and noted in prior reports, as districts are closed EMAS no longer collects or reports on data from the facilities within those districts. As data presented in the PMP and reports is aggregate across all facilities within a phase, EMAS is expecting to see variation in performance in some areas as fewer and fewer facilities are included in the aggregate calculations each quarter. EMAS is closely monitoring facility-by-facility data to ensure there are not significant reductions in actual individual-level performance. Phase 2 and 3 districts showed substantial progress in audit processes overall this quarter, including their ability to conduct audits within 24 hours of a maternal death occurring. Whereas in the previous quarter only 43% of Phase 2 facilities conducted audits within 24 hours of a maternal death, this quarter 87% of Phase 2 facilities performed audits within that timeframe. Seventy-three percent of Phase 3 facilities conducted audits within 24 hours of a maternal death this quarter, up from 49% in the previous quarter. After working to disseminate the preliminary death review form over previous quarters, EMAS is now seeing how the form is contributing to more expeditious audits being conducted. EMAS will continue to work with facility management to encourage the participation of all relevant parties in the audit process.


Figure 7: Maternal and Neonatal Death Case Reviews in EMAS-supported Hospitals, Phases 2 and 3 (Y4Q4-Y5Q3)

In addition to these quantitative measurements, overall, a majority of facilities report that feedback from audits is now regularly shared with facility management. Given that facilities were not even doing audits prior to EMAS, this is a significant achievement. This quarter, several good examples of facilities taking action as a result of audits have been noted. For example, in Tangerang, audit data helped support an effort to get funding to host a clinical rotation at Tangerang hospital for a doctor and midwife from a nearby puskesmas. Using the simplified audit tool helped RSI Sultan Agung in Kota Semarang to streamline the patient admission mechanism in the emergency room, leading to more efficient preparation for emergency procedures and shorter wait times. Other facilities used the audit process this quarter to decrease response time, procure needed emergency equipment, improve coordination between and among units, recognize the need to hire additional staff, and to reinforce to referral facilities the importance of stabilizing clients effectively before referral. 1.5 Build capacity of PF teams to monitor clinical performance in puskesmas To date, the Penyelian Fasilitastif (PF) teams have conducted their routine supportive supervision using the referral performance monitoring tools, amongst others. In this quarter, EMAS began to familiarize existing PF teams with the clinical performance standards and dashboards/clinical indicators during the referral mentor activities (described in Activity 2.8 below). This year, EMAS is working with PF mentors to develop a simple form and process for referral case reviews so there is a standardized approach across puskesmas that increases their ability to more easily follow up and make improvements in the referral process within the facility. The form was disseminated to test facilities earlier this year to obtain feedback that would make the form more

86%

97%

55%

69%

46%

70%

14%

57%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Y4 Q4 Y5 Q1 Y5 Q2 Y5 Q3

Phase 2 Maternal DeathsPhase 3 Maternal DeathsPhase 2 Neonatal Deaths ≥ 2000 grams Phase 3 Neonatal Deaths ≥ 2000 grams


user-friendly. In Quarter 2, DHOs from Phase 3 districts encouraged their facilities to begin utilizing the form. It is now being used in all Phase 3 puskesmas, thanks to dissemination support from Phase 1 and 2 puskesmas mentors. 1.6 Finalize EMAS technical guides and update job aids In order to incorporate experience and lessons learned to date, this year EMAS is revising and finalizing the existing technical guides. These technical “how-to” guides include mentoring, use of dashboards, facilitating clinical rotations, conducting emergency simulations, using performance standards, and conducting near-miss/death audits. In addition, clinical job aids will be updated as needed. EMAS will support the dissemination of these updated technical guides and job aids to all facilities. During the previous quarter, the guidelines were disseminated to LKBK and Muhammadiyah mentoring teams for use in their routine mentoring activities, and EMAS worked to collect input from QICs, CMs, local mentoring teams to revise the technical guides. After continued “field-testing” in Quarter 3, users had no further comments for improvement. However, EMAS is still awaiting feedback from the MOH, and will incorporate this feedback into finalized versions of the technical guides in Quarter 4. 1.7 Incorporate performance monitoring approaches/tools into national accreditation/other systems EMAS is collaborating with BUK-R (Subdit Akreditasi) and BUK-D (Subdit Standardisasi) to explore incorporating EMAS approaches into accreditation standards. Although many EMAS approaches are already included in Perbup, SK, Collaborative Improvement Guidelines, and some puskesmas accreditation tools, incorporating EMAS approaches into accreditation tools will mandate that facilities must establish and maintain these approaches. For example, accreditation standards could require facilities to use dashboards, conduct death reviews, track and review data, conduct emergency drills, develop MOUs to network with other hospitals and puskesmas, use the referral DST. In Quarter 3, EMAS convened a meeting with the BUK-R, KARS, facility staff, and related stakeholders. The meeting achieved its key desired outcome; it was agreed that EMAS approaches will be incorporated into national accreditation tools. The EMAS team completed an initial review of the existing standards, making suggestions for where EMAS approaches could be inserted. Over the next quarter, EMAS will hold several workshops with relevant MOH directorates to finalize incorporation of the standards. 1.8 Strengthen mentors to ensure strong mentoring pool To date, EMAS has already assembled a pool of key mentors to conduct mentoring in Phase 2 and 3 districts. This year, EMAS is working to maintain and strengthen their performance, and further build the mentoring capabilities of Phase 2 and 3 facilities through regular visits by EMAS clinical staff, DHOs, Pokjas, and as needed, LKBK mentoring teams. Focusing on building mentor capacity will enable the creation of other mentors once their clinical performance improves.


Districts and provinces have been focusing on building capacity of mentors this quarter, as well as other strategies to ensure a quality pool of mentors is in place. Among these activities:

• In Banten, the Tangerang DHO facilitated a one-month clinical rotation in Tangerang hospital for 5 EMAS PONED puskesmas (PKM Balaraja, PKM Curug, PKM Teluk Naga, PKM Sepatan, and PKM Kronjo). Following completion of the rotation, the DHO designated those 5 facilities as “Excellence Puskesmas” in Tangerang, from where future mentors can be developed.

• In North Sumatra, the Langkat DHO held a technical update for 30 mentors using APBD funds.

• In West Java, the PHO allocated funds to support mentors to conduct monthly mentoring visits in each district. The purpose of these visits is not only to strengthen performance of the facilities, but also to help EMAS staff and other mentors to identify new potential mentors within the districts. Thirty-nine new potential mentors have since been identified and will complete mentor standardization by provincial mentors in the next quarter.

• In Central Java, mentor standardization activities were held for Grobogan district’s clinical mentor team from 4 hospitals and 10 puskesmas. By standardizing these district mentors, they are now able to conduct mentoring both in replication districts and within Grobogan district. The 10 puskesmas mentors who completed the standardization have already begun mentoring activities in 20 non-EMAS puskesmas using APBD funds.

• In South Sulawesi, EMAS clinical mentors and QICs are building the capacity of all full support puskesmas in Bulukumba and Gowa to become mentors for limited support puskesmas in those districts. Each full-support puskesmas will be expected to become a mentor to at least one limited-support puskesmas, with the goal of ensuring all puskesmas in Bulukumba and Gowa are exposed to EMAS interventions.

OBJECTIVE 2: INCREASED EFFICIENCY AND EFFECTIVENESS OF REFERRAL SYSTEMS

A. PROGRESS TOWARD YEAR 5 PERFORMANCE MEASURES Table 2: Progress towards Year 5, Objective 2 indicators


Progress Summary Phase 2 Phase 3

Year 5 Outcomes (EMAS PMP Indicators)

% of EMAS referral networks that achieve 80% of standards contained in the referral performance monitoring tools

Phase 2: 80% Phase 3: 60%

ACHIEVED

95%

% of EMAS-supported hospital referral cases managed by SijariEMAS

No target 48% 64%


% of referral cases with hospital response occurring within 10 minutes upon receipt of SijariEMAS notification

Phase 2: 80% Phase 3: 70%

78% 89%


Progress Summary Phase 2 Phase 3


% of reported maternal and perinatal deaths audited using the Maternal Perinatal Audit (MPA) process in EMAS districts

100% Maternal

25% Neonatal

71% Maternal

56% Neonatal

53% Maternal

28% Neonatal


Referral performance monitoring tools developed with EMAS assistance are adopted by MOH

N/A In process

B. NARRATIVE DESCRIPTION

2.1 Disseminate the Ministerial Regulation (Permenkes) on Collaborative Management of Referral

In Year Four, EMAS assisted the MOH (BUK-R) to draft a ministerial regulation entitled, Guidelines for Improving Collaboration within Maternal and Newborn Health Services at Basic and Referral Levels (Collaborative Improvement Guidelines). This regulation provides the legal mandate for EMAS approaches to be implemented at the district level, and enables district health offices to request annual funds to support those approaches. EMAS collaborated with BUK-R to disseminate these Collaborative Improvement Guidelines in Banten and South Sulawesi during Year Four, and in East Java and North Sumatra during the first two quarters of Year 5. West and Central Java have yet to disseminate the due to MOH reorganization and staff Collaborative Improvement Guidelines transitions. EMAS will work in the next quarter to accelerate finalization and dissemination

