Stories of Most
Significant Change
from Kinerja USAID
Table of Contents
Introduction ... 2
Summary of Findings ... 4
Study Process ... 6
1. Method ... 6
2. Site and storyteller selection ... 7
3. Identification of domains of change ... 7
4. Story collection ... 7
5. Selection process ... 8
6. Limitations... 9
Most significant changes: stories ... Error! Bookmark not defined. Kabupaten Sambas, West Kalimantan Province ... 10
Kota Singkawang, West Kalimantan ... 15
Probolinggo, East Java ... 20
Introduction
After decentralization, Indonesia has made substantial progress in strengthening local
governments, and has greatly increased local budget resources and service delivery
responsibilities. Local democracy and autonomy have been expanded, and capacity for local
governments in management and governance has been steadily increasing.
However, despite this overall progress, there remain some critical gaps in certain sectors local
government capacity. The health sector is one such area, with local service delivery remaining
weak. Roles and responsibilities are poorly defined; the quality of services at health facilities is
low and unpredictable; outreach services are limited; and health facilities are often poorly
equipped and stocked. These are just some examples of the limitations of public healthcare
provision in twenty-first century Indonesia.
Kinerja was a five-year project from United States Agency for International Development
(USAID). It was funded by the democracy and governance program, and focused on improving
service delivery in five provinces in Indonesia. The program was designed to reduce the gap
between targeted performance and actual performance by testing and replicating governance
interventions that measurably improved performances in the education, health, and business
sectors.
The original program worked in the four provinces of Aceh, West Kalimantan, South Sulawesi,
and East Java from 30 September 2010 to 28 February 2015. A no-cost extension was granted
to a e d the p og a e d s date to “epte
e
5. I Ma h
, Papua P o i e as
added to the program, bringing the total number of provinces assisted to five.
Kinerja was designed to address both the demand and supply sides of local public service
delivery. This was done to avoid stimulating demand without a subsequent local government
response, or alternatively, without providing services that remain unused by the public, while
keeping in mind the critical need to maintain a balance and facilitate successful models of
functioning feedback mechanisms.
Ki e ja s
M&E Framework emphasizes quantifying the measurable differences the project has
made in health, education and business, but it must be acknowledged that this type of
quantification may not offer practical insights into impact and recommended changes.
In recent years, storytelling has emerged as an important component of organizational learning,
and a useful tool for monitoring and evaluation (Dart 2000). In fact, stories are an ideal medium
for development practitioners to help them make sense of the array of program impacts and to
better understand the range of stakeholder values
–
what is important, and why? Taking the
complexity
of Ki e ja s i te e tio s
into account, it is important that time is allocated for the
various stakeholders to enter into meaningful dialogue about what happened in the field, and
whether these experiences represent the outcomes that were expected (Davies and Dart 2005).
Kinerja chose to undertake a study using the MSC approach due to its highly participatory
nature. MSC engages stakeholders not only in collecting but also in analyzing the data. The
methodology allows for the identification of the important changes that a project brings about,
from the viewpoint of beneficiaries who experienced the impact of the project.
However, MSC should not be the sole technique used for producing conclusive opinion for the
overall success of a project. This technique should be seen as complementary to the other
monitoring and evaluation methods. MSC stories are rather a rich source of hypotheses about
how things did or did not work, as well as identifying changes that were unintended or
unexpected.
The study was carried out by Isma Novitasari Yusadiredja and Rika Setiawati in August and
Septmber 2015. The report was developed in coordination with Kate Walton and Andri
Pujikurniawati from Kinerja in December 2015 and published in March 2016.
Thank you to all who were involved and interviewed during the research, and to all Kinerja staff
who participated in the selection of most significant stories.
Fo o e i fo atio , please isit Ki e ja s e site at
http://www.kinerja.or.id
or email
Summary of Findings
The study showed that positive changes can occur in public service delivery when three sets of actors – citizens, service providers, and governments – interact well and work together. By supporting and building the capacity of both the supply side (the government and service providers) and the demand side (the community and service users), Kinerja has shown that the availability, accessibility, and quality of health services can be improved. Improvements can be identified as having occurred by the fact that there are now less complaints from the community about service quality, users are more satisfied, and services are more frequently accessed.
