cd6cff8f f230 48a0 8b6d 399cedffc50b
Stories of Most
Significant Change
from Kinerja USAID
March 2016
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
Bondowoso, East Java ............................................................................................................................ 22
1
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.
The Most Significant Change method was developed in the 1990s by Davies and Dart, and helps
to clarify the changes that occur as the result of a program, project, or intervention. MSC can be
described a storytelling technique, collecting qualitative evidence of changes as perceived by
the various stakeholders (including indirect beneficiaries such as users of public health facilities)
involved in the project.
2
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
info@kinerja.or.id.
isit Ki e ja s
e site at http://www.kinerja.or.id or email
3
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
much of an impact they could actually have on service quality. Staff stopped simply following habits and
routines, and started changing how they worked, which resulted in staff not only becoming more
enthusiastic, happy, and friendly, but in improved customer satisfaction and better health outcomes.
4
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
have positive birth experiences, and more children will have a good start to life.
5
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
Although every step plays an important role, it is not mandatory to follow all ten steps in order
to successfully implement the MSC approach. Kinerja took into consideration the available time
and resources (financial and human), and focused on what we considered to be the
fundamental steps to the process, as depicted in the following diagram.
6
2. Site and storyteller selection
In consultation with Ki e ja s staff a d
evaluation:
Province
East Java
West Kalimantan
a age e t, the following sites were identified for
District
Probolinggo
Bondowoso
Sambas
Kota Singkawang
Based on Kinerja s MSC study objectives, the stories were collected from a group of preidentified 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 years 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
The collection of MSC stories was conducted by two external research consultants. Using
external consultants meant that the stories were, in theory at least, provided as neutral and
7
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.
All 39 stories were distributed to the participants. Participants were divided into three groups.
Each group was assigned to select 5 stories that they considered most significant. All stories
considered significant by each group were read aloud by the workshop participants, and the
facilitators took notes. Each group was required to state the background or reasons why they
chose particular stories. After the stories were heard, a process to identify the three stories that
were considered most significant was begun. A long, open discussion was held until the final
selections were made and all participants agreed.
8
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.
Another challenge was the difficulty of selecting the fi al ost sig ifi a t stories. Workshop
participants recognized that all stories had some important information within them, and this
made selection tricky.
9
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)
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.
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,
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 ;
the staff below them simply followed orders.
Now, the staff work together with the
10
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.
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.
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.
For example, the centre once received some
feedback from patients that service was too
slow. The complaints were discussed with all
staff, and the staff decided to make a service
flowchart that would make services run faster.
The flowchart was developed and hung on the
wall by the reception desk, so that all patients
can know exactly what they are required to do
at the centre: register, be seen by a medical
professional, be seen by other staff if required
(such as a dentist), visit the lab if required,
collect medicine if required, then pay and go
home. This sort of flowchart was never
previously displayed at the health centre, so
patients were often confused where to go and
what to do. Now, things are much clearer.
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
input from patients.
Befo e, if e e ei ed feed a k f o
the community, it was like we were
being criticised in negative way. Like
we had an opposition. But now, we
actually want to receive feedback all
the ti e!
To deal with feedback from the community,
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
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
Ki e ja s suppo t e ds.
11
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 MultiStakeholder Forum (MSF) in Sejangkung SubDistrict, Sambas 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.
Nurul learnt that maternal and neonatal deaths
can actually be avoided when she attended a
workshop u
Ki e ja s lo al pa t e , PKBI.
The facilitators told the participants that in East
and West Nusa Tenggara, part of Eastern
Indonesia, a program there was able to reduce
the number of neonatal deaths from 20 to zero.
Nurul was surprised to learn this, and was
fascinated that through working with all the
12
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 for 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
delivery room at
Semparuk
Community
Health Centre,
the land for
which was
donated by the
village as a result
of the lo al MSF s
advocacy.
Safe Childbirth
(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 MultiStakeholder 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.
Narti and Eliah especially like the new feedback
system their health centre has set up. When
13
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
and the provision of antenatal care
for mothers could be separated in
order to speed up and provide more
clarity. The midwives liked the idea
and agreed to implement it.
Narti and Eliah feel that there have also been
significant changes in safe childbirth in their
sub-district. Before, many women still gave
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
had enough time to refer the woman to us –
that she had arrived and the baby was born
immediately. It was just an excuse [to justify
thei helpi g of the o a ]. But o , it s ee
made clear to the TBAs that they have to
encourage women to give birth at a health
fa ilit . It s eall helped a lot. We used to get
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 subdist i t. But the a gue that Ki e ja s
program was different, because it
clearly and simply laid out all of the
steps to developing a strong,
sustainable midwife-TBA program.