. Collaborative Improvement Guidelines in remaining provinces 2.2 Continue strengthening referral systems in Phase 1, 2, and 3 districts using “total coverage”

strategy

This year, EMAS achieved a “total coverage” strategy whereby all facilities within a district are networked in the referral system via a Perjanjian Kerjasama (PK), provided job aids and linked with SijariEMAS to promote maximum participation in the referral network. Comprehensive PKs have been signed in all districts, meaning that all possible hospitals and puskesmas within those districts – more than 1300 facilities in total – have signed on to a PK. This quarter, meetings were conducted in Tangerang, Kota Semarang, Brebes, Cilacap, Pekalongan, Grobogan, Tuban, Nganjuk, Langkat, Madaling Natal, and Karawang among hospitals included in the PK to monitor progress of the


referral system in the district, share experiences, address barriers and challenges, and update on RTL findings and recommendations related to referrals. EMAS is also introducing cross-regional PKs in some districts where administrative barriers were identified for making referrals across district or provincial lines. This means that facilities in non-EMAS districts will be able to more efficiently refer to EMAS target facilities, and vice-versa. As of Quarter 3, 11 districts now have cross-regional PKs in place. A new cross-regional PK was established this quarter in Gowa district, signed by all DHOs and hospitals from Gowa, Takalar, Makassar, and Jenepono districts. Several other EMAS districts still have cross-regional PKs in the development stage; the time that it takes to finalize and approve the cross-regional PKs varies across districts depending on availability of approvers. Over the past four quarters, most Phase 2 and 3 districts achieved significant improvement in meeting referral system performance standards (Figure 8). All Phase 2 districts have achieved 80% referral performance standards. With the exception of Indramayu, Nganjuk, and Mandaling Natal, all other Phase 3 districts have exceeded the Year 5 target of 80%. Figure 8: Percentage of referral standards achieved by Phase 2, and 3 districts

PHASE 2

91%

73%

96%

92%

94%

99%

90%

92%

94%

75%

87%

92%

85%

89%

95%

99%

88%

92%

95%

95%

84%

94%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Tangerang

Langkat

Labuhan Batu

Kota Semarang

Karawang

Jombang

Gowa

Cilacap

Bulukumba

Brebes

Bogor

Y5Q3 Y4Q4

Target 80 %


Target 80 %

PHASE 3

EMAS has provided technical assistance to districts to implement systematic, district-level maternal and perinatal death audits to better understand the underlying factors contributing to deaths. Nearly all districts are now fully following the 2010 MPA Guidelines, a process which required significant time and effort on behalf of EMAS staff, but that is expected to help increase the frequency at which MPAs are conducted. Tangerang district, for example, continued showing strong commitment to the MPA process, using APBD funds this quarter to audit 100% of maternal deaths and over 25% of neonatal deaths. In Kota Semarang, hospital directors recognized that there was low adherence to the MPA guidelines this quarter, and as a result they held a meeting to identify challenges and reaffirm their commitment to the MPA process. They planned a training activity for the next quarter to refresh ER doctors on maternal and emergency treatment, one of their MPA recommendations. Understanding that their funding for MPAs is limited, the Jombang DHO has allocated funding for MPAs to be routinely conducted every 6 months, wherein the DHO selects cases to review that may have a significant learning impact for all health providers in the district. In North Sumatra, MPAs are conducted more regularly; Labuhan Batu DHO has implemented 4 maternal death audits and 5 newborn death audits, and Langkat has conducted the MPA process for 100% of maternal deaths. In South Sulawesi, LKBK convened a provincial-level meeting for regional and vertical hospitals on reviewing MPA findings. It is expected that the meeting will encourage hospital participation in the district-level MPA process. Figure 9 shows the percent of all maternal and newborn deaths reported and reviewed by the MPA process across Phase 2 and 3 districts. Both Phase 2 and Phase 3 districts improved in the percentage of all maternal deaths reported and reviewed by the MPA process, but decreased in the percentage of newborn deaths audited. EMAS recognizes that newborn MPA audit performance among Phase 2 and 3 districts is much lower than desired. As discussed in prior reports, progress in conducting routine MPAs is often variable by quarter due to district budgeting processes; some districts have only allocated funds for MPAs to be conducted semi-annually, for example. EMAS encourages all districts to conduct AMPs regularly, and while many districts have committed to the

77%

37%

48%

38%

8%

39%

45%

89%

89%

83%

69%

79%

77%

88%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Wajo

Tuban

Pekalongan

Nganjuk

Mandaling Natal

Indramayu

Grobogan

Y5Q3 Y4Q4


MPA process and allocated necessary funding, there are still districts that have not provided the financial support required to carry out the MPA process. Figure 9: Percentage of all maternal and newborn deaths reported and reviewed by the MPA process, Phases 2 and 3

PHASE 2

PHASE 3

2.3 Expand the utilization of SijariEMAS in Phase 1, 2, and 3 districts After having been established in all Phase 1 and 2 districts, SijariEMAS is now being used in all Phase 3 facilities as well, with the exception of a few stand-alone facilities. As district PKs are updated and expanded on a regular basis, additional providers and facilities will be added into SijariEMAS. More than 1400 facilities have been linked with the SijariEMAS system. Utilization of SijariEMAS to facilitate referrals is high in many districts; it 50% or higher in Brebes, Bulukumba, Karawang, and Tangerang in Phase 2, and Indramayu, Nganjuk, Pekalongan, and Wajo in Phase 3. Brebes, Bulukumba, Tangerang, Grobogan, Indramayu, and Pekalongan all demonstrated

71% 71% 61%

71%

19%

39% 20% 14%

Y4 Q4(Maternal)

Y5 Q1(Maternal)

Y5 Q2(Maternal)

Y5 Q3(Maternal)

Y4 Q4(Newborn)

Y5 Q1(Newborn)

Y5 Q2(Newborn)

Y5 Q3(Newborn)

28%

58% 42%

53%

24% 18% 8% 7%

Y4 Q4(Maternal)

Y5 Q1(Maternal)

Y5 Q2(Maternal)

Y5 Q3(Maternal)

Y4 Q4(Newborn)

Y5 Q1(Newborn)

Y5 Q2(Newborn)

Y5 Q3(Newborn)

Maternal Newborn

Maternal Newborn


significant increase in utilization over the previous quarter, thanks to implementation of district-specific strategies to expand SijariEMAS. Figure 10 below shows the district-by-district percent of cases managed using SijariEMAS. SijariEMAS utilization in individual districts may vary from quarter to quarter. There may be multiple reasons for the fluctuation, including that not all call center phone calls are entered into the SijariEMAS system, that a RSUD might see increases in referral from outside of the district, or technical issues. The DHO dashboards are enabling DHOs to be more aware of any issues, and to more rapidly take action. Figure 10: Percentage of Cases Managed Using SijariEMAS in Phase 2, and 3 Hospitals

PHASE 2

82%

0%

42%

17%

72%

28%

33%

40%

58%

61%

41%

61%

36%

46%

50%

76%

40%

22%

50%

38%

18%

40%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Tangerang

Langkat

Labuhan Batu

Kota Semarang

Karawang

Jombang

Gowa

Cilacap

Bulukumba

Brebes

Bogor

Y4 Q4 Y5 Q3


PHASE 3

This quarter, several activities took place to support SijariEMAS utilization across districts. In Tangerang, the DHO clinical team monitored SijariEMAS usage at the puskesmas level during their supportive supervision visits. An EMAS ICT Officer undertook intensive monitoring of the SijariEMAS system in Tangerang to ensure the system could be up and running 24 hours a day, 7 days a week Also in Tangerang, a series of meetings were held between programmers from the Banten PHO and the EMAS team to plan the SijariEMAS handover and sustainability of the system. Cilacap district in Central Java held a workshop on data use, information, and SijariEMAS dashboard utilization for representatives from 3 EMAS hospitals, 7 limited-support hospitals, and EMAS puskesmas. The Nganjuk DHO in East Java created a brochure job aid that describes the steps of using SijariEMAS to refer cases, and distributed this brochure to all hospitals, puskesmas, and IBI. Tuban district in East Java and the North Sumatra PHO both convened meetings this quarter for health providers to evaluate their SijariEMAS experience and address challenges. In West Java, mentors from Bogor partnered with an EMAS replication district, Sukabumi, to conduct a SijariEMAS orientation for two hospitals in the district using APBD funds. 2.4 Build PHO, DHO and hospital capacity to monitor SijariEMAS in Phase 1, 2, and 3 districts This year, EMAS is continuing to build capacity of PHO, DHO, and hospital management to closely monitor and analyze SijariEMAS data using dashboards in place at the DHO. Many DHOs are demonstrating significant commitment to monitoring SijariEMAS by reviewing dashboards on a daily basis. These include Tangerang in Banten, Brebes, Cilacap, Grobogan, Kota Semarang, and Pekalongan in Central Java, Nganjuk and Tuban in East Java, Labuhan Batu in North Sumatra, and Bulukumba in South Sulawesi. Most other districts report using the dashboards weekly or monthly to review the status of referrals. The districts in West Java have not yet started using the SijariEMAS

