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AREA OF WORK:
CHILD AND ADOLESCENT HEALTH 1
Country Issues and Challenges :
In Indonesia, health and other services in general are more and more
starting to respond to the needs and demands of most adolescents. A number
of projects and programs, supported by the government with or without donor
assistance, have been in place for some time but most of them focus only on
a limited number of issues relevant for adolescents and not on their overall need.
The 2004 - 05 focus of the project will be to support the further development of
national and sub-national adolescent health strategies and their implementation
including the need for coordination between partners, the access and quality of
adolescent friendly health services in the context of a more "public friendly" approach
and the access for adolescents to reliable and relevant information on which the adolescent
can base her or his decisions.
Expected Contribution :
- Planning and technical guidelines, especially for the district level, to improve
the health of adolescents based on a national Adolescent Health Strategy.
CHILD AND ADOLESCENT HEALTH 2
Country Issues and Challenges :
Indonesia still has relatively high infant and under-five mortality rates with
very high rates in a limited number of districts. The problems encountered in the
neonatal period and the impact of infectious diseases, especially pneumonia, malaria
and diarrhoea, compounded by nutritional problems, contribute to more than 80% of the
child mortality. IMCI, introduced by WHO in 1995, is being adopted and used by many
districts and provinces. Most of the technical guidelines needed for IMCI including
planning guides, are developed and used although some should be improved especially those
that deal with newborn health. There is a need to reconcile the limitations of the current
IMCI approach with the overall need of all children (sick and healthy). There is also a need
to start looking at ways to reduce the national infant and child mortality rates by targeting
geographical areas where these rates are highest and by targeting, together with other health
programs such as maternal health, neonatal mortality.
The focus of the 2004 - 05 work plan will be the challenge to develop overall district
strategies for child health in line with a national child health policy: The implementation
of comprehensive and integrated child health interventions, the improvement of existing tools
and the development of tools to assist the change of focus on the sick child to the overall
health of the child. This will be achieved by adhering to the principles of the IMCI approach
(the roles of the family/community level, improving health workers skills and the health systems
needed for child health) including the important issue of nutrition, particularly breast feeding,
and to the relevant articles of the Convention of the Rights of the Child (CRC). In addition it
will attempt to "map" and assist geographical areas where child health interventions may have the
greatest impact on child mortality.
Expected Contribution :
- A more comprehensive approach in line with the CRC, to child health, especially at the
district level, that includes all the three components of the integrated management of childhood
illness, the neonatal period and nutritional issues such as breastfeeding. This Expected
Contribution, although under Global Expected Result (GER) CAH 3.1.3, will also greatly contribute
to GER's CAH 3.1.1 (CRC), CAH 3.1.4 (neonatal health) and NUT 4.2.4 (malnutrition/nutrition).
RESEARCH AND PROGRAM DEVELOPMENT IN REPRODUCTIVE
HEALTH
Country Issues and Challenges :
WHO estimates, reproductive ill-health accounts for 33% of the total disease burden
in women as compared to 12.3% for males of the same age. Every year around 4.500.000 are
giving birth in Indonesia and around 15.000 develop complications, which lead to their death.
The number of neonatal deaths can be estimated around 120.000. From different researches it
is reported that malnutrition and anaemia, adolescent fertility and pregnancies with associate
risks, the rising incidence of STDs and HIV/AIDS, malaria in pregnancy and abortion complication
are issues that deserve further studies to better understand their implication and contribution
to the high number of maternal and neonatal deaths in Indonesia.
In some provinces (as North Maluku, West Timor, Sumatera Barat) the incidence of Malaria in
pregnancy and congenital malaria is very high and there is urgent need of a sounded policy
and strategy development.
With the very high number of SB reported in some provinces as Sumatra Barat , Jawa Tengah,
Kalimatan Timur it is compelled to have more information on the possible causes of IUD, syphilis
is one of them and a policy related to STI/HIV has to be the next step.
The very low rate of births attended by skilled personnel is one of the challenges for the
maternal and neonatal care system that has posted thousands of midwives in the villages of Indonesia.
To understand what keeps the women out of reach of the skilled personnel requires proper investigation
to be able to tackle the problem from the root.
The first step to reach political involvement is to convince the policy maker with sound
data that proper action has to be taken.
Expected Contribution :
- Technical support provided to MOH for the development of policy and strategy to prevent
malaria in pregnancy and congenital malaria, HIV vertical transmission and syphilis in pregnancy
and to establish some priority researches in MPS area and in implementing evidence-based standards
and policy to reduce maternal and neonatal mortality and morbidity.
MAKING PREGNANCY SAFER
Country Issues and Challenges :
The improvement of the maternal and neonatal health in Indonesia is one of the MOH commitments
through the implementation of the Strategy for the Reduction of the Maternal and Neonatal Mortality
and Morbidity. After Indonesia has made important investments in the development of basic
infrastructure and human resources for a comprehensive Primary Health Care delivery system, the
indicators have not shown the expected positive results. Despite progress among other socio-economical
indicators Maternal and Neonatal Mortality are still very high with estimated 334 deaths /100.000 live
births -Sisterhood method 1997- and Neonatal mortality rate of 25/1000.