Service providers
The eadi ess of se i e p o ide s to e plo i o ati e tools a d i itiati es i Ki e ja s pa t e dist i ts was identified as a key method of improving services. By being willing to re-assess programs and moving
e o d doi g thi gs as the ha e al a s ee do e , se i e p o ide s ha e sho that s all ha ges
can have big impacts. For example, by genuinely involving both midwifes and traditional birth attendants (TBAs) in midwife-TBA partnerships, the partnerships become much stronger and more women give birth at health facilities, compared with the traditional top-down, government-led style of partnerships. When all partners feel appreciated, listen to, and properly involved, health programs become more likely to succeed and to have a positive impact on health outcomes. Two health centers in West Kalimantan, for example, said that before they had governance-based midwife-TBA partnerships, around 50% of births in their catchment areas had been with TBAs; now, only one or two births per year are assisted by TBAs.
Co u it e e s ide tified fou ke ha ges that o u ed i health e te s follo i g Ki e ja s
program: 1) improved interpersonal relations between patients and health workers; 2) improved availability and adequacy of resources and services, including reduced waiting times; 3) increased comfortability of the health center; and 4) better medical care. Health workers were said to be better listeners and treated the patients more kindly and respectfully, and now tended to give more detailed information on pregnancy, ante-natal care, childbirth, and breastfeeding. Health workers also were perceived to arrive at work on time, and stay later into the afternoon than before. They were also more enthusiastic and worked harder to handle more patients in a day than they used to, which led to shorter waiting times. Many physical changes were also identified by patients as having taken place at the health centers since Kinerja began working there – patients reported that centers were generally cleaner, more comfortable, and better organized. Medical care was also seen to have improved, following the implementation of service standards.
Crucial to all of these changes was the occurence first of a change in thinking. Heads of health centers
a oss Ki e ja s sites said that the had ee huge ha ges i hat the alled thei staff s i dsets.
Since being introduced to principles of good governance such as transparency and public participation,
health e te staff e e ide tified as ha i g e o e illi g age ts of ha ge o e the ealised ho
Governments
The willingness of governments to support service providers in improving healthcare services and in involving community members was also shown to be crucial. By reinforcing existing policies and regulations, and developing new regulations to cover gaps, governments are able to demonstrate to citizens that they are committed to the principles of good governance. When governments genuinely listen to their citizens and commit to fulfilling their rights, problems are more easily identified and service quality improves.
Patients, service providers, and government staff all identified that new local policies and regulations had been central to the improvements they saw at health centers. This was particularly the case for local government-level regulations on immediate and exclusive breastfeeding, which government staff believed acted as a strong push factor to changing policies on breastfeeding at health facilities. Community
Fi all , i Ki e ja s pa t e dist i ts, the e thusias of the o u it has ee ital to se i e
improvement. When acting as an oversight mechanism by joining a community forum (in this case,
Ki e ja s ulti-stakeholder forums), community members are able to push for change by identifying problems, finding solutions, and advocating for fixes. Budgets and plans become more relevant and more capable of solving health issues when the community is involved, and service providers are more likely to follow standard procedures when they are aware that service users know their rights and are capable of demanding them.
Co u it e e s i Ki e ja s pa t e dist i ts epo t elie i g that thei go e e ts o
genuinely listen to them and have realized that services will be better implemented if communities, service providers, and governments work together rather than individually as they used to. Members of multi-stakeholder forums said that they are also able to act as a bridge between service providers and the community, and can solve problems that would previously have gone unresolved because of poor relationships. Many multi-stakeholder forum members also stated that they felt they now have
important roles to play in the community as a conveyer of information from the health centers, and that this was improving health outcomes in areas such as safe delivery and breastfeeding.
Conclusion
The study of the most significant changes coming out of the Kinerja program shows that incorporating and strengthening key good governance principles – transparency, accountability, responsiveness, and public participation – in public service provision has a positive impact. Patients are more aware of their rights; medical professionals are more aware of their responsibilities; and governments are more aware of what is needed to provide high-quality, reliable health care. Over a longer period, these changes will lead to improvements in health outcomes, the beginnings of which can already be seen in many of
Ki e ja s pa t e dist i ts. Th ough good go e a e, less o e a d a ies ill die, o e o e ill
Study Process
1.
Method
The Most Significant Change (MSC) tool was originally designed to involve ten steps of
implementation:
1.
Finding champions and raising interest in using the approach
2.
Establishing domains of change
3.
Defining the reporting period
4.
Collecting stories of change
5.
Reviewing stories within a predetermined structure
6.
Providing stakeholders with feedback about the review process
7.
Putting in place a verification process for the stories collected
8.
Quantifying the data
9.
Conducting secondary analysis
10.
Revising the MSC process
2.