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 nonmedical support to delivering mothers and newborn 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
few that are assisted by TBAs usually occur
he a o a a i es at a TBA s house in
advanced labour.
If a o a gi es i th ith a TBA, it s isk fo
the mother. Anything could happen. She could
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
hospital]. This is i po ta t.
14
We Do t Need to Wait All Day
Anymore
(Ria, a mother from Semparuk)
Kota Singkawang, West Kalimantan
Patients Rights
(Head Midwife, North Singkawang Community
Health Centre)
Ria is 25 years old. She lives in Semparuk Subdistrict, in Sambas, and is a regular user of the
Semparuk Community Health Centre. She is
currently seven months pregnant with her
second child.
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
and to eat nutritious food so that her child is
healthy.
I ‘ia s pe spe ti e, the “e pa uk Co
u it
Health Centre has changed a lot since she had
her first baby in 2012. The building itself has
been improved, and there are more staff than
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
the staff attendance and punctuality:
If ou a t to go [to the health
centre] now, you can even go at 8am.
There will be staff there. So you can
go early in the morning, and you
do t ha e to ait u til idda , o
the afte oo a
o e.
The head midwife of North Singkawang
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
aware of their rights. The staff at the centre
de ided to ha g i fo atio o patie ts ights
on the walls so that they could be easily read
and understood. For example with regards to
antenatal care, there are now posters that
describe the 10 types of care a woman is
supposed to receive during her check-ups.
Previously, she says, the women would just
accept whatever was given to them, and there
was no information on what standard services
they should receive.
Before Kinerja assisted the staff at North
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
that the e e t allo ed to e ith thei aby.
15
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
been involved since 2012. One woman, Alusia,
had just recently joined her local MSF in East
Singkawang, as it was only formed during the
lo al go e
e t s e pa sio of Ki e ja s
program in 2015.
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.
Mayuri says that since Kinerja, his local
community health centre has a new referral
procedure in place for when patients need
transferring to hospital. The procedure is public
knowledge and has been explained to the
community, so that all community members
16
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
woman how if she took good care of herself
from the first trimester of her pregnancy, both
physically and nutritionally, she should be able
to breastfeed her child.
Alusia agrees that there has been an
i p o e e t i people s k o ledge, ot just
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
pregnancy, her husband had still let her
perform hard physical tasks such as carrying
sacks of rice in from the field after harvest.
Alusia and other members of the MSF
contacted the man and spoke to him; she
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.
Photo: Health centre staff and MSF members
take part in a training supported by Kinerja.
17
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
improvements. Sri says that some of the
changes that have happened include the
development and display of SOPs and patient
service flows, the improvement of the waiting
room, and a positive change in staff attitude.
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
signed, the staff realised that their job was to
serve patients, and that they should be more
friendly and welcoming. The rooms are now
cleaner and more organised, which makes
patients feel more comfortable and thus more
likel to use the health e t e s fa ilities.
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.
We e ei e the o plai ts i thei
raw form. Then we investigate, are
the complaints accurate? Who was
involved? We identify them and ask
the a out the o plai ts. If the e
quiet or only try to make excuses for
thei eha iou , eah, that s o al.
We k o
hat that ea s.. [laughs]
Sri Sumiati summarises the most significant
change at West Singkawang Community Health
Centre as improved two-way communications
between medical staff and patients. Both staff
and patients are now more honest and open,
and Sri rates this as very important. She says
that patients now frequently offer feedback and
complaints about services, and much more
often ask questions about their pregnancies and
their children than they used to. Sri believes
that if the centre makes improvements that
solve patient complaints, then the patients will
feel that they are receiving better care and they
will have less complaints.
18
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
by Kinerja are in fact considered to be so
successful by the local government that new
ones will be established in the two remaining
sub-districts of the city – Central and East
Singkawang.
But, after considering everything, Muwati still
nominates the establishment of the probreastfeeding 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.
Muwati says that the pro-breastfeeding
regulation has also improved understanding of
the importance of exclusive breastfeeding in
Singkawang. Before Kinerja, many health
centres and hospitals used to sell or provide
formula milk to new mothe s, a d did t
encourage them to breastfeed. Since the
regulation came into place, this is no longer
allowed.
19
Probolinggo, East Java
The Contribution of the Community
(Dr Wahyu, Head of Sumberasih Community
Health Centre)
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 all the ti e.