80%

45%

63%

69%

88%

47%

26%

89%

59%

16%

62%

12%

10%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Wajo

Tuban

Pekalongan

Nganjuk

Indramayu

Grobogan

Mandaling Natal

Y4 Q4 Y5 Q3


dashboard. EMAS will continue to work with DHOs to build their capacity to use dashboard data to monitor referrals. Other progress has been made in terms of monitoring SijariEMAS this quarter. EMAS is very encouraged that DHOs are now becoming more engaged in SijariEMAS and widely promoting its use. The head of the Tangerang DHO presented on the SijariEMAS dashboard during a Pokja meeting this quarter. The Bulukumba DHO uses their dashboard to monitor in real-time all maternal and neonatal emergency cases that are referred to RSUD Bulukumba. In the next quarter, EMAS will highlight these examples in other districts to engage DHOs in SijariEMAS monitoring. 2.5 Integrate SijariEMAS into evolving national systems

This year, EMAS and PUSDATIN are collaborating to integrate SijariEMAS with the SIKDA national system, potentially streamlining data reporting systems into one system. Pilot testing of the SIKDA/SijariEMAS integrated system in Gowa, Tangerang, Deli Serdang, and Karawang continued in Quarter 3. Over the next quarter, EMAS expects to receive feedback from the pilot projects and will share findings in the Quarter 4 report. In the previous quarter, SPGDT has approved EMAS’s proposal to integrate SijariEMAS with SPGDT. EMAS continues to provide inputs and technical assistance to the SPGDT system as it develops. The MOH held a National SPGDT National Launch Event this quarter, where SijariEMAS was prominently featured. The launch event was attended by key stakeholders from across the health system. 2.6 Develop business plan for SijariEMAS sustainability To date, EMAS has encountered or explored a variety of options for transferring ownership and management of SijariEMAS from EMAS to a permanent entity. EMAS has drafted a “business plan” that will outline the options for handing SijariEMAS over to government or private sector entities to maintain and manage SijariEMAS. This quarter, EMAS incorporated feedback from USAID into a finalized business plan draft, and met with PTLs to present the plan internally. 2.7 Update Referral System Technical Guides/Job Aids This year, EMAS is working to update and expand the EMAS technical guides to accommodate variations in districts in terms of how EMAS approaches are implemented. In the previous quarter, EMAS conducted a workshop to update the technical guidelines. Changes included:

• Updating referral mentoring guidelines • Adding best practices in governance, including guidelines for advocating for Bupati

regulations and supporting facilities to meet new health regulations and policies • Adding business plans and sustainability plans for ICT, and mobile application and ICT

mentoring guidelines were updated, and • Updating guidelines for CSOs by Muhammadiyah

This feedback was incorporated, and EMAS originally planned to present the guidelines to the MOH this quarter. However, there was reorganization among MOH staff this quarter, which has delayed


meeting. EMAS advisors will meet with new MOH staff in the next quarter to complete finalization of the guidelines. 2.8 Develop additional referral mentor teams in each district EMAS is working with existing mentors in Phase 2 and 3 districts to convene workshops to prepare additional “champion” DHOs and health facility staff as mentors for PF, PK, SijariEMAS, Pokja, Civic Forum, MPA, and public service monitoring. To date, three referral mentor teams (consisting of 7 people each) have been prepared in all but one district. Wajo district has only one referral mentor team; the other two teams are going to complete training in Quarter 4. The other established referral mentor teams continued to gain experience this quarter as mentors both within their districts and for other districts. For instance, referral mentor teams from Kota Semarang, Cilacap, and Pekalongan districts in Central Java all conducted mentoring in replication districts this quarter using DeKon funding. The referral mentor team from Grobogan district helped establish a total coverage PK in Pati, a replication district. In Gowa district, referral mentor teams helped facilitate the development of a cross-regional PK. The four referral mentor teams from West Java introduced EMAS referral interventions to 5 replication districts this quarter; these trainings were managed by the PHO.

OBJECTIVE 3: STRENGTHENED ACCOUNTABILITY AMONGST GOVERNMENT, THE COMMUNITY AND HEALTH SYSTEM

A. PROGRESS TOWARD YEAR 5 PERFORMANCE MEASURES Table 3: Progress towards Year 5, Objective 3 indicators

Performance Measure End of Year 5

Target

Progress Summary

Phase 2 Phase 3


% of EMAS-supported districts with Pokjas that meet Vanguard criteria

30 Reported in Q2 and Q4

% of EMAS-supported districts with civic forums that meet Vanguard criteria

30 Reported in Q2 and Q4


# of local regulations that are signed in support of MNH

No target 102


B. NARRATIVE DESCRIPTION 3.1 Support Pokja to develop local regulations The Pokjas in all 30 districts have a legal basis to function (via SK) and have proven to play an important role in facilitating change. The role of the Pokja has been to follow-up action plans from audits, facilities/referral assessments, and to respond and follow up to feedback from the civic forum to address gaps that impact MMR and NMR. The Pokja has proven successful in advocating to DPRD to obtain funding for strategic activities and approaches and has been successful in helping to draft SKs to support key district level regulations about MNH priorities (eg. facility deliveries). This quarter, 6 local regulations across 4 provinces were issued, covering a range of topics related to MNH issues. In addition, a number of regulations further institutionalizing EMAS-supported approaches were also finalized this quarter. Highlights of these regulations include:

• Banten: In Tangerang, the Bupati issued a SK to upgrade 5 non-PONED puskesmas to PONED classification.

• Central Java: In Pekalongan, the Bupati issued a SE regarding maternal and neonatal mortality in the district. The Bupati also issued a SK on the establishment of clinical mentor teams and the district referral system.

• North Sumatra: Official letters were issued in Labuhan Batu and Madaling Natal concerning midwife responsibilities and use of DST and SijariEMAS for referrals.

• South Sulawesi: The Bulukumba Bupati issued a SK confirming the updated district mentor list and providing detailed job descriptions for mentors.

In the next quarter, EMAS will continue to support the Pokja to pursue local regulations related to the provision of emergency maternal/newborn services, based on the PK. 3.2 Provide technical assistance to Pokjas at the district and provincial level This year, EMAS is providing technical assistance during quarterly Pokja meetings to ensure that assessment results, audit results, service statistics and action plans are discussed. Through these meetings, EMAS will continue to increase the capacity of the Pokja in monitoring, advocacy, public consultation, planning, budgeting and legal drafting of MNH policy. Table 4 provides an update on the status of Pokja development in each district. Among Phase 2 district Pokjas, only Langkat remains at Stage 2 of development, and the remaining Phase 2 Pokjas have reached the highest stage of development. In Phase 3 districts, Tuban and Madaling Natal reached the second highest stage of development, with the remaining Phase 3 districts achieving the highest stage of development.


Table 4: Status of Pokja development in Phase 2 and 3 districts

ACHIEVED STAGE 1 ACHIEVED STAGE 2 ACHIEVED STAGE 3

Phas

e 2

ALL ACHIEVED Langkat

Tangerang, Brebes, Cilacap, Kota Semarang, Jombang, Labuhan Batu, Bulukumba, Gowa, Bogor, Karawang

Phas

e 3

ALL ACHIEVED Tuban, Madaling Natal Grobogan, Pekalongan,

Nganjuk, Wajo, Indramayu

Strong progress was seen this quarter in the ability of Pokjas to influence budgets, monitor facility data, and follow up on issues identified. For example, in Tangerang district, the Pokja held their quarterly evaluation meeting, attended by hospital directors and Pokja members from professional organizations, BPJS, PMI, FOPKIA, and DHO. DHO presented on overall progress of EMAS in the district, including findings from supporting supervision visits, mentoring, and audits, barriers and challenges, and an update on SijariEMAS data using the dashboard. The group then divided into teams to formulate RTL for the coming quarter. Several East Java districts held “handover” Pokja meetings this quarter, in which they transitioned Pokja management from EMAS to local governments. EMAS staff were present to reemphasize the role of the Pokja in maternal and newborn health, and to discuss Pokja responsibilities after EMAS close-out. The Wajo Pokja in South Sulawesi worked on its sustainability plan this quarter to prepare to transition to local governments after EMAS support ends, and in Bulukumba and Gowa, Bupatis declared their commitment to sustaining Pokjas in those districts after EMAS. The Pokja in Bogor district worked this quarter to finalize a PERDA KIBBLA that paves the way for EMAS activities to be integrated into institutional, financial, and regulatory mechanisms, including mentoring, replication, and M&E. The Pokja also worked on a proposition to ensure all pregnant women in the district have a “free pass” to receive health services in puskesmas or referral sites. Provincial Pokja meetings were held in Banten, East Java, and North Sumatra this quarter. The Banten provincial Pokja held small-group meetings with the PHO to make plans for a provincial mentoring workshop, advocate for a governor decree encouraging facility-based deliveries, and draft a cross-regional PK. The East Java provincial Pokja attended a meeting at the PHO to discuss the provincial action plan after EMAS, and the North Sumatra provincial Pokja met to plan Tim 21 provincial mentoring priorities for the next quarter. Other provinces decided to reschedule provincial Pokja meetings until after the Lebaran holidays. 3.3 Strengthen capacity of the Civic Forums in Phase 1, 2, and 3 districts to monitor maternal and newborn health and advocate for improvements/action