Site and storyteller selection
In consultation with
Ki e ja s staff a d a age e t
, the following sites were identified for
evaluation:
Province District
East Java Probolinggo
Bondowoso
West Kalimantan Sambas
Kota Singkawang
Based on Kinerja
s
MSC study objectives, the stories were collected from a group of
pre-identified types of respondents. In general, the respondents were decided that they should be
stakeholders who had witnessed and/or experienced the situation both before and after
Ki e ja s i te e tio .
The following roles were identified as targets for interviews:
1.
District Health Office staff: Head of the Office, or staff of the MCH department, who had
at least 2 year
s e pe ie e ith Ki e ja.
2.
Community health centre (
puskesmas
) staff: Head of Centre, Head Midwife, or staff
id ife ho had at least ea s e pe ie e ith Ki e ja.
3.
Community members: Pregnant mothers who receive ante-natal care for their current
or recent pregnancies, and had also been pregnant before. The women must have used
the local community health centre for their previous pregnancy or deliver, as well as for
their current or most recent pregnancy or delivery.
4.
Multi Stakeholder Forum (MSF) members: Members who have been active for at least 2
years during the Kinerja assistance period.
5.
Community journalists (CJs): CJs who have been active for at least 2 years during the
Kinerja assistance period and who received training from Kinerja.
3.
Identification of domains of change
Domains of change are general categories that are used to group the stories collected during
the MSC research process. Before grouping the stories into different domains of change, Kinerja
staff and the research consultants decided that the stories would aim to capture and illustrate
changes that occurred on the supply side (that is, the service provider side), with a particular
focus on the community health centres called
puskesmas
. It was expected that the stories
would convey changes in service quality, governance, and community participation.
4.
Story collection
objective stories, as the storytellers were not influenced by the presence of Kinerja staff. To
ensure consistency in the information recorded in different districts, researchers developed and
used common interview guidelines. As previously mentioned, the researchers intended to
collect stories based on three over-arching domains of change:
1.
Changes in quality of public services
2.
Changes in governance
3.
Changes in community participation.
Data collection was done in the aforementioned four sites, and during the process, over 40
stories were collected. After cleaning data, 30 stories were selected from all districts.
Stories were collected using in-depth interviews with selected respondents. Stories were
collected on 10-15 August 2015 in East Java and on 21-26 August 2015 in West Kalimantan.
Each interview lasted around 30 to 45 minutes. When approaching potential participants, the
stud s o je ti es e e e plai ed efo e o se t as e uested to pa ti ipate. If the
consented to be interviewed, participants were also required to give their consent to be
recorded using a digital tape recorder.
Each interview was named with the real name of the storyteller. Real names were also used to
name audio files and transcripts. All notes and audio files are kept by the researchers and the
Kinerja team in password-locked computers, and will be retained for five years from the
beginning of the study. Recorded data and handwritten notes were transcribed and typed into
a word processing program. After transcription, all transcripts were then summarized into short
stories.
5.
Selection process
The stories collected from each district were discussed and the final selections made during a
mini-workshop held on 22 September 2015. Current and former Kinerja staff from East Java,
West Kalimantan, South Sulawesi and Aceh were invited to the workshop; the national office
staff also attended. The workshop was held in order to validate and verify the changes
conveyed in the stories collected.
At the end of the first stage, there were 15 stories from all groups that were considered
significant. These stories represented 5 stories from Sambas, 5 stories from Kota Singkawang, 3
stories from Probolinggo, and 2 stories from Bondowoso. 3 stories were eventually chosen as
most significant: one from Singkawang, one from Sambas, and one from Probolinggo.
6.
Limitations
This study was conducted to shed light on the changes that occurred on the supply side,
focusing on the puskesmas. Therefore, stories outside this scope were not able to be captured.
During the collection phase, some beneficiaries from the community level were very shy and
did not find it easy to tell their stories. Therefore, because participation in the interview is
voluntary, the sample of stories collected may be biased towards the stories of more confident
and outspoken individuals.
Stories of most significant change
This pu li atio does ot i lude all sto ies olle ted du i g Ki e ja s M“C study. Instead, we have
fo used o offe i g a sele tio of sto ies that illust ated hat so e of the p og a s stakeholde s o side ed to e the ost sig ifi a t ha ges o u i g as a esult of Ki e ja s suppo t i West
Kalimantan and East Java provinces.
Kabupaten Sambas, West Kalimantan Province
A Change in Mindset
(Marzini, Head of Semparuk Community Health Centre)
Photo: Marzini, Head of Semparuk Communtiy Health Centre, Sambas.