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 heal
Significant Change
from Kinerja USAID
March 2016
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
Bondowoso, East Java ............................................................................................................................ 22
1
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.
The Most Significant Change method was developed in the 1990s by Davies and Dart, and helps
to clarify the changes that occur as the result of a program, project, or intervention. MSC can be
described a storytelling technique, collecting qualitative evidence of changes as perceived by
the various stakeholders (including indirect beneficiaries such as users of public health facilities)
involved in the project.
2
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
info@kinerja.or.id.
isit Ki e ja s
e site at http://www.kinerja.or.id or email
3
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
much of an impact they could actually have on service quality. Staff stopped simply following habits and
routines, and started changing how they worked, which resulted in staff not only becoming more
enthusiastic, happy, and friendly, but in improved customer satisfaction and better health outcomes.
4
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
have positive birth experiences, and more children will have a good start to life.
5
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
Although every step plays an important role, it is not mandatory to follow all ten steps in order
to successfully implement the MSC approach. Kinerja took into consideration the available time
and resources (financial and human), and focused on what we considered to be the
fundamental steps to the process, as depicted in the following diagram.
6
2. Site and storyteller selection
In consultation with Ki e ja s staff a d
evaluation:
Province
East Java
West Kalimantan
a age e t, the following sites were identified for
District
Probolinggo
Bondowoso
Sambas
Kota Singkawang
Based on Kinerja s MSC study objectives, the stories were collected from a group of preidentified 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 years 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
The collection of MSC stories was conducted by two external research consultants. Using
external consultants meant that the stories were, in theory at least, provided as neutral and
7
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.
All 39 stories were distributed to the participants. Participants were divided into three groups.
Each group was assigned to select 5 stories that they considered most significant. All stories
considered significant by each group were read aloud by the workshop participants, and the
facilitators took notes. Each group was required to state the background or reasons why they
chose particular stories. After the stories were heard, a process to identify the three stories that
were considered most significant was begun. A long, open discussion was held until the final
selections were made and all participants agreed.
8
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.
Another challenge was the difficulty of selecting the fi al ost sig ifi a t stories. Workshop
participants recognized that all stories had some important information within them, and this
made selection tricky.
9
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)
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.
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,
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 ;
the staff below them simply followed orders.
Now, the staff work together with the
10
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.
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.
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.
For example, the centre once received some
feedback from patients that service was too
slow. The complaints were discussed with all
staff, and the staff decided to make a service
flowchart that would make services run faster.
The flowchart was developed and hung on the
wall by the reception desk, so that all patients
can know exactly what they are required to do
at the centre: register, be seen by a medical
professional, be seen by other staff if required
(such as a dentist), visit the lab if required,
collect medicine if required, then pay and go
home. This sort of flowchart was never
previously displayed at the health centre, so
patients were often confused where to go and
what to do. Now, things are much clearer.
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
input from patients.
Befo e, if e e ei ed feed a k f o
the community, it was like we were
being criticised in negative way. Like
we had an opposition. But now, we
actually want to receive feedback all
the ti e!
To deal with feedback from the community,
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
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
Ki e ja s suppo t e ds.
11
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 MultiStakeholder Forum (MSF) in Sejangkung SubDistrict, Sambas 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.
Nurul learnt that maternal and neonatal deaths
can actually be avoided when she attended a
workshop u
Ki e ja s lo al pa t e , PKBI.
The facilitators told the participants that in East
and West Nusa Tenggara, part of Eastern
Indonesia, a program there was able to reduce
the number of neonatal deaths from 20 to zero.
Nurul was surprised to learn this, and was
fascinated that through working with all the
12
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 for 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
delivery room at
Semparuk
Community
Health Centre,
the land for
which was
donated by the
village as a result
of the lo al MSF s
advocacy.
Safe Childbirth
(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 MultiStakeholder 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.
Narti and Eliah especially like the new feedback
system their health centre has set up. When
13
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
and the provision of antenatal care
for mothers could be separated in
order to speed up and provide more
clarity. The midwives liked the idea
and agreed to implement it.
Narti and Eliah feel that there have also been
significant changes in safe childbirth in their
sub-district. Before, many women still gave
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
had enough time to refer the woman to us –
that she had arrived and the baby was born
immediately. It was just an excuse [to justify
thei helpi g of the o a ]. But o , it s ee
made clear to the TBAs that they have to
encourage women to give birth at a health
fa ilit . It s eall helped a lot. We used to get
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 subdist i t. But the a gue that Ki e ja s
program was different, because it
clearly and simply laid out all of the
steps to developing a strong,
sustainable midwife-TBA program.
