annex - compendium of good practices - UNICEF

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ANNEX: COMPENDIUM OF GOOD PRACTICES

1 Improving the Quality of Integrated Management of Childhood Illness at Primary Health Facilities through On-the-Job Training and Routine Facilitative Supervision

Aceh 2

2 Improving the Quality of Care for Mothers and New-borns at Health Facilities through Sustainable Point of Care Quality Improvement

Aceh 5

3 Digital Monitoring Systems: Lesson Learned from Aceh Aceh 8

4 Mainstreaming an Integrated Approach to Address Maternal and Child Malnutrition through Improved Planning and Budgeting

Aceh 11

5 Family Based Monitoring of New-born Health West Nusa Tenggara 13

6 Technical Support for Cold Chain Equipment Service & Maintenance in East Nusa Tenggara Province

East Nusa Tenggara 16

7 Combining On-the-Job-Training for Malaria Microscopist with Microscope Services and Maintenance to Improve Malaria Diagnostic Quality Assurance in East Nusa Tenggara

East Nusa Tenggara 19

8 Improving the Quality of Hospital Care for Mothers and Newborns through Point-of-Care Quality Improvement (POCQI) at District Hospitals

West Nusa Tenggara 22

9 Acceleration of Malaria Control in Endemic Villages through Community Engagement and Utilization of Village Funds

Maluku 25

10 Community Empowerment and Mobilization through Participatory Learning and Action for Malaria Elimination

North Maluku 27

11 Promotion of Maternal, New-born and Child Health through Building Health Worker Capacity and Data Management at Community Health Centres

North Maluku 29

12 Improving Maternal and Neonatal Services through On-the-Job Training for the Integrated Management of Childhood Illness

Papua 31

13 UNICEF Support to Polio Outbreak Response in Papua Papua 33

14 Use of Human-Centred Design to Increase Routine Immunization Coverage

East Java 36

15 Optimizing the Triple Elimination Prevention Programme through Private Services (midwives, clinics, hospitals) in Districts and Cities

East & Central Java 38

Full publication can be accessed through: www.unicef.org/indonesia/reports/compendium-of-good-practices

COMPENDIUM OF GOOD PRACTICESto support achievement of Sustainable Development Goals for Children in Indonesia

ANNEX2021

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Improving the Quality of Integrated Management of Childhood Illness at Primary Health Facilities through On-the-Job Training and Routine Facilitative Supervision General topic area: Good health and well-beingLocations: Aceh (Langsa City, Sabang City, Singkil, Simeulue)

Summary of the

Approach

The UNICEF-supported pilot to improve the quality of integrated management of childhood illness (IMCI) through on-the-job training (OJT) was completed in Aceh Jaya District and Langsa City by the end of 2018. In 2019, the Ministry of Health (MoH) decided to replicate the training in three locations (Singkil, Simeulue, and Sabang City) using formal guidelines.

ICMI is an integrated approach to addressing maternal and child malnutrition through local healthcare workers. The first step was to prepare qualified trainers at all levels. The MoH trained provincial master trainers in January 2019. Training for district health officials and mentors based at community health centres (puskesmas) was conducted in February-March 2019. Healthcare workers from sub health center (pustu) and village midwife clinic (polindes) received OJT to complete all 17 MoH modules between April and June 2019. One mentor was assigned to a maximum of three mentees.

Pre-and post-tests were conducted to assess improvement in knowledge and skills, using a standardized MoH guideline. Upon completion of OJT, District Health Offices (DHOs) and relevant professional organizations issued certifications. The whole process was supervised by provincial master trainers and DHO officials.

Facilitative supervision of post-training services was conducted during the third quarter of 2019 and continued quarterly throughout 2020. Advocacy with heads of puskesmas was conducted to ensure the availability of equipment and medicines and to support internal supervision. DHOs coordinated the monthly monitoring of IMCI data collected. A ‘WhatsApp’ group was formed to facilitate communication, technical consultations and reminders about monthly data collection. An evaluation was conducted in late 2019 at puskesmas, pustu and polindes.

To stimulate demand, cadres at integrated health centres were invited to a workshop on increasing public awareness about danger signs for children that require immediate visits to a health facility. Topics covered also included the administration of proper medication, such as oral rehydration solution for children with diarrhoea.