Marzini is the head of the Semparuk Community Health Centre, one of the 27 government community health centers
(puskesmas) in Sambas District, West
Kalimantan Province. He has been the head of the Semparuk centre since 2014. Previously he was the head of Sungai Kelambu Community Health Centre, also in Sambas. Although he has only been at Semparuk for a bit over one year, Marzini has long known about Kinerja through
his p e ious e t e s i ol e e t ith the
program, and since moving to Semparuk, he has even presented at a number of large events,
including in the provincial capital of Pontianak, on the changes that have taken place at Semparuk since working with Kinerja.
Marzini feels that there have been many positive changes at Semparuk in the last year.
The e t e s staff a e pe fo i g ette a d
service quality is improving. Marzini believes that underlying all this is a change in mindset – that is, a change in how his staff think.
With Ki e ja s suppo t, a eall
significant change that has taken
place at our centre has been a change
in mindset, in thinking. Firstly, we
do t just thi k a out doi g ou
routine tasks anymore; we think of
ou sel es o as age ts of ha ge ,
that we can bring innovations into
the centre and can make it better.
This has been a big change in how we
thi k.
This change in thinking has brought about many improvements at the Semparuk Community Health Centre. Marzini nominated the involvement of all staff in planning as one of the most significant changes. Before, planning was
do e o l the e t e s a age e t tea ;
management to decide on how they want to
i p o e the e t e s pe fo a e a d se i es.
This had led to all staff feeling personally responsible for making improvements.
One example of the improvements made is the physical changes the health centre has undergone. The reception desks and waiting room have been cleaned up and improved, and posters are now displayed on the walls. This makes people more comfortable.
It s like i a hotel, Ma zi i sa s, s ili g. If
people come here and are made to feel comfortable [because of the pleasant atmosphere], they will immediately feel 50%
ette .
These improvements were all suggested by the staff of Semparuk, and were jointly carried out so that everyone played a role.
Marzini believes that another major change in how he and his staff think is that they are now open to receiving feedback from the community. Before Kinerja began working with the centre, staff felt that feedback was not helpful and was more like criticism. Now, there is more willingness to take suggestions and Semparuk health centre has a feedback process. Complaints and suggestions can be made through telephoning the centre, through SMS, in person (face-to-face), or by filling out a complaint form. The centre is committed to receiving and following-up on all feedback as
long as patients follow the proper process for submitting complaints. This information has been provided to the community in order to increase their participation in the system. For example, the centre once received some can know exactly what they are required to do at the centre: register, be seen by a medical what to do. Now, things are much clearer. Marzini explained that the health centre deals with all feedback itself, and tries to solve its own problems. However, if necessary, he also
takes up patie ts o plai ts ith the Dist i t
Health Office to be resolved.
Marzini notes that the community is much more involved in general now, and not just in providing feedback. Kinerja supported the establishment of a Multi-Stakeholder Forum (MSF), made up of community members, and provided training for citizen journalists. At first, the health centre saw the MSF and the citizen journalists as trouble – they seemed to be always trying to find problems. But now, says Marzini, he and his staff have realised that their contribution is actually important, and helps the health centre to improve. They act as a conduit
fo the o u it s aspi atio s a d eeds, a d
ensure there is smooth coordination between the centre and the community. Marzini hopes the MSF and the citizen journalists will continue to be active in the years to come, even after
Now, We Want to Care
(Nurul Fauzah, MSF Sejangkung)
Photo: Nurul Fauzah (left), a member of the MSF in Sejangkung, Sambas.
Nurul Fauzah is a member of the Multi-Stakeholder Forum (MSF) in Sejangkung Sub-District, Sambas Sub-District, West Kalimantan. She has been part of the MSF since 2011. Nurul is also a member of the Community Health Board, a volunteer at the integrated health services post that provides healthcare for mothers and babies, and a volunteer at an early learning centre.
There are 10 members in the Sejangkung MSF, around half of whom are very active. They come from a wide range of backgrounds: the local religious affairs office, blood donation organisations, youth groups, and many more. The members attended multiple types of training from Kinerja, including training on advocacy and writing, before they began regularly attending the local health centre s meetings and monthly mini-workshops.
Nurul sees her role as an MSF member as a way of supporting interactions between the community, the government, and health services.