To date, Civic Forums have been developed and supported to serve as a liaison between local government, facilities, and community. In that role, the Civic Forums continue to successfully advocate for and facilitate increased access to hospitals and puskesmas for mothers and newborns. Table 5 provides an update on the status of civic forum development in each district. As of Quarter 3, all Phase 2 districts have reached either Stage 4 (“developing well”), or Stage 5 (“adult”). Phase 3 civic forums are currently in either Stage 3 (“developing”) or Stage 4 (“developing well”). EMAS will continue to support Phase 3 civic forums over the coming months as they work to develop their roles within the community, and will also support them as they begin their transition to be managed through local government. Table 5: Status of civic forum development in Phase 2 and 3 districts

STAGE 1: EMBRYO

STAGE 2: EARLY

DEVELOPMENT

STAGE 3: DEVELOPING

STAGE 4: DEVELOPING

WELL

STAGE 5: ADULT

Phas

e 2

ALL ACHIEVED ALL ACHIEVED ALL ACHIEVED

Kota Semarang, Jombang, Gowa, Bogor, Karawang

Tangerang, Brebes, Cilacap,

Labuhan Batu, Langkat,

Bulukumba

Phas

e 3

ALL ACHIEVED ALL ACHIEVED Tuban,

Madaling Natal, Wajo

Grobogan, Pekalongan,

Nganjuk, Indramayu

A number of civic forums were quite successful this quarter in helping link with civic society, expand public participation and serve as a monitoring body for quality of services. The Tangerang civic forum successfully established FOPKIA in 7 non-EMAS sub-districts, and also conducted recruitment and training for MKIA from those sub-districts. Tuban district successfully established FMM in each sub-district, funded through APBD. The Madaling Natal civic forum conducted a joint monitoring activity with RSUD Panyabungan to obtain and review patient and community feedback regarding RSUD services. The hospital funded this activity using its own budget. In Indramayu, the civic forum worked with the local government to develop a strategic village-level accountability plan to conduct routine monitoring in PONED puskesmas. Other district civic forums worked this quarter to socialize EMAS approaches at the community level, conduct hearings to government officials to advocate for maternal and newborn health activities in replication districts, and establish feedback mechanisms between patients and health facilities.


The Civic Forums also assist in identifying and supporting Motivator Kesehatan Ibu dan Anak (MKIA) in the sub-districts. There are presently over 8,000 MKIAs supporting pregnant women across EMAS districts. 3.4 Promote best practices in public service accountability In Quarter 2, the Ministry of Administrative Reform and Bureaucratic Reform (PANRB) held its annual, national-level competition called National Public Service Innovation (SINOVIK), where Pinrang and Karawang districts were recognized nationally and globally in 2015. The competition provides an opportunity for all public providers from across Indonesia to showcase and demonstrate their innovations. In 2016, three EMAS districts (Tangerang, Cilacap and Sidoarjo) were recipients of the TOP 99 of SINOVIK award to recognize their achievements, chosen from among 2,476 innovations. The innovations submitted include “Rapid, Accurate and Appropriate Outpatient Services in 10 minutes” from Puskesmas Sampang in Cilacap, “Hand in Hand Saving Mothers and Newborns” from Tangerang district, and “SiMaNEis - Sidoarjo Maternal and Neonatal Emergency SMS Gateway” from Sidoarjo district. This quarter, the evaluators awarded the top 35 innovations in the final phase of the competition. Tangerang district was honored as one of these top 35 innovations. The award was presented from the Vice-President of Indonesia to the Bupati of Tangerang.

SUSTAINING EMAS MENTORING APPROACHES 4.1 Prepare PHO teams to organize and coordinate mentoring plans and activities This year, the PHOs are becoming more directly involved in coordinating/facilitating the mentoring process (eg. managing the mentoring schedule, issuing the letters for each mentoring visit, and monitoring the mentoring and following up). This gradual transfer of responsibilities to the PHO enables EMAS to test and demonstrate the feasibility of the PHO tapping into mentoring resources to improve quality and referral systems across the province. Each province is expected to have a different mechanism for managing and coordinating mentoring. Progress has been made across most provinces this quarter. Highlights by province include:

• Banten: The PHO PONED team organized and conducted an on-the-job PONED training for four puskesmas in Tangerang. The PHO allocated IDR 1 billion in its FY2015 budget to replicate the EMAS mentoring mechanism and other approaches in new districts, and IDR 500 million to sustain EMAS activities in EMAS-supported districts.

• Central Java: This quarter, the Central Java PHO developed a mentoring plan to distribute clinical mentor teams across 6 replication districts. The PHO allocated DeKon funding this quarter to support K1 and K2 mentoring for two hospitals and four puskesmas in Kendal regency, a replication district, by Semarang mentors.

• East Java: The East Java PHO has grown more confident in managing their mentoring schedule for EMAS districts and replication districts, assigning seven staff people to coordinate mentoring schedules and agendas for the province.

• North Sumatra: The provincial mentoring team, known as Tim 21, continues to manage the mentoring schedule for North Sumatra districts. The mentoring mechanism SK for the province has not yet been finalized. However, the PHO has allocated DeKon funding to being


mentoring and other EMAS approaches in five replication districts, which will begin in the next quarter.

• West Java: The PHO has now established provincial mentor teams who can conduct mentoring in 22 districts/cities. This mechanism is facilitated by SATGAS. In 5 of these replication areas, local government secretaries have been actively engaged in planning for the mentoring process, and have visited model facilities in EMAS districts.

• South Sulawesi: The mentoring mechanism SK in South Sulawesi has not yet been finalized. It is currently being reviewed by the provincial Pokja. A meeting will be held in the next quarter to facilitate the establishment of a knowledge sharing network for mentors across districts. EMAS will continue to follow up on the progress of the mentoring SK in the next quarter.

4.2 Ensure provincial governments are fully knowledgeable about provincial mentor capacity and best practices EMAS has made a concerted effort this quarter to more actively engage provincial governments in mentoring-related activities. To be able to effectively facilitate mentoring, PHOs need to increase their knowledge about the mentoring resources they can draw upon within their provinces. The Banten provincial mentoring team convened a four-day workshop this quarter for more than 150 champions representing EMAS health facilities, the PHO, as well as replication districts. The workshop objectives included consolidating and organizing provincial mentors, sharing mentoring experiences, introducing EMAS approaches to replication districts, and revising the provincial mentor SK. The Central Java PHO attended the closeout event in Kota Semarang district, where awards were given out to high-performing performing puskesmas and hospitals where mentors have expressed commitment to sustaining the EMAS program in Semarang. East Java PHO held a provincial Pokja meeting to discuss the provincial mentoring action plan and gain commitment from mentors across the EMAS districts. In addition to the events described above, some provinces have held provincial-level mentor recognition and knowledge dissemination events. West, East, and Central Java have already held such events in previous quarters. South Sulawesi plans to hold their provincial recognition event in collaboration with the PHO’s National Health Day celebration in November. Other provinces are still in the planning stages of their events; in some cases, these events may be combined with other provincial health events based on funding or scheduling challenges. The DirJen has instructed non-EMAS MOH priority districts to replicate EMAS approaches using DeKon funds. As of Quarter 3, each province has identified replication districts; in some cases, initial mentoring activities have already started in these districts, and in others, mentoring and other EMAS approaches will be introduced over the coming months. 4.3 Build national commitment to and mechanisms for mentoring While the bulk of activities to coordinate mentoring takes place at the sub-national level, the national MOH also has an important role to play. For example, by helping to support and promote mentoring by provincial governments.


This quarter, EMAS worked with Dirjen Kesmas, Dr. Anung, at the RAKERNAS meeting to discuss the sustainability of the EMAS approaches. EMAS developed TOR and budget inputs for EMAS interventions to be integrated into the DeKon budget. The Dirjen Kesmas also met with EMAS PTLs to discuss recommendations and strategies for EMAS sustainability.

III. MONITORING AND EVALUATION 5.1 Implement strong routine program monitoring This quarter reporting concluded in the majority of Phase 1 and 2 districts with the exception of Tangerang District. Routine monitoring also ended in stand-alone Muhammadiyah hospitals. Going forward, the M&E team will focus on Phase 3 districts and continue routine monitoring for hospital and puskesmas data.

Regular data collection and support activities are ongoing for all phase 3 districts. To ensure the data are useful for giving input program, the M&E team continues to provide a monthly, facility-level clinical dashboard for use at the national provincial, and district team levels. In year five, the clinical team has conducted Skype calls with provinces and districts to discuss their achievement using these data. This activity has supported awareness of the data, which in turn has strengthened its quality.

During this quarter’s M&E workshop, team members were trained on Stata to assist with data analysis efforts.

