1. Reducing Maternal and Neonatal Mortality in the District Hospital through the Best Practices Implementation Package (Comprehensive Emergency Obstetrics and Neonatal Care) Jaringan Nasional Pelatihan Klinik ( National Clinical Training Network ) The Association of Indonesian Health Professional Training Units Indonesian Ministry of Health Directorate of Medical Services

2. Purpose Comprehensive Emergency Obstetrics and Neonatal Care (CEONC) designed for Improving Emergency Obstetrics and Neonatal Care in the Referral Hospital CEONC might reduce hospital MMR & NMR, but the challenges are: – Different priority setting between National and Local Government Health Program (decentralization system) – About 40% of maternal and neonatal death occurred in hospitals – CEONC was not established in all public hospitals – Only 15% of rural and 32% of urban emergency referral cases treated adequately in hospitals MOH-Directorate General of Community Health, 2007 – Only 32% of hospitals are practicing AMTSL. USAID/Prevention of Postpartum Hemorrhage Initiative (POPPHI), Active Management of Third Stage of Labor Report, August-September 2006

3. Implementing CEONC in District Referral Hospital – JNPK-ESD endorsed by MOH-Directorate of Medical Services to implement CEONC in Tangerang District Hospitals. JNPK-ESD Collaboration on CEONC Implementation, 2008 – CEONC adapted and refined from ALARM (Canadian RCOG) and Basic Neonatal Care (HSP-USAID) by Professional Organizations-MOH – Although entitled Emergency Care, the package also entailed preventive measures (i.e., Infection Prevention, Partograph, AMSTL, IBF, KMC, Neonatal Immunization, Postpartum Family Planning, etc.) – Conducted within MOH Health Delivery System and accommodate Local Government Autonomy Regulation in collaboration with Tangerang Hospital and District Health Office-Family Health and Health Service Section Total budget: US $ 38,500 – 2008/09: US $ 27,350 – 2009/10: US $ 11,150

4. Progress Success in meeting objective – Twenty hospital staffs (3 ob-gyns, 2 pediatricians, 9 midwives, 6 nurses) certified as competent providers and trainers in CEONC – Four health centers certified for BEONC and 40 community midwives certified for LSS – Established collaborative monitoring and supervision program DHO-Hospital-Health Centers – Results Initial CEONC input (62%) & performance (67%) improved to 90% & 93% (maternal) and from 67% & 62% to 90% & 88% (neonatal) Mid-term Maternal Death reduced from 32/2998 to 12/3503 live-birth (Hospital MMR reduced from 800 to 300/100,000 live-birth) Midterm Perinatal Death (stillbirth and early neonatal death) reduced from 85 (34 and 52)/2998 live-birth to 49 (25 and 24)/3503 live-birth (Hospital PMR reduced from 42 to 20/1000 live-birth) Annual Maternal Death: 52/5002 (2008) reduced to 29/7018 live-birth (2009) or MMR reduced from 800 to 300/100,000 live-birth and Perinatal Death: 122 (47 and 65)/5002 (2008) reduced to 87 (36 and 51)/7018 live-birth (2009) or PMR reduced from 30 to 16/1000 live-birth

5. Progress Success in meeting objective – Refined CEONC existing packages and adaptation of learning process (in-house instead of training institution-based) – Established Standard CEONC in Tangerang Hospital (i.e., standard of care, protocols, client’s privacy and satisfaction, infection prevention, standard equipments, etc) – Changed annually to monthly supportive supervision – Established collaborative monitoring and supervision program (DHO- Hospital-Health Centers) – Created Emergency Care Communication Network between hospital, health office, and community providers for optimum and timely referral of emergency – Founded Collaboration Committee to accommodate National and Local Government Health Program

6. Progress Other results that reflect successes – MOH donated CEONC Equipments for Tangerang District Hospital (revealed by increase of standard of inputs) – MOH endorsed Tangerang District Hospital as a model for CEONC services – Four Primary Health Cares and 24 community midwives certified for early identification, proper stabilize and timely referral of emergency obstetrics and neonatal cases – Increasing (three-fold) wireless communication between health centers, health providers and CEONC Team for obstetrics and neonatal emergency care and referral – Established District Hospital and DHO collaboration for monthly PHC & Community Midwives supportive supervision