O e of ou ost i po ta t tasks has ee
about government regulations and policies. You
k o , Oh the egulatio is like this e ause the se i e flo has to e like this. “o e sha e that
information with the community, with our neighbours, our friends, the mothers and
a ies se i e post. We tell the “o the
process at the health centre is like this.. you pay
this to get i su a e.. a d so o . We tell people
that with their health insurance that they should give birth at the health centre, not [with traditional birth attendants], and we tell them
about the importance of breastfeedi g.
Nurul has seen a lot of changes in the community and at the health centre since she
joi ed the M“F. The health e t e s ope i g
hours are now followed, for example, and they
do t ope late o lose ea l . The health e t e
also displays a service flowchart so that patients better understand how to get a checkup. Nurul says that the community itself feels like the health centre has improved a lot – a simple example that has made a difference has been replacing the waiting room chairs with more comfortable ones, so that everyone feels happy while they are waiting to be seen.
Befo e, Nu ul sa s, the o u it did t ha e
sufficient access to information on government policies. For example, when the previous pregnancy insurance scheme was replaced with the national insurance scheme, the MSF was able to explain the changes to the community. Previously, the community may have not received this sort of information.
different stakeholders, the lives of mothers and babies can be saved.
Nurul is happy to be a member of the MSF. She likes working with friends who have the same goals, and feels that their work is more effective when they work together rather than individually. Nurul feels that the MSF has been very successful so far in sharing information that is needed by the community. She feels that she has changed a lot since joining the MSF:
I did t used to pa that u h
attention to pregnant women, for
example. Women would die giving
birth, and we would just say that that
as God s pla f
or them. That was
our understanding of it. But it turns
out that humanity plays a big role [in
what happens to someone], too. So
now,
e a t to a e.
Nurul would like to see the MSF formalised by the government through the legalisation of the
fo u s status. If the a e fo all e og ized
by the government, they will be allocated a small budget to use for their activities. Nurul hopes this can be achieved in the near future.
Photo: The new
(Narti & Eliah, midwives at Semparuk Community Health Centre
)
Photo: One of the midwives at Semparuk Community Health Centre, Sambas.
Narti and Eliah are midwives at Semparuk Community Health Centre in Sambas District.
The the sel es did ot atte d Ki e ja s a ti ities i the egio , e ause the e t e s
management normally attended instead, and later shared the information with other staff. The two midwives believe there were lots of changes that occurred because of the Kinerja program. One was the new style of partnerships between midwives and traditional birth attendants, which was more transparent and participatory than before. Other changes identified by Narti and Eliah as important included the addition of a breastfeeding room; improvements in carrying out immediate initiation of breastfeeding for new-born babies; the pregnancy tracker map; and the complaint system. They also felt that the Multi-Stakeholder Forum (MSF) was an important addition to their sub-district, although they
e e t e ti el su e hat its eal ole as
supposed to be.
pregnant mothers come to the centre for a check-up, they are given a feedback form to fill out. The form includes questions on all parts of their check-up, from the moment they enter the building to the moment they leave. Once filled out, the forms are put into the suggestion box, and the box is opened by the head midwife once a month.
For example:
Semparuk Community Health Centre
once received suggestions asking
them to improve the healthcare
a aila le at the othe s a d a ies
health post (
posyandu
). The requests
wondered if the weighing of babies
birth assisted by traditional birth attendants, who lack proper medical training and equipment. Now, they say, because of the new partnerships between midwives and traditional birth attendants (TBA), more and more women are choosing to give birth at the health centre with the help of a trained midwife.Sometimes, women still want to give birth with
a TBA. Befo e, TBAs used to sa that the had t
called to assist births at homes, which was hard
e ause e ofte ould t i g a lot of
equipment of medicines, but now [they come to
us] a d it s ade a ig diffe e e.
Narti and Eliah say that there have
always been partnerships between
midwives and TBAs in their
sub-Kinerja helped the Semparuk Community Health Centre to hold meetings at the neighbourhood and village levels about the importance of delivering babies in facilities and assisted by midwives. Community members, midwives, and TBAs were all invited. After a number of meetings, memoranda of understanding were signed between midwives and TBAs, and witnessed by village heads. Now, TBAs work as assistants to the midwives, providing non-medical support to delivering mothers and new-born babies. TBAs receive an incentive of Rp.30.000 (US$3) every time they refer a pregnant woman to their midwife partner. According to Narti and Eliah, almost all births in Semparuk are now attended by midwives. The haemorrhage, for example. But if she was giving birth with us [midwives], we know what the
sig s a e. O if the i th as t ad a i g, fo
example, we would know to refer her [to a
We Do t Need to Wait All Day
Ria married in 2011, and had her first child the following year. Her ante-natal care for both pregnancies has been from the Semparuk Community Health Centre. She remembers having her blood pressure checked, her height
a d eight easu ed, a d he a s hea t
beat checked. The centre also gave her vitamins and iron tablets to take, and milk to drink. The midwives also advised her to get enough rest there used to be. The staff are even present at 8
o lo k i the o i g, he efo e the e as
nobody. The centre is also cleaner than before. For Ria, the most important change has been Community Health Centre, located in Singkawang City, West Kalimantan, has been working there for 25 years. She says she has noticed a number of important changes since Kinerja began supporting the health centre. The smaller changes include the addition of a breastfeeding room at the centre, and extra focus by the staff on performing immediate breastfeeding after births and on supporting exclusive breastfeeding.