Some community health centres utilized their budget to provide incentives for their staff and village midwives who performed neonatal home visits using the IMCI approach to monitor infant health.

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Key Results Achieved

Outputs:

• 10 provincial master trainers in Aceh: three provincial health office (PHO) staff, three paediatricians from the Aceh branch of Indonesia’s Paediatrics Society, two midwives from the province’s Midwives Association and two nurses from the Aceh branch of the Indonesian Nurses Association.

• 5 DHOs have at least two staff trained to conduct IMCI facilitative supervision. A total of 18 DHO staff were trained to conduct supervision utilizing standard MoH supervision tools.

• 49 community health centres have at least two staff trained to serve as IMCI mentors; 103 IMCI mentors are prepared deliver OJT to other health workers.

• 304 village midwives and nurses at 302 pustu and polindes were trained in IMCI through OJT

• Each of 49 puskesmas received DHO supervision at least once per quarter.

• Each pustu/polindes was supervised by a mentor at least once per quarter.

Outcomes:

• The percentage of children under five visiting puskesmas implementing IMCI rose from 62 per cent in February 2019 to 94 per cent in June 2020.

• An increased number of children with diarrhoea received oral re-hydration solution (ORS) - from 57 per cent in February 2019 to 96 per cent in June 2020

Replicability/up-scaling

In 2020 scale-up was taking place in three learning districts

Cost

• Training puskesmas mentors: IDR 2,2 million (USD 150) / person

• OJT: no cost (village midwives can join the IMCI OJT during the weekly visit to puskesmas -- with optional transport allowance and refreshment of IDR 750,000 (USD 51) / person

• Printing IMCI flipchart and forms: IDR 450,000 (USD 31)

• Supervisory visits by DHO to puskesmas: IDR 1,5 million (USD 103) / visit

• Supervisory visits by puskesmas mentor to pustu/polindes: IDR 150,000 (USD 10) / visit

• Workshop for cadres: IDR 150,000 (USD 10) /person

Skills• Understanding of and skills related to IMCI, as per guideline

• Mentoring skills

Stake- holders

• Provincial Health Office (PHO)

• District Health Office (DHO)

• Community health center (puskesmas) officials

• Puskesmas health workers

• Pustu/polindes health workers

• Professional organizations

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Lessons Learned

• Through OJT, IMCI training can be performed at a low cost and without the need for classroom training.

• Routine supervision using a standard tool motivates health workers to improve the quality of their service.

Further readings and information

Local media news:

• https://www.ajnn.net/news/aceh-deklarasi-gerakan-perangi-stunting/index.html

• https://aceh.tribunnews.com/2020/07/04/tingkatkan-pelayanan-kesehatan-anak-di-nagan-raya-unicef-latih-tenaga-medis

Contact details

• Tira Aswitama, Health Specialist UNICEF ([email protected])

• Bobby Marwan Syahrizal, Maternal and Child Health Specialist UNICEF ([email protected])

• Lisna Andria, Child Health Coordinator Provincial Health Office/PHO Aceh ([email protected])

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Improving the Quality of Care for Mothers and New-borns at Health Facilities through Sustainable Point of Care Quality Improvement General topic area: Good health and well-being, maternal and child healthLocations: Aceh (Langsa City, Peureulak, Aceh Timur and Bireuen)

Summary of the

Approach

Point of care quality improvement (POCQI) interventions were first conducted in 2019 at Langsa Hospital, selected due to the high number of maternal-child health (MCH) referrals - indicating a need for improvement in pre-referral case management. POCQI is a management approach used by health workers at model hospitals to ensure that patients receive quality care. While POCQI primarily focuses on re-organizing care using existing resources, it also contributes to addressing other related issues. It is a problem-solving approach applied in the local context of a health facility and usually does not require additional resources.

The POCQI approach involves:

• Establishing improvement teams to identify problems and implement solutions

• Implementing a collaborative approach to ensure adherence to guidelines based on standards of care

• Conducting training of health providers in technical and quality improvement (QI) methods to implement the quality improvement system

• Continuous monitoring of performance through supportive supervision and self-assessments of the quality of care provided, to measure progress towards the achievement of higher standards (intense early in the intervention, followed by quarterly supervision to monitor continuity and identify new interventions)

• Documentation and publication of QI efforts and recognition and celebration when standards are achieved

• Scaling-up to all hospitals and health facilities and communities.