EMAS online monitoring system Last quarter a district dashboard report was developed for the EMAS online monitoring system to show the progress of priority data elements. Information available on the quarterly report include service statistics, the number of maternal and newborn complications and related deaths, and performance on both clinical and referral standards. The online report was shared this quarter with M&E team members during the quarterly M&E workshops in May and also at a meeting with all of the provincial team leaders in June 2016. To date, the dashboard has been used by district and provincial team leaders to review and share data, e.g. at Pokja meetings. 5.2 Ensure M&E sustainability and exit strategy The M&E team is continuing the development of three video tutorials to support sustainability efforts. The three videos will cover the following topics: (1) how to complete the health center register books; (2) how to complete the hospital register books; and; (3) a tutorial on data use and the data for decision-making posters. The videos will include testimony form stakeholders including the DHO head, hospital director and midwives who work at hospitals and puskesmas. The recorded testimony relates to the benefits of using the standardized registers and also discuss the importance of using data to inform decision-making. This quarter M&E Officers, DTLs and QICs spoke with district and hospital staff to ensure that the planned videos would be useful. Stakeholders were very positive about the videos and noted that the


videos could be used by Mentors and also by the DHO. The latter would use the video to help introduce the registers to new facility and/or new district. 5.3 Conduct EMAS program evaluation The evaluation team presented results from the baseline round of data collection. A slide deck was developed and the same content shared in both English and in Bahasa Indonesia. The presentation was presented in five of the six provinces with district and health facility staff. The presentation will be shared in Banten Province in August 2016. The findings were also shared with USAID. In preparation for the endline data collection, a contract was prepared with Summit Institute for Development (SID). The evaluation team worked with SID to plan data collector training activities for July. Additionally, the evaluation team updated the study field guide, modified the data collection instruments, and updated the study’s ethical approval. 5.4 Conduct EMAS program evaluation: data analysis & results preparation In April, Jhpiego conducted a week-long writing workshop designed to prepare EMAS authors to develop peer-reviewed publications. Coauthors continue to work on three manuscripts started during the EMAS Writing Workshop. Topic areas include the maternal death review, the newborn death review, and a paper describing inputs to strengthen the referral system. The fourth paper, focused on MNH data strengthening efforts, was submitted to the WHO Bulletin and is currently under review.

IV. DISSEMINATION AND DOCUMENTATION 6.1 Document EMAS approaches, results, learning, and successes In Year Four, EMAS developed a plan for documenting key EMAS approaches, results and learning. EMAS is continuing to focus on documenting priorities outlined in the plan and will continue to conduct analyses and case studies to capture key learning for a variety of audiences in Year Five. An important component of the documentation plan for Year Five involves analyzing, writing up and packaging findings from the initial round of data collection from the EMAS Program Evaluation. After last quarter’s Jhpiego-led writing workshop, EMAS authors continued to work on their manuscripts for eventual submission to peer reviewed journal. Further details are described under Activity 5.4. EMAS engaged the services of a consultant to complete the process of documenting replication within and beyond EMAS target areas. This analysis was completed in Quarter 3. The consultant compiled findings into a report, which will be finalized in the next quarter and presented to USAID.


6.2 Engage media and conduct events EMAS is continuing to engage with media outlets in Year Five to draw media attention to MCH issues. Among the publicity generated for EMAS this quarter, the national MOH publication Mediakom published articles on EMAS activities in Central Java in its April issue. The authors, Puskomlik staff, accompanied EMAS staff to several EMAS-supported sites in the previous quarter and wrote about their experiences. EMAS activities were also covered in a Kompas article this quarter; the article discussed the EMAS health innovations that have helped to improve maternal and newborn health services at RSUD Sidoarjo in East Java. Finally, EMAS achievements in Tangerang district were nationally highlighted when Tangerang district was honored as one of Top 35 SINOVIK public innovations competition. Their innovation was chosen from a group of more than 2,400 applicants. The award was presented from the Vice-President of Indonesia to the Bupati of Tangerang. More information on this accomplishment is described under Activity 3.4.

V. IMPLEMENTATION CHALLENGES/ISSUES

• As highlighted in earlier sections, the award for EMAS consortium partner, Muhammadiyah, came to a close at the end of this quarter. Prior to the end of their award, Muhammadiyah noted several facilities (primarily in East Java) where mentoring activities could not be completed as expected. Support and activities required to complete mentoring in these facilities has been subsumed under the workplans of the EMAS provincial and district workplans and included in Jhpiego’s budget. Jhpiego has also contracted (as consultants) former Muhammadiyah staff who worked as Clinical Mentors supporting these facilities to ensure seamless support to these facilities as they complete the mentoring process.

• Interest in replicating EMAS approaches outside of EMAS target area continues to be strong. Meeting these demands frequently require inputs and travel from EMAS staff, who must also focus on achieving targets in Phase 3 districts. Frequently this requires careful consideration to ensure activities in Phase 3 districts are being prioritized while at the same time maintaining momentum for expanding EMAS approaches in new areas.

VI. MANAGEMENT As district offices continue to close out each quarter, EMAS has closely monitored their administrative and financial compliance with USAID and Jhpiego regulations. One of the EMAS consortium partners, Muhammadiyah, also ended activities during Quarter 3. EMAS worked with Muhammadiyah to monitor their final expenses and meet their financial and narrative reporting requirements. A summary of management related highlights include:

• An independent firm conducted an audit of Muhammadiyah’s program expenditures. The auditor questioned some of their cost share documentation and felt it did not sufficiently


meet USAID standards. As a result, insufficiently documented cost share from Muhammadiyah will be replaced from other sources. See Annex B for other potential sources of cost share that EMAS is anticipating over the coming months.

• EMAS has identified approximately 900 administrative and program tasks that need to be completed to successfully close out EMAS activities across 30 districts, 6 provinces, and the Jakarta office. The EMAS team has established a management system to track completion of tasks by province, which is helping to keep EMAS management to stay on track throughout this extremely complex close-out process. Starting in Quarter 4, EMAS will conduct monthly close out meetings with USAID to share progress on meeting all close out requirements.

VII. EMAS COST SHARE The EMAS project has a $9.7 million cost share requirement. Continued progress has been made in documenting and reporting cost share. In total, $317,137 in cost share has been identified, documented and reported through financial systems this quarter. This brings EMAS’s total documented and reported cost share contribution to $10,081,644, surpassing the program’s cost share obligation by $381,644. An additional $2,744,642 million in cost share has already been committed and will gradually convert to actual cost share and be reported in financial systems to USAID as it is spent. Details on cost share recorded during Quarter 3 can be found in Annex B. Adjustments to these amounts, due to findings from the Muhammadiyah audit will be made and reflected in the next quarterly report.


ANNEX A: YEAR 5 PMP

PMP # PMP Indicator Phase 2 Phase 3

1 Percentage of EMAS-supported health facilities that are functioning as Vanguards

Reported in Q2 and Q4 Reported in Q2 and Q4

Overall Score (all facilities)

Vertical hospital

Hospital

Puskesmas

2 Percentage of EmONC standards achieved by EMAS-supported facilities

Num. Den. % Num. Den. %

(1) hospitals achieving 80% of maternal standards

35 38 92% 31 59 53%

(2) hospitals achieving 80% of newborn standards

33 38 87% 19 59 32%

(3) hospitals achieving 80% of IP standards

34 38 89% 30 59 51%

(4) hospitals achieving 80% of clinical governance standards

29 38 76% 16 59 27%



(1) puskesmas achieving 80% of maternal standards

92 96 96% 48 71 68%

(2) puskesmas achieving 80% of IP standards

87 95 92% 45 71 63%

3 Percentage of severe pre-eclampsia/eclampsia cases managed with magnesium sulfate (MgSO4) at EMAS-supported facilities


Overall Score (all facilities) 2,407

2,461

98% 2,190

2,403

91%

Hospital Private 349

365

96% 588

659

89%

Hospital Public 1,491

1,515

98% 1,190

1,323

90%

Puskesmas 567

581

98% 412

421

98%

4 Percentage of deliveries that receive at least one dose of uterotonic postpartum during the third stage of labor at EMAS-supported facilities



22,953

100% 25,976

26,008

100%



Hospital Private 7,869

7,869

100% 12,409

12,415

100%


8,894

100% 9,531

9,556

100%

Puskesmas 6,135

6,190

99% 4,036

4,037

100%

5 Percentage of live births who are breastfed within 1 hour of birth at EMAS-supported facilities



22,913

77% 17,628

25,823

68%

Hospital Private 5,906

7,935

74% 8,586

12,346

70%


8,792

65% 5,127

9,447

54%

Puskesmas 6,067

6,186

98% 3,915

4,030

97%

6 Percentage of women delivering in EMAS-supported hospitals between 24 to 34 weeks gestation who receive one or more doses of antenatal steroids


Overall Score (all hospitals) 934 1022 91% 628 786 80%

Hospital Private 183 221 83% 270 316 85%

Hospital Public 751 801 94% 358 470 76%



7 Percentage of EMAS-supported facilities that conduct regularly scheduled death reviews of fresh stillbirths (intrapartum deaths) > 2000 grams