7. Challenges The technical challenges: Fulfilling standard of input – advocate MOH to donate equipments for CEONC hospital (317 fulfilled need 123 more) Provider behavior and compliance toward practicing best practices – requested Professional Organizations to include CEONC competencies as one of Professional License Prerequisite (usually only provided for Professional Organization events) – conduct regular supportive supervision (not proposed in last year health budget plan) – collegial approach (professional-based usually better than bureaucratic-based approach) Changed clinical to community-based emergency services – MMR will not reduced if hospital focused only in individual cure and care – encourage hospital to collaborate with DHO to empower PHC and CM The political commitment and policy challenges: maternal and neonatal mortality was not a high scale priority – provide and compare valid data of Standard of Minimum Services those must accomplished by the Local Government to be categorized as Good Governance the local autonomy might change national to local health program – advocacy for community right toward access, coverage and equality of quality health services

8. Lessons Learned Health Intervention must be part and expectedly contribute to the National Health Development Program Do not create new, but improved or modified or filled the gap of the existing programs those appropriate to global initiatives Get support or endorsement and enrolled Ministry of Health and Local Health Authority in any step of program implementation The Best Practices Package must be familiar and daily practiced by the providers or players (starting with what already exist and improved gradually) and used integrative approaches Conduct the best practices implementation in a collaborative manner with all related stakeholders and provide objective and reliable information on the intervention main goal and benefits Obtained good model and results before approaching health organizations or institutions for replication

9. Scaling-Up JNPK (assisted by ESD) planned to scale-up best practices to: Banten Province (Serang Provincial Hospital and Cilegon Municipal Hospital) Jakarta Province (Fatmawati National Hospital) JNPK requested by MOH-Directorate of Medical Services to established CEONC in 317 government hospitals (2008: 33 hospitals, 2009: 172 hospitals, 2010: 112 hospitals) and amended health budget for training of 123 hospitals in 2011 Preparation: – Formed Improvement Collaborative Team (consist of national, provincial and district stakeholders) and Plan for Scaling-Up CEONC and its service delivery network – Established CEONC in those hospitals through training, regular supportive supervision, and certifying clinical staffs – Collaborate with Hospital and DHO to create emergency services and communication network in emergency care – Empower hospitals and DHO to maintain high-quality CEONC services and replicate this intervention to other hospitals with their own or local government resources

10. Modifications Considering some issues before conducting scaling-up activities: Know your partners before introducing or offering your scaling-up proposal because it will determine the need of modification Confirmed stakeholders commitment and their authority in implementing your program or intervention in order to calculate the adequacy of budget and health resources Adapt local norms, culture and regulation to make your program doable and work properly Considering assistance from health professional leader or experts because some best-practices might not familiar to the health professionals society, health managers or authority, and health institutions The success of one, might not have the same results to others

11. Capacity Building The capacity building that occurred during CEONC Implementation: Enable JNPK/NCTN to refined/modified best-practices package that fit to district hospital, PHC and community midwives setting Enhance collaboration of MOH and Local Government (Hospital, PHO/DHO, PHC and Community Midwives) to conduct health program/intervention in an integrative manner Empower the hospital to do a self-assessment, implement best- practices, conduct continuous quality improvement system, and create emergency care communication and service network Combine Hospital – DHO health resources to ensure access and quality emergency services in their catchments area

12. Scale-Up Challenges Challenges faced during scale-up: Policy and regulation is not uniform between provinces and districts – Use national policy and regulation that obligatory to the local government Full support from the government is almost impossible due to the annual work plan and budget had completed before the implementation program started – Good calculation of project budget need and donor assistance while looking for the opportunity of central/local government support – Use collateral budget approach while the local government modify their budget Different level of human resources capability/competency that might distorted the course of the project – Training, Coaching, and Supportive Supervision – Select the people to the best of your knowledge