Introduction and training of health workers and hospital managers was facilitated by staff trained by UNICEF and the MCH section of the Provincial Health Office (PHO). Six units at Langsa Hospital formed QI teams consisting of doctors, nurses, midwives and other relevant staff. The teams analysed clinical data at their units and identified gaps and possible solutions utilizing POCQI tools.

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Initial POCQI interventions targeted simple interventions that did not require additional funds or resources: increasing breastfeeding at the hospital and reducing hypothermia. Introducing paediatric screening processes at the hospital’s outpatient clinics was also included. Capacity-building sessions for health workers were conducted on breastfeeding and management of hypothermia, facilitated by the Aceh branch of Indonesia’s Paediatric Society (IDAI). Site assessments were conducted to examine the conditions and facilities of the units. An intervention plan was developed by team members and implementation was monitored by hospital managers, district and provincial health offices, UNICEF and Yayasan Darah untuk Aceh. Progress was discussed every month; if no progress was achieved, the plan was adjusted.

The success achieved by this simplified approach immediately improved job-satisfaction among health workers and kept them motivated to work as a team - working together to ensure continuous quality improvement. The changes began as easy and became more challenging over time as part of ensuring patient satisfaction with the care received. Gaps identified by the team were resolved through their own initiatives.

An evaluation at Langsa Hospital was conducted by Ministry of Health (MoH) and Provincial Health Office (PHO) at the end of 2019. MoH officials were impressed by the process and the teams’ progress.

Implementation of POCQI in Langsa Hospital is one of the success stories from Aceh. The team presented the intervention at the MoH annual national health meeting in 2019, and the MoH invited the hospital manager and health staff to share their experience during the national POCQI meeting. Team members also facilitated some regional POCQI training at the national level.


• Increased coverage of breastfeeding in delivery rooms (for early initiation), maternity wards, neonatal wards

• Cases of hypothermia declined at units responsible for emergency new-born care

• Paediatric screening was introduced at the outpatient clinic

• Team members continued to use the POCQI approach to improve the quality of patient care.


• Scale-up to neighbouring district hospitals began in early 2020.

• Zubir Mahmud Hospital in Aceh Timur and Sultan Azizsyah Hospital in Peureulak launched POCQI interventions in early 2020.

• In mid-2020, Bireuen District Hospital was selected by the MoH to replicate the programme due to the high number of maternal and neonatal deaths in the district.

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Cost • Training for health workers: IDR 450,000 (USD 30) per person

Skills• Understanding of WHO-UNICEF POCQI guidelines


Stake- holders

• Provincial health office (PHO)

• District health office (DHO)

• Paediatrician association (IDAI) and Association for Obstetrics and Gynecology (POGI)

• Hospital manager

• Health workers in each unit

Lessons Learned

• POCQI created early success that immediately improved job-satisfaction among health workers and kept them motivated to work as a team.

• Working together ensured a sustainable movement towards continuous quality improvement

• Quality improvement does not always require additional resources or funds.


POCQI Approach to Improve Breastfeeding at Langsa Hospital Fact Sheet, GoI and UNICEF

Contact details



• Dr. Sulasmi, Head of Public Health Department PHO Aceh ([email protected])

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Digital Monitoring Systems: Lesson Learned from Aceh General topic area: Health monitoring Locations: Aceh (Banda Aceh City, Sabang City, Langsa City, Aceh Singkil, Aceh Jaya, Simeuleu)

Summary of the

Approach

Posyandu are integrated service posts created and managed by the government. The digital posyandu monitoring system (ePosyandu) was launched in 2019 using web-based technology platforms, Rapid Pro and ONA, to facilitate a real-time digital data-collection system that utilizes short message services (SMS) and digital data visualization.

RapidPro delivers integrated messaging for child well-being, including:

• Registration of pregnant women and caregivers of children under two years of age, conducted by health post cadres

• Scheduled SMS reminders for posyandu visits, immunization schedules and child development milestones for caregivers, based on the child’s age.

• SMS reminders on antenatal care and iron consumption to pregnant women, based on their trimester.

The ONA platform is used to facilitate monthly reporting of posyandu key performance indicators and yearly assessments, submitted by community health centre staff and village midwives. Using a geo-tagging function, the system can facilitate both online and offline data collection with a high degree of accuracy and efficiency, minimizing human errors likely to occur in manual monitoring and reporting.

