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IndonesiaA Situational Analysis on Newborn Health

Composition of Country Team 1. Dr Mujadid, Child Health Directorate, MoH2. Dr L Daisy, Child Health Directorate, MoH3. Dr A Riskiyana, Maternal Health, MoH4. Dr Karina Widowati, UNICEF 5. Ms Rustini Floranita, WHO6. Dr M Bateman, Senior Health Advisor, USAID7. Ms Mildred Pantouw, MCH Specialist, USAID8. Dr Pancho Kaslam, EMAS, JHPIEGO9. Dr Ardi Kaptiningsih, Consultant

Country profile

33 provinces, 399 districts, 98 municipalities, 6 994 subdistricts, 81253 villages2162 hospitals, 9557 health centres, 212 629 integrated health posts104 060 midwives (65 475 community midwives – deployed at village level)

Source: *Population census 2010; **IDHS 2012; *** IDHS 2007

Total pop* 237.6 mWomen 15-49 years* 131 mU5* 22.7 mTFR** 2.6Total live births 4.3 mMMR *** 228NMR** 19Neonatal deaths* 95 301Stillbirths (2009) 62 300Preterm babies (2010) 65 700

Trends of U5MR, IMR and NMR, 1991-2015Proportion of newborn deaths contributing to child mortality

30%

43%48%

Source: IDHS 1987-2012

4

1991 1994 1997 2002 2007 20120

10

20

30

40

50

60

70

80

90

0

50

100

150

200

250

300

350

400

450

500

450

390

334307

228

facility Birth SBA MMR

Cove

rage

(%)*

*

MM

R pe

r 100

,000

live

bir

th*

102

Source: *IDHS; ** MoH routine reporting

MMR target

Correlation between proportion of skilled care at birth, facility birth and MMR

Causes of neonatal mortality, 2010

Preterm birth com-plications

45%

Asphyxia²21%

Sepsis¹11%

Pneumonia4%

Congenital13%

Others6%

Preterm birth complic’n 45% Asphyxia 21% Congenital anomaly 13% Sepsis 11% Other causes 6% Pneumonia 4%

Source: Countdown to 2015 report

NMR disparity among regions, 1990-2010

Widening the gap

Source: KH Nguyen et al. Indonesia equity report. University of Queensland, 2011.

Continuum of care – wealth quintiles

Met N

eed

First

ANC

4+ ANC visit

s

Tetanus t

oxoid

SBA

Instutional

delivery

Post nata

l care

Breast fe

eding

DPT first dose

Vitamin A prev.

Full v

accin

ation

0%

20%

40%

60%

80%

100%

Total_Q1 Total_Q2 Total_Q3 Total_Q4 Total_Q5

Source: MoH, 2012

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Coverage of key MNH interventions

CPRANC

SBA

Institu

tional Deliv

ery

2 days p

ost part

um

Exclusiv

e Breast Fe

eding0

20

40

60

80

100

120

61

93

73

46

70

32

62

95.783

63

42

2007 2012

Source: IDHS 2007-2012

Targets for MCH improvement, 2009 and 2014

Strategic goals Target for 2009

Target for 2014

Maternal mortality ratio (per 100 000 live births) 226 118

Infant mortality rate (per 1 000 live births) 26 24

Neonatal mortality rate (per 1 000 live births) na 15

ANC coverage at least 4 visits (%) 90 95

Coverage of skilled care at birth (%) 90 90

First neonatal visit (%) 84 90

Household practicing healthy and clean lifestyle behaviours (%) 60 70

Source: Medium-term development plan 2004-2009 and 2010-2014

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Policies related to newborn health

Newborn health issues

• Financial schemes• Address inequity issues• Early initiation of and

exclusive breastfeeding• National Program for

Community Empowerment (PNPM Generasi)

• Scaling-up nutrition movement

Related policies

• Focus on main causes of neonatal deaths thru: EmONC, ENC, MPA, quality improvement, supervision

• Reaching the majority: special attention to 9 provinces (75% of total pop) and 3 most lagging behind provinces

• Importance of an integrated MCH services: MIP, PMTCT and elimination of congenital syphilis, etc