But she believes that one of the most significant changes has been that patients are now more Singkawang to develop better understanding of patient rights, staff used to separate mothers and babies immediately after delivery. The women just used to accept this and not question it, because they assumed that what the midwife was doing was best practice and
But now, through awareness raising programs and promotional materials such as posters, she says the women in North Singkawang now request not to be separated from their babies because it is their right to be together.
The head midwife considers this to be the most significant change at North Singkawang Community Health Centre since Kinerja began supporting them.
We as
id i es, as se i e
providers,
need
to
be
more
introspective.
We need to learn where
our deficiencies are, and how we can
improve the quality [of our services],
too.
To Save Lives
(Hatijah, Yeti, Alusia, Waldi, and Mayuri – members of various MSFs in Singkawang)
These five MSF members – three women and two men – had just finished disseminating the results of a satisfaction survey when they were interviewed. They told the team that they were members of different sub-district level MSFs, from North Singkawang, South Singkawang, and West Singkawang, and that four of them had
Each of the five MSF members were also active in other social welfare activities, such as the
Dist i t “o ial Welfa e Offi e s Co u it
Social Workers program, where they became used to talking to the community and sharing information. They are happy to now be working on issues of maternal and child health in addition to the topics they previously covered, such as HIV/AIDS, tuberculosis, and domestic violence.
Hatijah, Yeti, Alusia, Waldi, and Mayuri stated that they had seen a number of positive changes in their communities and at their community health centres since Kinerja began working in Singkawang. The centres have all developed service improvement charters, with detailed promises on how they will improve staff performance and healthcare quality. For example, the MSF members note that now the staff are more friendly than before, and that there are clear service flowcharts on display, so that all patients know where to go and what to do. The centres have also improved physically, with more chairs in the waiting rooms and more-organised reception areas.
The MSFs in Singkawang have also
helped to spread information to the
community. Mayuri and Yeti say that
patients were previously sometimes
tricked by staff about how much they
needed to pay, whereas now there is
a clear service flowchart and a
transparent fee list. The MSFs have
ensure this information is displayed
at the health centres.
now understand how and when patients are to be referred to the hospital.
Hatijah notes that there has also been an
i ease i people s k o ledge of
breastfeeding, especially on the importance of exclusive breastfeeding. She tells a story of how she successfully encouraged one mother to overcome her fears of breastfeeding and to try it with her first child. Hatijah explained to the
with regards to breastfeeding but also in terms of maternal health more generally. She says she once succeeding in convincing a man to take better care of his pregnant wife, who had previously miscarried and was worried about losing the pregnancy. During her first believes that he really had no idea that women should not perform heavy physical work during pregnancy. Following their intervention, the man no longer lets his wife work in the fields, and she is now happily seven months pregnant.
Alusia otes that if she as t a e e of the
MSF, she would never have given such information to people before. She feels empowered now.
All of the five MSF members agree that knowledge is incredibly important. They each strive to build their own knowledge so that they can share it with their local communities, which they have recently started doing through a door-to-door awareness raising program.
Each person identifies a different change as the one they considered most significant. Mayuri selects the fact that the MSF can access information that was previously unavailable or hard to access (such as a list of fees) as most significant. Yeti thinks that the creation and display of the patient referral procedure was most important, but also nominates the District
Health Offi e s suppo t fo the M“F as a
significant development. Waldi agrees.
Alusia picks her own improvement of maternal and child health knowledge as the most significant change for her. She can now explain the importance of things like delivering in a health facility to members of her community, and feels this brings big benefits. Hatijah agrees, saying that her knowledge has also grown, and she likes being able to share that with others. When asked why they had chosen these changes as the most significant, Hatijah
i ediatel espo ds: Be ause the sa e li es! What else ould e the easo ? The
others smile in agreement.