Furthermore, all data is visualized on a dedicated website, supporting the monitoring process for health managers at all levels and offering insights for more accurate and timely evidence-based interventions. A complementary android application was developed to perform actions more quickly than the website and to facilitate the offline access.

Mixed-method training activities were conducted by combining face-to-face training embedded into integrated management of childhood illness (MTBS) activities, cascade training delivered by implementing partners and e-learning via video, to scale up coverage beyond the initial districts of intervention.


• Through integrated messaging, ePosyandu engages with various community members ranging from caregivers to cadres, village midwives and health clinic staff. It allows for two-way communication between government and communities and reliably provides up-to-date information on their individual communication devices.

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• EPosyandu captures several key health indicators, such as number of visits and counselling practices, as well as specific data on maternal health, nutrition and immunization for mothers and children. The overall total of indicators determines the classification from the highest to the lowest categories: Mandiri (more than 80 per cent); Purnama (from 70 to 80 per cent); Madya (from 60 to 70 per cent); and Pratama (below 60 per cent). The indicators cover facilities, cadres, infrastructure, funding, governance, programme implementation and performance.

• The web-based visualization shows over 98 per cent of reporting coverage and compliance as of December 2020. Local governments play a crucial role through their immense support and encouragement of community healthcare personnel and village midwives to report on posyandu conditions in their respective area.


• Scaling up was conducted in two cities, Banda Aceh and Langsa.

• E-learning videos are available for scaling-up in UNICEF intervention districts, aiming to educate health practitioners about how to utilize the features. They contain tutorials and step-by-step explanations on how to classify and prepare monthly reports. The widespread usage of smart phones benefitted this effort.

Cost

• Development of website (funded by UNICEF)

• Development of video tutorial (funded by UNICEF)

• Data collection tools:

− ONA & RapidPro (funded by UNICEF)

− Internet / SMS package: IDR 15,000 (US$1) / puskesmas

• Introduction & training at sub-national level (co-funded by UNICEF & local government): IDR 50 – 100 million (USD 3,400 – 6,800) /district

Skills

• Reporting

• Mobile phone operation

• Relevant professional background knowledge

Stake- holders

• Development planning agency

• Provincial and district health offices

• Puskesmas staff

• Village midwives

Lessons Learned

• Rapid posyandu mapping is feasible. Integrated with the Ministry of Home Affairs village identification code, which has nationwide coverage, the geotagging feature of the posyandu monitoring system makes mapping accurate and reliable.

• Close monitoring improves posyandu performance. Capturing the real-time situation, more than 850 posyandu have been mapped and classified based on their activity status and capacity.

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• District support increases reporting coverage. Collaboration among puskesmas staff, village midwives and district health officers facilitate smooth functioning of the ePosyandu monitoring system.

• The ability to visualize data and facilities helps to identify problems. Within this system, it is feasible to track the situation and progress, informing the need for intervention. It also allows health managers access to numerical details.

• Improved coverage is linked to data utilization. The technology helps to decrease human error and time consumption, compared to manual processes.


• ePosyandu Website: www.eposyandu.com/

• ePosyandu Mobile App: www.play.google.com/store/apps/details?id=com.ikea.aceh.unicef.sip&hl=en_US

• ePosyandu Video Tutorial: www.youtu.be/f3IQbe1UnEM and www.youtu.be/RDgZjQVLoMI

Contact details

• Suci Wulandari, Data Centre Specialist UNICEF ([email protected])


• Dr. Teuku Chik Mohamed Iqbal Fauriza, M.Kes, Head of Health Promotion Section PHO Aceh ([email protected])

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Mainstreaming an Integrated Approach to Address Maternal and Child Malnutrition through Improved Planning and Budgeting General topic area: Good health and well-being Locations: Aceh (Aceh Jaya, Sabang City, Singkil, Simeulue)

Summary of the

Approach

Launched in early 2019, the programme began with training for programme managers and planners at 44 government-run community-based health centres (pukesmas), including District Health Office (DHO) staff and programme managers from four districts. The training sought to deliver management guidelines developed by the Provincial Health Office (PHO) and introduce microplanning tools useful for situation analysis and prioritization. In so doing training would build capacity for planning and budgeting and for applying a strategic approach to maternal and child malnutrition.

