challenges of community health workers in sustaining maternal and child health program in indonesia
TRANSCRIPT
Challenges of Community Health Workers in sustaining maternal and child health
program in Indonesia
Symposium on Community Health Workers
The REACHOUT project is funded by the European Union
Ralalicia Limato
Hotel Africana, Kampala, Uganda21 February 2017
Introduction
Maternal Health
MMR (2012) 359/100,000
live births (IDHS)1
1. Statistics Indonesia et. Al.,2013, Indonesia Demographic and Health Survey 2012
MDGs MMR (2015) 102/100,000
live births
Introduction
Efforts to improve maternal health
INSURANCE SCHEMES
JAMKESMAS (Community Health Insurance)• 2009 – present
JAMPERSAL (Delivery Insurance)• 2011 - 2013• Free ANC, PNC and delivery
services for women
JKN (National Health Insurance)• 2014 – present
POSYANDU(Community integrated post)
• National community-based program
• Established in 1985• Aim: to provide
activities that encourage active participation of the communities
• Served by the CHWs
PROGRAM BIDAN DESA(Village-based midwives
program)
• Started in 1989• Aim: to place skilled
birth attendants closer to the community (village)
• To provide maternal and child health services
Posyandu
• Community integrated post that provides various services and activities
• Health services: antenatal care, postnatal care, family planning, child growth monitoring, elderly health – once a month
• Other activities: early childhood education, women empowerment, various community engagement activities
• 5 – 12 Posyandu/village
CHWs
Who are CHWs in Indonesia?
• Community Health Workers are called kader community members who voluntarily give services in the Posyandu
CHWs
Registration Weighing Filling the patient’s record book
Delivering health promotion Assisting midwife/nurse
Task and responsibilities in the Posyandu
CHWs
Task and responsibilities outside Posyandu
• Home visit and health counselling
• Referral pregnant women to midwife for delivery
CHWs
RecruitmentCommunity members nominated individuals who are willing to work voluntarily as kader. They are recruited by community leaders and village head after discussion
CHWs
Supervision CHWs are supervised by• Community leaders & village
head • Village midwife/nurse
Incentives Rp. 50,000.00 (≈ USD 4) per month
Aim
To explore the challenges of the CHWs to deliver maternal and child health (MCH) services
Methods
Methodology Qualitative
Setting 2 districts (Southwest Sumba and Cianjur), Indonesia
Participant
• Health stakeholders: Puskesmas and District Health Office officials• Non-health stakeholders: Sub-district and village officials• Health-care providers: village midwives, kader and TBA (Traditional Birth Attendants)• Community: women (who had been pregnant) and men
Method of data collection
• Purposive sampling• 185 semi-structured interviews and 13 Focus Group Discussions (FGDs)• Data were collected in November 2013, November 2014 and September 2015
Data analysis Nvivo10, coding framework
Ethics Hasanuddin University, South Sulawesi, Indonesia
Findings
Challenges of CHWs in sustaining MCH program
Community level CHWs level Health system level
Results
Community level The paternalistic cultural norm hindered referral of pregnant women by the CHWs/kader for facility delivery
Results
• “My challenge is the communities couldn’t accept what I told them. The pregnant woman wanted to deliver at home because her husband didn’t permit her to deliver in the health facility.” (SSI CA 109 CHW)F)
• “Usually the husband and family members who are responsible to determine the pregnant woman’s birthplace.” (SSI CA 114 MW F)
• “When my pregnancy was 9 months old, I asked my husband who would assist the delivery? ‘Oh TBA’ he said.” (SSI CA 126 MO F)
Results
CHW levelLimited training opportunities for CHWs/kader lead to suboptimal quality of service
Results
• “We don’t have special training for kader. We don’t have budget for that.” (SSI CA 037 HS M)
• “There are some kader that haven’t got training yet… The new ones who haven’t got any trainings, they don’t understood their work.” (SSI CA 021 MW F)
• “What hinders their work... some kader are lacking of resource quality like knowledge and skills to do the work.”(SSI CA 044 MW F)
Results
Health system levelFavouritism in CHWs/kader recruitment and retention hindered the continuity of their work in the Posyandu
Results
• “Because every time the head of village changes, the program from the new head of village would be new and not similar with the old one… He would choose other people, mostly his relatives, and the activities would be different. The previous activities would not be continued.”(SSI CA 022 CHW F)
• "Kader recruitment and dismissal are based on the favor of the community leader and not based on their performance." (SSI QI1 010 MW F)
Discussion
• Paternalistic culture disempowered pregnant women to make decision about their pregnancy challenged the referral from CHWs to the midwife
• Home delivery might cause late complication management and late referral maternal death
Discussion
• The political system challenge health system challenge influenced the recruitment and retention of the CHWs. The trained CHWs were terminated and replaced by the new CHWs due to the political interest of the village head/community leader
• This impacts the training opportunities and quality for services CHWs provide
Conclusion
• CHWs/kader are the first point of contact of the communities (suburban and rural) to access MCH services
• Their services are challenged by gender-based decision making, favouritism in recruitment and training limitations
• Greater involvement of local leaders to recognise kader’s voluntary work and quality services is crucial to help them sustain MCH programs