Communication between Health
Professionals and Patients
(Sri Sumiati, Head of North Singkawang Community Health Centre)
Photo: Some of the staff at North Singkawang Community Health Centre.
Sri Sumiati is the Head of North Singkawang Community Health Centre in Singkawang City. She has been head since April 2015, and was previously the head of West Singkawang Community Health Centre (2013-2015). She has been involved with Kinerja at both centres. One of the biggest changes Sri Sumiati has seen since working with Kinerja has been the impact of developing and signing service charters. These service charters are created based on feedback fielded from community members during a complaint survey, and are made up of a number of specific promises for Staff are also arriving at work earlier and leaving later – average work hours were from 9am to 12pm, but now most staff arrive at 8am and leave around 1.30pm. This means more patients can be seen and waiting times are decreased.
Befo e Ki e ja s suppo t, West “i gka a g
Community Health Centre did not have many patients. Sri nominates a few reasons as to why this may have been the case: the staff were rude and unfriendly, and the waiting rooms and inspection rooms were uncomfortable and unclean. But after the service charter was
Sri thinks the existence of the multi-stakeholder forum (MSF) is one of the biggest influencing factors. The MSF frequently passes on complaints and feedback from the community to the health centre.
Exclusive Breastfeeding
(Muwati, staff member in Maternal and Child Health Section, District Health Office,
Singkawang City)
Muwati works in the maternal and child health section of the District Health Office in Singkawang City. She has taken part in a number of Kinerja-supported activities, and is keen to talk about the changes she has witnessed in Singkawang.
In addition to supporting safe delivery, Kinerja also supports immediate and exclusive breastfeeding. Muwati says that Kinerja helped
the it s go e e t de elop a egulatio that
encourages women to breastfeed and requires offices and other places of work to provide breastfeeding rooms. With a government regulation in place, the District Health Office and other departments now work much harder
to suppo t the it s othe s a d e su e thei
children grow strong and healthy.
Muwati also nominates the establishment of the city and sub-district MSFs as a positive change. She explains that the MSF members are representatives of all the different groups in the city and sub-districts. Muwati thinks that the health staff at the community health centres appreciate the help the MSF gives them, and likes that the MSF assist them in sharing information with the community. It makes their work easier, Muwati explains, especially because a lot of awareness raising activities used to fall on the shoulders of the village midwives, who were already very busy and overburdened. Now, with the MSFs, there is a much smoother two-way flow of information, and relationships between the community and the health centres have become stronger – midwives can pass important information on to community members, while community
members can easily give feedback and make suggestions for improvement.
According to Muwati, the MSFs also help from a social work aspect. For example, if there is a patient who needs medical assistance, MSF members often take them to the health centre themselves. Or when a blood donor is needed, MSF members frequently offer to donate themselves or to find someone with the correct bloodtype. This greatly helps the health centres. The MSFs of the three sub-districts supported
But, after considering everything, Muwati still nominates the establishment of the pro-breastfeeding government regulation as the most significant change. For example, she says
that id i es p e iousl did t ha e suffi ie t
knowledge of immediate initiation of breastfeeding – maybe they did when the graduated, she says, but since then, perhaps they have forgotten. Now, after being assisted by Kinerja, the quality and rates of immediate breastfeeding have improved throughout Singkawang. The minimum period for immediate breastfeeding is now one hour; previously, it was just half an hour.
Probolinggo, East Java
The Contribution of the Community
(Dr Wahyu, Head of Sumberasih Community Health Centre)
Photo: The new fingerprint registration system at work at Sumberasih Community Health
Centre, Probolinggo.
Although Dr Wahyu has only been the head of Sumberasih Community Health Centre for a little more than one year, he has noticed many things that are different at Sumberasih if he compares it to the health centre he worked at previously. The service quality is better, and the community is more involved at Sumberasih. He
puts this do to Ki e ja s suppo t; his last
three months, the centre holds a meeting with health volunteers and the local multi-stakeholder forum (MSF) to discuss problems and receive input from community members. He says the MSF acts as a bridge between the health centre and the community, because they support a two-way flow of information.
The MSF at Sumberasih also helped carry out a complaint survey in the local community. The survey aimed to get feedback regarding the performance of the health centre and on the general health status of the community. Dr
Wah u app e iates the M“F s o t i utio i
running the survey, and says that his staff did t
feel at hed o i estigated at all:
Fo e, I see the M“F s a ti e ole as
a positi e o e. We do t feel judged!