Overall Score (all facilities) 10 14 71% 15 21 71%


Hospital Public 8 11 73% 11 16 69%

Puskesmas 0 0 no case 0 1 0%

Note: 121 facilities at Phase 2 and 111 facilities at phase 3 did not report a fresh stillbirth > 2000 grams

8 Percentage of EMAS-supported facilities that conduct regularly scheduled death reviews on neonatal deaths > 2000 grams





Puskesmas 3 3 100% 0 0 no case



Note: 103 facilities at Phase 2 and 92 facilities at phase 3 did not report a newborn death > 2000 grams

9 Percentage of EMAS-supported facilities that conduct death reviews on all maternal deaths within 24 hours of occurrence





Puskesmas 2 2 100% 0 0 no case

Note: 112 facilities at Phase 2 and 106 facilities at phase 3 did not report a maternal death

10 Percentage of EMAS-supported hospitals that conduct regularly scheduled near miss reviews




Hospital Public 12 12 100% 10 13 77%

Note: 19 facilities at Phase 2 and 31 facilities at phase 3 did not report a near miss case



11 Obstetric Case Fatality Rate (hospital)

reported annually reported annually

12 Newborn mortality rate (facility)


13 Fresh stillbirth and very early neonatal death rate (hospital)


14 Percentage of referral standards achieved by EMAS-supported referral networks

District # of facilities Score District # of facilities Score

Bandung Phase 2

graduated Grobogan 14 88%

Blitar graduated Indramayu 12 77%

Bogor 13 94% Mandailing Natal 11 79%

Brebes 12 84% Nganjuk 15 69%

Bulukumba 11 95% Pekalongan 12 83%

Cilacap 13 95% Tuban 14 89%

Cirebon Phase 2

graduated Wajo 11 89%

Gowa 11 92%

Jombang 15 88%

Karawang 13 99%

Kota Semarang 16 95%



Labuhan Batu 5 89%

Langkat 8 85%

Pasuruan graduated

Tangerang 26 92%

15 Percentage of EMAS-supported hospital referral cases managed using SijariEMAS

District Num. Den. % District Num. Den. %

*Excludes stand-alone hospitals; limited to EMAS-support hospitals

Blitar graduated Grobogan 790 1691 47%

Bogor 650 1603 41% Indramayu 1865 2120 88%

Brebes 311 507 61% Mandailing Natal 56 214 26%

Bulukumba 161 277 58% Nganjuk 783 1137 69%

Cilacap 480 1207 40% Pekalongan 1099 1742 63%

Gowa 167 499 33% Tuban 643 1415 45%

Jombang 335 1178 28% Wajo 331 414 80%

Karawang 1442 2001 72%

Kota Semarang 160 958 17%

Labuhan Batu 78 272 29%

Langkat 0 84 0%

Pasuruan graduated

Tangerang 910 1105 82%



16 Percentage of referral cases with a hospital response occurring within 10 minutes upon receipt of SijariEMAS notification

District Num. Den. % District Num. Den. %

*Excludes stand-alone hospitals; includes ALL hospitals in a given district

Blitar graduated Grobogan 763 823 93%

Bogor 760 857 89% Indramayu 2,176 2,227 98%

Brebes 1,116 1,414 79% Mandailing Natal 29 92 32%

Bulukumba 105 161 65% Nganjuk 727 828 88%

Cilacap 432 511 85% Pekalongan 993 1,186 84%

Gowa 124 167 74% Tuban 437 563 78%

Jombang 226 344 66% Wajo 264 331 80%

Karawang 1,846 2,024 91%

Kota Semarang 126 176 72%

Labuhan Batu 32 78 41%

Langkat * 0 0

Pasuruan graduated

Tangerang 860 1,480 58%

* Langkat has a techical problem at Sijariemas on this quarter.

17 Percentage of women with severe pre-eclampsia/eclampsia (PE/E) who are referred to EMAS-supported hospitals and who receive at least one dose of magnesium sulfate (MgSO4) before referral


Overall Score (all hospitals) 861 1,402 61% 682 1,112 61%




Hospital Public 806 1,221 66% 533 847 63%

*Excludes stand-alone hospitals

18 Percentage of newborns with suspected severe infection who are referred to EMAS-supported hospitals and who receive at least one dose of antibiotic before referral





*Excludes stand-alone hospitals

19 Percentage of reported maternal and perinatal deaths audited using the Maternal Perinatal Audit (MPA) process in EMAS-supported districts

District Maternal % Neonatal %

District Maternal % Neonatal %

Blitar graduated Grobogan 50% (3/6) 4% (3/79)

Bogor 33% (5/15) 13% (5/38) Indramayu 42% (5/12) 0% 0/70)

Brebes 63% (10/16) 0% (0/64) Mandailing Natal 0% (0/4) 0% (0/21)

Bulukumba 100% (2/2) 85% (11/13)

Nganjuk 100% (3/3) 40% (8/20)

Cilacap 100% (12/12) 0% (0/21) Pekalongan 40% (2/5) 7% (2/29)

Gowa 120% (6/5) 19% (6/32) Tuban 100% (5/5) 5% (3/59)

Jombang 50% (3/6) 5% (2/39) Wajo 100% (1/1) 56% (5/9)

Karawang 32% (6/19) 0% (0/33)



Kota Semarang 69% (9/13) 28% (10/36)

Labuhan Batu 0% (0/3) 0% (0/12)

Langkat no case no case

Pasuruan graduated

Tangerang 132% (25/19) 30% (12/40)

20 Percentage of EMAS-supported districts implementing citizen feedback mechanisms for MNH services

Reported annually Reported annually

21 Percentage of EMAS-supported districts with Vanguard pokjas


22 Percentage of EMAS-supported districts with Vanguard civic forums


*PMP table for Year 5, Quarter 3 includes data from the following: Phase Two: Facility service statistics were collected from 39 hospitals and 96 puskesmas and Clinical standards assessment were collected from 38 hospitals and 96 puskesmas; Phase Three: Facility service statistic were collected from 60 hospitals and 72 puskesmas and Clinical standards assessments were collected from 59 hospitals and 71 puskesmas.


ANNEX B: COST SHARE MATRIX

EMAS Cost Share Report

Activity/Project Description Status

Actual Committed Potential

Name of EMAS activity supported by non-USG funds OR Name of

project/program that contributes to EMAS goals funding with non-

USG funding

Description of the activity/project

Reported and

Recorded as cost share to

USAID

Documentation Being Finalized

Funds committed, but not yet

spent or recorded

Likely cost share, but not

yet been committed

Support to EMAS Workplan Activities

1 Government - Equipment Provision of health equipment for health facility and ICT equipment for Call center $339,050

2 Government - Activities support, study visit, event & Training

Government support and contribute to the success of activities that related with EMAS program implementation on the field

$74,373 $307,061

3 INDOSAT Contribution on Meeting Cost in Activity - socialization MKIA $3,978

4 Health Facility (RSU/RSUD/Puskesmas) - Equipment and Supplies

Provision of Equipment and Supplies in Health facility for EMAS Program $251,002

5 Health Center (Puskesmas) - renovation

Funding the renovation of NICU, etc for Puskesmas in EMAS intervention $4,330


6 IDI Grobogan Support and contribute to the success of activities that related with EMAS program implementation on the field

$1,237

7 RS Panti Rahayu " Yakkum" - Purwodadi, Central Java

Support and contribute to the success of activities on Clinical Mentoring that related with EMAS program implementation on the field

$73

Sub Total $0 $329,705 $651,399 $0

Support to EMAS Program Objectives

8 Government - Replication & Adoption EMAS Model

Scale up of EMAS activities outside of target areas

9 GE Foundation - SMS Bunda

SMS service targeting pregnant women in the ANC and PNC period to expand reach of EMAS to reach mothers in communities directly

$317,137 $653,148

10 BP Berau Ltd - scale up Adopt EMAS program in Puskesmas Babo and RSUD Bintuni - West Papua $41,898

11 UNICEF - scale up Adopt EMAS program in RS Fatimah Makassar - South Sulawesi $45,136

12 BMGF - Family Planning Services Improving or initiating postpartum family planning services in hospitals and puskesmas in MOH priority provinces

$1,270,516

13 Government - Activities support, study visit, event & Training

Government support and contribute to the success of activities that related with EMAS program objective on the field

$127,681

14 AT&T Ideation Workshop that will bring together an array of thought leaders to

$50,000


address maternal and neonatal mortality rates in Indonesia

15 Bill and Melinda Gates Foundation – FP Choices Study $138,794.32

Sub Total $317,137 $45,136 $2,093,243 $188,794.32

Grand Total Year 5, Quarter 3 $317,137 $374,841 $2,744,642 $188,794.32

Grand Total Reported Previously $9,764,507

Total Accumulative to date $10,081,644 $374,841 $2,744,642 $188,794.32


ANNEX C: MEDIA SUMMARY, YEAR 5 QUARTER 3 EMAS was covered by a few different media outlets this quarter, raising awareness of maternal and newborn health issues and what EMAS is doing to address those issues. As mentioned under Activity 6.2, the national MOH publication Mediakom published articles on EMAS activities in Central Java in its April issue. News outlets across Indonesia reported on EMAS achievements in districts closing out, Bupati decrees on MCH topics, and impact of EMAS interventions on maternal and newborn health. A total of 38 articles referencing EMAS were published this quarter. Links to these pieces are listed below. April 2016