• Inequity issues

Availability of essential drugs and supplies in delivery room

IV cannulae

Crystal

loid

Oxytocin

MgSO4

Calcium gl

uconate

Antihyperte

nsive

Cortico

steroids*

Ampicillin

IV*

Gentamyc

in IV *

Metronidazo

le*

Misoprosto

l

Oxyge

n0

10

20

30

40

50

60

70

80

90

100

Hospital

Health Centers

Midwifery Clinics

Drugs and supplies

% fa

ciliti

es d

oing

the

proc

edur

e ac

cord

ing

to st

anda

rd

*) available anywhere in the health facility

Source: Assessment quality of MNH care 2012

Performance on implementation of Breastfeeding

Inform

ation on Breastf

eeding

Early bre

astfeeding in

itiation

Giving pumped breastm

ilk if

baby can't

be breastf

ed

No food or d

rink oth

er than bre

astmilk

24-hour r

ooming-in

Breastf

eeding on demand

Not usin

g pacifiers

or arti

ficial t

eats0

10

20

30

40

50

60

70

80

90

100

Hospital

Health Centers

Midwifery Clinics

Indicators

% fa

ciliti

es d

oing

the

proc

edur

e ac

cord

ing

to s

tand

ard

Source: Assessment on quality of MNH care 2012

Routine Newborn Care

Hypotherm

ia prevention

Vitamin K1

Eye antibiotics

Oral P

olio Vacc

ination

Hep-B Vacc

ination0

20

40

60

80

100

HospitalHealth CentersMidwifery Clinics

% fa

ciliti

es d

oing

the

pro

cedu

re

acco

rdin

g to

sta

ndar

dPerformance on selected newborn care procedures

Quick asse

ssment

Keeping the baby w

arm

Positioning

Suctioning

Giving tacti

le stimulation

Drying th

e baby

Initiating ventilation0

20406080

100

Procedures

% fa

ciliti

es d

oing

the

pro

cedu

re

acco

rdin

g to

sta

ndar

d

Neonatal Resuscitation

Source: Assessment quality of MNH care, 2012

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Major bottlenecks in newborn care by health system building blocks

Leadership (including partnerships) Strategies and solutions

Insufficient management capacity and skills at provincial and district/municipality level

Lack of skills for health planning and budgeting at district/municipality level

Collaboration with and regulation of the private sector needs strengthening

Unclear roles and responsibilities at different administrative levels

Risks of desentralisation on health priorities

• Local action plan to accelerate MDGs achievement in 33 provinces• Advocacy and technical/ managerial supports to provinces and districts

Health financing Strategies and solutions Financial barriers: referral is not widely

incentivized for institutional deliveryMaternal and newborn services and care are covered for all Indonesians by health insurance (tax-based)

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Health information system Strategies and solutions

Neonatal and perinatal death audits are not regularly performed

Poor capacity and skills at provincial and district level to collect, analyse and interpret data which impacts the quality of data

Newborn mortality and healthcare data are included in the NHIS and the DHS

Human resources Strategies and solutions

Unequal distribution of HR (15% of rural area without villages midwife)

Limited technical and managerial supports to decentralized provinces and districts

Poor retention of HR especially in remote and rural areas

Shortage of pediatricians and obstetricians Problem in competency (skills, knowledge and

attitude) on routine newborn care, emergency care and management of complications

Poor HR planning and no adequate HR data collection system in DHO and PHO

Poor monitoring of training institutions

Quality and adequate midwifery, nursing and medical schools

Encourage training of local/ indigenous people to enhance staff retention

Involving professional associations in HR management and ensure competency

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Access to essential drugs and commodity Strategies and solutions

Stock-outs of essential drugs and BEmOC commodities at PHC level are common

Lack of knowledge of correct storage and use of drugs and commodities among health facility staff at PHC and referral facilities

All drugs needed for maternal and newborn care are included in essential drugs list

Service delivery and organisation Strategies and solutions

• Lack of policy to enforce certification and accreditation of CEmONC (24 hrs-7 days) function in all hospitals

• Uneven/substandard policy for private hospitals• Limited access to hospitals with CEmONC: rural: 51%; urban:

91%; Papua 18%, the Moluccas 37%, Nusa Tenggaras 51%, Kalimantan 53%

• Human resources: 83% public hospitals with obstetrician, 75.5% with pediatrician, 49% with anesthesiologist

• Continuity: only 59.1% ready for obstetric operation within 30 minutes

• Quality: 21% can do all 9 signal functions

• Address those issues locally, according to local situation and needs

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Next plan for development of INAP

• Continue with more detailed bottleneck analysis : starts in early September 2013

• Key partners involved : related programs in MoH, province representatives, partners, e.g. WHO, UNICEF, EMAS, USAID, AusAID, professional organizations

• Monthly technical meetings of TWG: from Oct 2013 – March 2014• First draft of INAP will be ready by December 2013 and final draft

by March 2014• Piloting the ENC component in selected districts (remote): January

2014• Final review of INAP document by mid-2014

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BEmONC

Priority bottlenecks Strategies and solutions

• No policy supporting for sustainability of BEmONC (such as mutation, availability of drug and equipment and lack of facilitative supervision)

• Inadequate competency level of BEmONC functions in pre-service education of doctors, midwives and nurses

• Location of BEmONC sometimes inappropriate• Only 47.4% of PHC BEmONC can provide 24-hour

services

• Clarity on policy related to BEmONC sustainability • Support provinces to identify and address local issues

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Prevention and management of preterm birth

Priority bottlenecks Strategies and solutions

• Limited actions in identifying maternal and other factors that lead to prematurity

• MoH has been promoting institutional delivery, although it is not written yet in the national policy

• Policy and guidelines for antenatal corticosteroids are not stated clearly

• Administration of corticosteroids for women with suspect premature labour has been implemented at hospital level

• Access: ineffective system of referral and emergency transfer of the mother from home to hospital in many areas of Indonesia, especially those with a low population density, such as Papua

• Lack of knowledge of the community regarding premature babies care

• Identify those factors and facilitate relevant actions accordingly• Elaborate on task shifting in administering antenatal corticosteroid at primary care level• Disseminate relevant guidelines on the subject to relevant health providers• Address local situation and needs • Individual, family and community education on the care of premature babies

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Thank You