We are actually happy to receive their
suggestio s. The a e t like
some
NGOs that just try to find problems or
mistakes a
ll the ti e.
One of the big changes that occurred after the implementation of the complaint survey was the establishment of a fingerprint registration
s ste at the e t e s e eptio desk. Patie ts centre since the complaint survey. Patients are now better aware of their rights and of what services they are supposed to receive.
Dr Wahyu elie es that Ki e ja s assista e has also helped his health centre improve its staff performance. They now have a Manager on Duty position, which is rotated between staff, to ensure that the services the centre provides run smoothly and are the best they can be.
E e F ida , D Wah u u s a edi al staff lass he e staff sha e thei k o ledge ith
policies, and programs. Once a week, the centre
also holds a joi t efle tio da , he e staff
reflect on their recent experiences and share inspiring and motivating stories.
The impact of these changes on maternal health outcomes has been notable, says Dr Wahyu.
Al ost all o e i the e t e s at h e t
area now come for antenatal care – a significant achievement. The percentage of births that take place at the centre and that are assisted by midwives continues to increase year on year, and the percentage of births assisted by traditional birth attendants is falling.
Overall, Dr Wahyu says that the most significant change at Sumberasih Community Health Centre is the increased involvement of the
o u it . He e plai s that the M“F s o k has had e t ao di a i pa t o the e t e s
performance and achievements, to the extent that he now cannot imagine working without the MSF.
Thumbs Up for Fast Service
(Haji Syukron, member of MSF Sumberasih)
Photo: The thu s up a er at Su erasih
Community Health Centre, Probolinggo.
Haji Syukron has been involved in the multi-stakeholder forum (MSF) in Sumberasih
sub-district since 2012, but has been most active since he retired from the District Education Office in 2013. He says there have been a lot of positive changes in the area since the MSF was established.
According to Haji Syukron, the MSF work as a bridge between the community and relevant government institutions such as the District Health Office. Since receiving training on how to advocate for change, Haji Syukron says he and
the district level MSF, and it turns out
health e t e s se i es. Whe the M“F a d the
health centre carried out the complaint survey, they received many complaints about long waiting times, for example. The health centre responded to this by installing a fingerprint registration system at the reception desk. Since then, Haji Syukron says that neither he nor the MSF have received any more complaints about waiting times. He also notes that the staff at Sumberasih seem to have become more friendly, and explain information much better to patients than they used to.
Haji Syukron chooses the improvement in health centre services as the most significant change. The fingerprint registration system has greatly reduced waiting times and patients are very satisfied with the services now.
Yes, thu s up, the se i e is fast. It s eall ee felt the o u it .
Photo: The fingerprint system in use at Sumberasih.
Bondowoso, East Java
Mums for Reproductive Health
(Dr Titik, Head of Family Health Division at the District Health Office, Bondowoso)
One of the most interesting changes for Dr Titik has been the development of service charters at each health centre. 14 health centres in Bondowoso now have their own service charters, where they promise to make certain improvements in the following year. The service charters are developed based on complaints received from the community during a complaint survey. Dr Titik notes that the service charters are useful because they make the health centres implement complaint mechanisms, which are actually required to gain government accreditation. Dr Titik says that
although it s a atio al e ui e e t to ha e
complaint mechanisms in place at all health centres, many people do not remember this, so Kinerja has helped them make complaints a central part of their work.
Another change regarded as important by Dr Titik has been the creation of two new government-supported roles: Umi Persamida
and Bunda Kespro. Umi Persamida acts as a role
model for women and encourages them to give birth at facilities and to breastfeed. Bunda
Kesp o a e Mu s fo ‘ep odu ti e Health ,
References and other sources
Dart, J.J. 2000. Stories for Change: A Systematic Approach to Participatory Monitoring. Proceedings of Action Reseach and Process Management (ALARPM) and Participatory Action-Research (PAR) World Conference. Ballarat, Australia.
Davies, R. and Dart, J. 2005. The Most “ig ifi a t Cha ge Te h i ue: A Guide to Its Use. Kinerja. 2014. Tata Kelola Inisiasi Menyusu Dini dan ASI Eksklusif [module].
http://www.kinerja.or.id/pdf/889f4355-4828-4272-9612-e02d8d5e68eb.pdf
Kinerja. 2014. Tata Kelola Persalinan Aman [module].
http://www.kinerja.or.id/pdf/b583809b-15bf-40b3-9702-1f00804fa7f3.pdf
Kinerja. 2015. Berbagi Praktik Baik Tata Kelola Kesehatan.