“Deliserdang Komit Tekan Angka Kematian Ibu”: http://www.antarasumut.com/berita/156899/deliserdang-komit-tekan-angka-kematian-ibu

“Kabupaten Deli Serdang akan Lanjutkan Program USAID EMAS untuk Menekan Angka Kematian Ibu dan Bayi Baru”: http://journalmonitor.net/2016/04/kabupaten-deli-serdang-akan-lanjutkan-program-usaid-emas-untuk-menekan-angka-kematian-ibu-dan-bayi-baru.html

“Bupati Deli Serdang Apresiasi Bantuan USAID”: http://www.gatra.com/life-

health/sehat/193699-bupati-deli-serdang-apresiasi-bantuan-usaid

“Program EMAS Menaruh Perhatian Besar Kematian Ibu dan Bayi di Kabupaten Asahan”: http://waspada.co.id/sumut/program-emas-menaruh-perhatian-besar-kematian-ibu-dan-bayi-di-kabupaten-asahan/

“Deli Serdang Komit Tekan Angka Kematian Ibu”: http://tabloidpewarta.com/daerah/item/906-deli-serdang-komit-tekan-angka-kematian-ibu

“Menekan Angka Kematian Ibu dan Bayi | Deliserdang Lanjutkan Program USAID EMAS”: http://www.jurnalasia.com/2016/04/05/menekan-angka-kematian-ibu-dan-bayi-deliserdang-lanjutkan-program-usaid-emas/

“Wabup Prihatin Masih Banyak Angka Kematian Ibu Melahirkan”: http://www.radarcirebon.com/wabup-prihatin-masih-banyak-angka-kematian-ibu-melahirkan.html

“Pemkab Tasikmalaya Luncurkan Program Emas”: https://kabarpriangan.co.id/pemkab-tasikmalaya-luncurkan-program-emas/

http://www.antarasumut.com/berita/156899/deliserdang-komit-tekan-angka-kematian-ibu

http://www.antarasumut.com/berita/156899/deliserdang-komit-tekan-angka-kematian-ibu

http://journalmonitor.net/2016/04/kabupaten-deli-serdang-akan-lanjutkan-program-usaid-emas-untuk-menekan-angka-kematian-ibu-dan-bayi-baru.html



http://www.gatra.com/life-health/sehat/193699-bupati-deli-serdang-apresiasi-bantuan-usaid

http://www.gatra.com/life-health/sehat/193699-bupati-deli-serdang-apresiasi-bantuan-usaid

http://waspada.co.id/sumut/program-emas-menaruh-perhatian-besar-kematian-ibu-dan-bayi-di-kabupaten-asahan/

http://waspada.co.id/sumut/program-emas-menaruh-perhatian-besar-kematian-ibu-dan-bayi-di-kabupaten-asahan/

http://tabloidpewarta.com/daerah/item/906-deli-serdang-komit-tekan-angka-kematian-ibu

http://tabloidpewarta.com/daerah/item/906-deli-serdang-komit-tekan-angka-kematian-ibu

http://www.jurnalasia.com/2016/04/05/menekan-angka-kematian-ibu-dan-bayi-deliserdang-lanjutkan-program-usaid-emas/

http://www.jurnalasia.com/2016/04/05/menekan-angka-kematian-ibu-dan-bayi-deliserdang-lanjutkan-program-usaid-emas/

http://www.radarcirebon.com/wabup-prihatin-masih-banyak-angka-kematian-ibu-melahirkan.html

http://www.radarcirebon.com/wabup-prihatin-masih-banyak-angka-kematian-ibu-melahirkan.html

https://kabarpriangan.co.id/pemkab-tasikmalaya-luncurkan-program-emas/

https://kabarpriangan.co.id/pemkab-tasikmalaya-luncurkan-program-emas/


“Bupati Launching Program Sutera Emas”: http://malang.memo-x.com/7926/bupati-

launching-program-sutera-emas/2

"Andi Aslam Patonangi inovator dari Pinrang”: http://inovasi.lan.go.id/index.php?r=post/read&id=679

“Minimalisir Kematian, Call Center 119 Diluncurkan”: http://www.panturanews.com/index.php/panturanews/cetakberita/13348

"Mengurangi Angka Kematian Ibu dan Bayi, Beginiki Caranya”: http://www.wajoterkini.com/2016/04/mengurangi-angka-kematian-ibu-dan-bayi.html

“Dinkes Lakukan Evaluasi Program EMAS”: http://jurnaltangerang.co/berita-dinkes-lakukan-evaluasi-program-emas.html

“Program Emas Dievaluasi Dinkes Kabupaten Tangerang”: http://tangselpos.co.id/2016/04/21/program-emas-dievaluasi-dinkes-kabupaten-tangerang/

May 2016

"Program EMAS Dalam Upaya Penyelamatan Ibu dan Bayi”: http://www.cakrawalamedia.co.id/program-emas-dalam-upaya-penyelamatan-ibu-dan-bayi/

“BUPATI CIREBON LAKUKAN PENCANANGAN GERAKAN PENYELAMATAN IBU DAN BAYI BARU LAHIR”: http://www.cirebonkab.go.id/id_ID/bupati-cirebon-lakukan-pencanangan-gerakan-penyelamatan-ibu-dan-bayi-baru-lahir/

“Dinkes Labura Bentuk Pokja Tekan Angka Kematian Ibu dan Anak”: http://www.metroasahan.com/news/labuhanbatu/2016/05/19/5989/dinkes-labura-bentuk-pokja-tekan-angka-kematian-ibu-dan-anak/

“Hanya Dua Rumah Sakit di Semarang Siapkan Dokter Kandungan 24 Jam”: http://metrosemarang.com/dua-rumah-sakit-semarang-siapkan-dokter-kandungan-24-jam

"Drill emergency Program Emas Puskesmas Poned Cikancung”: https://www.youtube.com/watch?v=O5u9f6ffcBA

“Tekan Angka Kematian Ibu dan Bayi, Dinkes Luncurkan Program Emas”: http://radarbone.fajar.co.id/tekan-angka-kematian-ibu-dan-bayi-dinkes-luncurkan-program-emas/

http://malang.memo-x.com/7926/bupati-launching-program-sutera-emas/2

http://malang.memo-x.com/7926/bupati-launching-program-sutera-emas/2

http://inovasi.lan.go.id/index.php?r=post/read&id=679

http://www.panturanews.com/index.php/panturanews/cetakberita/13348

http://www.wajoterkini.com/2016/04/mengurangi-angka-kematian-ibu-dan-bayi.html

http://jurnaltangerang.co/berita-dinkes-lakukan-evaluasi-program-emas.html

http://jurnaltangerang.co/berita-dinkes-lakukan-evaluasi-program-emas.html

http://tangselpos.co.id/2016/04/21/program-emas-dievaluasi-dinkes-kabupaten-tangerang/

http://tangselpos.co.id/2016/04/21/program-emas-dievaluasi-dinkes-kabupaten-tangerang/

http://www.cakrawalamedia.co.id/program-emas-dalam-upaya-penyelamatan-ibu-dan-bayi/

http://www.cakrawalamedia.co.id/program-emas-dalam-upaya-penyelamatan-ibu-dan-bayi/

http://www.cirebonkab.go.id/id_ID/bupati-cirebon-lakukan-pencanangan-gerakan-penyelamatan-ibu-dan-bayi-baru-lahir/

http://www.cirebonkab.go.id/id_ID/bupati-cirebon-lakukan-pencanangan-gerakan-penyelamatan-ibu-dan-bayi-baru-lahir/

http://www.metroasahan.com/news/labuhanbatu/2016/05/19/5989/dinkes-labura-bentuk-pokja-tekan-angka-kematian-ibu-dan-anak/

http://www.metroasahan.com/news/labuhanbatu/2016/05/19/5989/dinkes-labura-bentuk-pokja-tekan-angka-kematian-ibu-dan-anak/

http://metrosemarang.com/dua-rumah-sakit-semarang-siapkan-dokter-kandungan-24-jam

http://metrosemarang.com/dua-rumah-sakit-semarang-siapkan-dokter-kandungan-24-jam

https://www.youtube.com/watch?v=O5u9f6ffcBA

http://radarbone.fajar.co.id/tekan-angka-kematian-ibu-dan-bayi-dinkes-luncurkan-program-emas/

http://radarbone.fajar.co.id/tekan-angka-kematian-ibu-dan-bayi-dinkes-luncurkan-program-emas/


June 2016

“Program Appasalama’ Selamatkan Ibu dan Anak”: http://beritakotamakassar.fajar.co.id/berita/2016/06/01/program-appasalama-selamatkan-ibu-dan-anak/