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 nonmedical support to delivering mothers and newborn 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
few that are assisted by TBAs usually occur
he a o a a i es at a TBA s house in
advanced labour.
If a o a gi es i th ith a TBA, it s isk fo
the mother. Anything could happen. She could
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
hospital]. This is i po ta t.
14
We Do t Need to Wait All Day
Anymore
(Ria, a mother from Semparuk)
Kota Singkawang, West Kalimantan
Patients Rights
(Head Midwife, North Singkawang Community
Health Centre)
Ria is 25 years old. She lives in Semparuk Subdistrict, in Sambas, and is a regular user of the
Semparuk Community Health Centre. She is
currently seven months pregnant with her
second child.
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
and to eat nutritious food so that her child is
healthy.
I ‘ia s pe spe ti e, the “e pa uk Co
u it
Health Centre has changed a lot since she had
her first baby in 2012. The building itself has
been improved, and there are more staff than
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
the staff attendance and punctuality:
If ou a t to go [to the health
centre] now, you can even go at 8am.
There will be staff there. So you can
go early in the morning, and you
do t ha e to ait u til idda , o
the afte oo a
o e.
The head midwife of North Singkawang
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
aware of their rights. The staff at the centre
de ided to ha g i fo atio o patie ts ights
on the walls so that they could be easily read
and understood. For example with regards to
antenatal care, there are now posters that
describe the 10 types of care a woman is
supposed to receive during her check-ups.
Previously, she says, the women would just
accept whatever was given to them, and there
was no information on what standard services
they should receive.
Before Kinerja assisted the staff at North
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
that the e e t allo ed to e ith thei aby.
15
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
been involved since 2012. One woman, Alusia,
had just recently joined her local MSF in East
Singkawang, as it was only formed during the
lo al go e
e t s e pa sio of Ki e ja s
program in 2015.
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.
Mayuri says that since Kinerja, his local
community health centre has a new referral
procedure in place for when patients need
transferring to hospital. The procedure is public
knowledge and has been explained to the
community, so that all community members
16
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
woman how if she took good care of herself
from the first trimester of her pregnancy, both
physically and nutritionally, she should be able
to breastfeed her child.
Alusia agrees that there has been an
i p o e e t i people s k o ledge, ot just
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
pregnancy, her husband had still let her
perform hard physical tasks such as carrying
sacks of rice in from the field after harvest.
Alusia and other members of the MSF
contacted the man and spoke to him; she
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.
Photo: Health centre staff and MSF members
take part in a training supported by Kinerja.
17
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
improvements. Sri says that some of the
changes that have happened include the
development and display of SOPs and patient
service flows, the improvement of the waiting
room, and a positive change in staff attitude.
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
signed, the staff realised that their job was to
serve patients, and that they should be more
friendly and welcoming. The rooms are now
cleaner and more organised, which makes
patients feel more comfortable and thus more
likel to use the health e t e s fa ilities.
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.
We e ei e the o plai ts i thei
raw form. Then we investigate, are
the complaints accurate? Who was
involved? We identify them and ask
the a out the o plai ts. If the e
quiet or only try to make excuses for
thei eha iou , eah, that s o al.
We k o
hat that ea s.. [laughs]
Sri Sumiati summarises the most significant
change at West Singkawang Community Health
Centre as improved two-way communications
between medical staff and patients. Both staff
and patients are now more honest and open,
and Sri rates this as very important. She says
that patients now frequently offer feedback and
complaints about services, and much more
often ask questions about their pregnancies and
their children than they used to. Sri believes
that if the centre makes improvements that
solve patient complaints, then the patients will
feel that they are receiving better care and they
will have less complaints.
18
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
by Kinerja are in fact considered to be so
successful by the local government that new
ones will be established in the two remaining
sub-districts of the city – Central and East
Singkawang.
But, after considering everything, Muwati still
nominates the establishment of the probreastfeeding 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.
Muwati says that the pro-breastfeeding
regulation has also improved understanding of
the importance of exclusive breastfeeding in
Singkawang. Before Kinerja, many health
centres and hospitals used to sell or provide
formula milk to new mothe s, a d did t
encourage them to breastfeed. Since the
regulation came into place, this is no longer
allowed.
19
Probolinggo, East Java
The Contribution of the Community
(Dr Wahyu, Head of Sumberasih Community
Health Centre)
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 all the ti e.
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 heal