Indicators reveal problem that have to be faced: while the first antenatal visit covers 90% of
the pregnant mothers, only 60% of the deliveries are attended by skilled personnel. Up to now
acceptance, access and utilization of basic and Complete emergency delivery care hinge both upon
a range of economical, behavioral, social, cultural and women's and men ability and knowledge to
decide if and where to seek care. The cause of this can varies from financial constrains, to lack
of confidence in a service that shows need of big improvement as the time referral in emergency
situation is still an issue in many districts, perinatal care is not responding to requisite of
quality and low is the understanding of the importance of birth preparedness: situation that
increase the risk of associated maternal and perinatal mortality and morbidity.
The experience of the feasibility and sustainability of regular, formative and supportive
supervision by and to the different level of the service has shown very difficult implementation
and, poor or no result. The supervision is an expensive exercise, it needs good trained and
dedicated people, it has to be regular, it has to give feed back, it has to produce result and
actions that are expected to be taken by both side the supervisor's and the supervised. Different
approaches have been experimented to improve the managerial and clinical quality of care; one
of them stresses the capacity of the health personnel to learn from its own error and limitation.
Making use of the experiences gained in other countries and to improve the local understanding and
proper use of the audit of Maternal and Neonatal Mortality there is need to better follow up its
utilization. Its proper application is the first step for the health staff to become actors and
responsible of its own improvement and to advocate and give advise to managers for changes that
will improve the service to the clients.
The same concept of improvement of the service through self and team monitoring and evaluation,
stays behind the support of implementation of the "Clinical Performance and Management system",
tool that need to be improved and redefined if to be introduced in a bigger scale in other
Provinces and Districts and in the pre service training.
The national Policy stated that: all deliveries should be assisted by trained Health staff;
meanwhile during a transitional period the partnership between TBA and Village midwives (BDD)
is highly encouraged. Following the issuance of Permenkes no 900 the legal authority of midwife
in assisting complicated deliveries is much broader and for the years 2010 all the BDD should
be equipped and trained to assist complicated deliveries and to be able to resuscitate and care
properly for the newborn. The many in service training seminars conducted and going on in the
country seems not having had a big impact in the quality of the obstetric services up to now
and surely they are not showing any contribution toward the decrease in the number of maternal
and neonatal deaths. To Contribute meaningfully to a continuous and sustainable improvement of
the quality of services, an important decision has to be made: a long term, permanent and
coordinated intervention has to be priorities to achieve a better and long lasting improvement
in the quality of care offered to the pregnant mothers and their babies. The decision cannot be
easy for many and different reason, but the improvement of the pre service training, has shown
in many countries to be the right option. A good quality pre-service training can be obtained
only following precise steps that start with the development of close coordination among different
ministries responsible of the MCH staff education. Positive outcomes will result from different
intervention: curricula updated and tailored to the needs of the country, serious deontological,
theoretical and practical training of midwifery teachers, serious deontological, theoretical and
practical training of the midwifery students, strict selection criteria to be admitted into the
Academy. The Midwifery Academies have to be a high standard school institutions, the training sites
have to be place where the workload is sufficient and the best quality services can be demonstrated
and coached. Great is the responsibility of the policy makers and the technical experts: taking the
right decisions is a big challenge and since a standard model has to be redesigned some government
institutions have to be supported to initiate and implement such a model in the next biennium. The
existing 117 midwifery Academy (46 MOH, 58 private, 12 owned by local government, 1 by the Army)
are a huge task to be monitored and to be properly quality controlled, surely new school will ask
to be accredit Ted for such a reason a sound intervention in this area is a must.
Expected Contribution :
- Assist MOH to provide and to strengthen capacity for maternal and neonatal quality
health service delivery at Central, Provincial and District level, in pre-service midwifery
education and strengthening coordination within MOH professional organizations and partners
for MPS planning, implementation monitoring and evaluation.
HIV/AIDS
Country Issues and Challenges :
As has been identified in the WHO SEAR strategic framework, in spite of efforts underway,
there are still many challenges. These include, among others, scaling up of successful prevention
interventions, increasing awareness of HIV/AIDS in the community, overcoming some of the biggest
obstacles to an effective response such as denial, blame, complacency and stigma, and providing
voluntary counseling and testing services, as well as care and support for those already affected.
Expected Contribution :
- Technical assistance provided for prevention of sexual transmission of HIV by strengthening of STI prevention and care.
- Technical Assistance provided for prevention of transmission of HIV through blood by
prevention of HIV among Injecting Drug users; and ensuring safe skin piercing practices at
health care settings (including protection for health care workers).
- Technical Assistance provided for strengthened Comprehensive care and support
including VCT; treatment of HIV/AIDS related diseases; and improving access to ART.
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