“AKI Masih Tinggi, Pemkab Adopsi Program Emas”: http://www.koran-sindo.com/news.php?r=5&n=93&date=2016-06-27

“Bulukumba Canangkan Kelanjutan Program EMAS USAID”: http://www.bulukumbakab.go.id/content/bulukumba-canangkan-kelanjutan-program-emas-usaid

“Brebes Lanjutkan Program Emas Usaid”: http://www.idzapriyanti.com/brebes-lanjutkan-program-emas-usaid/

“Demi Tekan AKI dan AKB, USAID Sosialisasi di Bulukumba”: http://news.rakyatku.com/read/10307/2016/06/23/demi-tekan-aki-dan-akb-usaid-sosialisasi-di-bulukumba

“Sijari Emas, Program Penanganan Kasus Ibu Hamil Hindari Kematian”: http://jateng.tribunnews.com/2016/06/06/sijari-emas-program-penanganan-kasus-ibu-hamil-hindari-kematian

http://sulselnews.com/74/tema-rujukan-ibu-bersalin-bahan-diskusi-usaid-emas-di-bulukumba

“Bulukumba Menuju “Zero” Kematian Ibu Melahirkan”: http://radarselatan.fajar.co.id/2016/06/24/bulukumba-menuju-zero-kematian-ibu-melahirkan/

“Kasdim 1411/Bulukumba Hadiri Pencanangan Keberlanjutan Gerakan Penyelamatan Ibu Bersalin Dan Bayi Baru Lahir”: http://kodim1411.kodam-wirabuana.mil.id/2016/06/28/kasdim-1411bulukumba-hadiri-pencanangan-keberlanjutan-gerakan-penyelamatan-ibu-bersalin-dan-bayi-baru-lahir/

“Brebes Lanjutkan Program Emas Usaid”: http://www.idzapriyanti.com/brebes-lanjutkan-program-emas-usaid/

“Setiap Tahun 500 Lebih Ibu dan Anak Meninggal Saat Persalinan di Sulsel”: http://makassar.tribunnews.com/2016/02/23/setiap-tahun-500-lebih-ibu-dan-anak-meninggal-saat-persalinan-di-sulsel

“Tim EMAS Berkunjung ke Tribun Timur”: http://makassar.tribunnews.com/2016/02/23/tim-emas-berkunjung-ke-tribun-timur

http://beritakotamakassar.fajar.co.id/berita/2016/06/01/program-appasalama-selamatkan-ibu-dan-anak/

http://beritakotamakassar.fajar.co.id/berita/2016/06/01/program-appasalama-selamatkan-ibu-dan-anak/

http://www.koran-sindo.com/news.php?r=5&n=93&date=2016-06-27

http://www.koran-sindo.com/news.php?r=5&n=93&date=2016-06-27

http://www.bulukumbakab.go.id/content/bulukumba-canangkan-kelanjutan-program-emas-usaid

http://www.bulukumbakab.go.id/content/bulukumba-canangkan-kelanjutan-program-emas-usaid

http://www.idzapriyanti.com/brebes-lanjutkan-program-emas-usaid/


http://news.rakyatku.com/read/10307/2016/06/23/demi-tekan-aki-dan-akb-usaid-sosialisasi-di-bulukumba

http://news.rakyatku.com/read/10307/2016/06/23/demi-tekan-aki-dan-akb-usaid-sosialisasi-di-bulukumba

http://jateng.tribunnews.com/2016/06/06/sijari-emas-program-penanganan-kasus-ibu-hamil-hindari-kematian

http://jateng.tribunnews.com/2016/06/06/sijari-emas-program-penanganan-kasus-ibu-hamil-hindari-kematian



http://radarselatan.fajar.co.id/2016/06/24/bulukumba-menuju-zero-kematian-ibu-melahirkan/

http://radarselatan.fajar.co.id/2016/06/24/bulukumba-menuju-zero-kematian-ibu-melahirkan/

http://kodim1411.kodam-wirabuana.mil.id/2016/06/28/kasdim-1411bulukumba-hadiri-pencanangan-keberlanjutan-gerakan-penyelamatan-ibu-bersalin-dan-bayi-baru-lahir/





http://makassar.tribunnews.com/2016/02/23/setiap-tahun-500-lebih-ibu-dan-anak-meninggal-saat-persalinan-di-sulsel

http://makassar.tribunnews.com/2016/02/23/setiap-tahun-500-lebih-ibu-dan-anak-meninggal-saat-persalinan-di-sulsel

http://makassar.tribunnews.com/2016/02/23/tim-emas-berkunjung-ke-tribun-timur


“Tahun 2015, Angka Kematian Ibu Melahirkan di Bulukumba Turun”: http://makassar.tribunnews.com/2016/06/24/tahun-2015-angka-kematian-ibu-melahirkan-di-bulukumba-turun

“Besok, EMAS Bahas Upaya Keselamatan Ibu Hamil dan Anak di Bulukumba”: http://beritabulukumba.com/45502/besok-emas-bahas-upaya-keselamatan-ibu-hamil-dan-anak-di-bulukumba

“Kasus Kematian Ibu dan Anak Merata: Program Emas USAID Berakhir”:

http://berita.suaramerdeka.com/smcetak/kasus-kematian-ibu-dan-anak-merata/

“Program EMAS di Tuban Berakhir”: http://bloktuban.com/berita-read.php/?show=4231-akhir-2016-program-emas-di-tuban-berakhir.html

“Pendampingan I Program EMAS di RSU PKU Muhammadiyah Rogojampi”: http://www.rogojampi.rsmuhammadiyahjatim.com/pendampingan-i-program-emas-di-rsu-pku-muhammadiyah-rogojampi/

http://makassar.tribunnews.com/2016/06/24/tahun-2015-angka-kematian-ibu-melahirkan-di-bulukumba-turun

http://makassar.tribunnews.com/2016/06/24/tahun-2015-angka-kematian-ibu-melahirkan-di-bulukumba-turun

http://beritabulukumba.com/45502/besok-emas-bahas-upaya-keselamatan-ibu-hamil-dan-anak-di-bulukumba

http://beritabulukumba.com/45502/besok-emas-bahas-upaya-keselamatan-ibu-hamil-dan-anak-di-bulukumba

http://berita.suaramerdeka.com/smcetak/kasus-kematian-ibu-dan-anak-merata/

http://bloktuban.com/berita-read.php/?show=4231-akhir-2016-program-emas-di-tuban-berakhir.html

http://bloktuban.com/berita-read.php/?show=4231-akhir-2016-program-emas-di-tuban-berakhir.html

http://www.rogojampi.rsmuhammadiyahjatim.com/pendampingan-i-program-emas-di-rsu-pku-muhammadiyah-rogojampi/

http://www.rogojampi.rsmuhammadiyahjatim.com/pendampingan-i-program-emas-di-rsu-pku-muhammadiyah-rogojampi/


ANNEX D: MATERNAL AND NEWBORN STATISTICS, YEAR 5 QUARTER 3

Phase 2 - Maternal and newborn service statistics (n = 39 hospitals and 96 puskesmas)

EMAS Phase 2 Facilities July - Sept

2015 Oct-Dec

2015 Jan-Mar

2016 Apr-June

2016

Number of women delivering 23755 22,272 21,576 22,953 Number of live births 23543 22,196 21,379 22,913

Number of live births ≥ 2000 grams 22490 21,171 20,413 22,078 Number of stillbirths (IUFD + intrapartum deaths)

534 439

483 368

Number of intrapartum deaths (fresh stillbirth) only

42 41

43 35

Number of intrapartum deaths ≥ 2000 grams 15 27 17 16 Number of newborn deaths 613 509 477 433

Newborn deaths ≥ 2000 grams 223 209 187 165 Newborn deaths < 24 hours and > 2000 grams 60 40 52 36

0-7 days (%) 503 (82%) 433 (85%) 405 (85%) 377 8-28 days (%) 110 (18%) 76 (15%) 72 (15%) 56

Total number of maternal deaths 72 84 72 64 Phase 3 - Maternal and newborn service statistics (n = 60 hospitals and 72 puskesmas)

EMAS Phase 3 Facilities July - Sept 2015

Oct-Dec 2015

Jan-Mar 2016

Apr-June 2016

Number of women delivering 12,349 22,882 20,644 26,008 Number of live births 12,259 22,693 20,485 25,823

Number of live births ≥ 2000 grams 11,847 21,870 19,781 25,005 Number of stillbirths (IUFD + intrapartum deaths)

277 460

460 494

Number of intrapartum deaths (fresh stillbirth) only 28 36 40 38

Number of intrapartum deaths ≥ 2000 grams 15 24 27 22 Number of newborn deaths 277 480 521 533

Newborn deaths ≥ 2000 grams 116 190 206 218 Newborn deaths < 24 hours and > 2000 grams 28 56 74 53

0-7 days (%) (86%) 237 (80%) 383 (77%) 401 420 8-28 days (%) (14%) 40 (20%) 97 (23%) 120 113

Total number of maternal deaths 30 42 59 61

Maternal and Neonatal Survival

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Transcript of Maternal and Neonatal Survival