UNICEF worked with the DHO and development planning office to provide technical assistance and facilitate planning and budgeting process in puskesmas, including a review of the situation analysis and focus on problem areas in each village and providing input on potential interventions specific to each village’s priority needs. Consultations among village midwives, health post cadres and village leaders were also conducted to validate the data and gather input on possible interventions.


• 44 puskesmas staff trained on microplanning for improved planning and budgeting to address maternal and child malnutrition

• 44 puskesmas conducted the planning and budgeting process

• 44 puskesmas conducted a situation analysis utilizing the microplanning tool

• Annual plans of puskesmas are more strategic with an increased budget allocation for the integrated approach to addressing maternal and child malnutrition.


• Replication is planned in four other districts, starting with knowledge-sharing, under coordination by the Aceh PHO.

• Facilitated by the PHO, DHOs and district planning agency, training was delivered to 76 puskesmas programme managers and planners in December 2020 to inform the 2021 annual planning and budgeting process.

Cost

• Training (1 day): IDR 500,000 (USD 35) per person

• Facilitation to each puskesmas: IDR 4.4 million (USD 300) per workshop at puskesmas

• Consultations with village midwives, health post cadres and village leaders: IDR 750,000 (USD 50) per session

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Skills

• Puskesmas management

• Data analysis and programme management

• Facilitation

Stake- holders

PHO, DHO, district planning agencies, puskesmas programme managers and planners

Lessons Learned

• The use of a simple Excel microplanning tool to support situation analysis as part of the planning process enabled puskesmas to identify key problems, priorities and focus areas for each village under their responsibility.

• Technical assistance and facilitation from DHOs and district planners for puskesmas during the planning and budgeting process should be in line with district priorities and the availability of funding.


• Aceh Anti-Stunting Movement Declaration: www.nasional.republika.co.id/berita/nasional/daerah/pnsm0e423/aceh-deklarasi-gerakan-perangi-emstuntingem

• Sabang City Government is Committed to Address Stunting in 2020: www.kanalinspirasi.com/pemerintah-kota-sabang-komit-tangani-masalah-gizi-dan-stunting-di-tahun-2020/

Contact details



• Dr. Sulasmi, Head of Public Health Department PHO Aceh ([email protected])

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Family Based Monitoring of New-born Health General topic area: Maternal, neonatal and child health Locations: West Nusa Tenggara (West and East Lombok)

Summary of the

Approach

West Nusa Tenggara (NTB) has the third-highest neonatal mortality rate nationwide, with 33 deaths per 1,000 live births - compared to the national average of 22 per 1,000 live births (Bappenas, 2017).

In early 2018 UNICEF began support to NTB’s Provincial Health Office (PHO) to improve the quality primary care and referral services for of new-borns and children. The effort was carried out in partnership with the provincial professional organization on public health (Ikatan Ahli Kesehatan Masyarakat).

NTB’s quality improvement (QI) team raised the issue of family/community participation in new-born monitoring, given the critical importance of this period to ensuring child survival.

The three partners agreed on a roadmap leading to adoption of the programme, including these steps:

• Data collection and analysis on new-born death in all districts

• Technical discussions with associations of paediatricians and obstetrics and gynecology (OB/GYN) on the danger signs that families could identify

• Technical discussion with the provincial family welfare (PKK) team on the important role families can play in monitoring the health of their new-borns and the importance of complementary health staff visits

• Family-based monitoring tools on new-born health and development

• Workshop to obtain inputs from health staff at community clinics (puskesmas) and hospitals

• Piloting and finalizing family-based monitoring tools

• Training and workshops for puskesmas and village midwives

• Coordination meetings with PKK to safeguard the innovation

• Incorporating the tools into maternal-child health manuals as one package to be used for post-natal care counselling.

Family-based monitoring tools on new-born health list 14 important symptoms to predict a potential risk to new-born health, such as on feeding pattern, urination and defecation, breathing and temperature. The tool allows families to easily observe their new-born’s health on a daily basis based on the indicators of risk (written in red) or good health (written in green). When risk is identified, families are advised to bring their new-born to a health professional as soon as possible for examination.

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• 34 midwives in West Lombok and 40 midwives in East Lombok were trained through the collaborative effort of paediatricians, doctors, midwives and the public health association.

• 575 mothers in West Lombok and 790 in East Lombok learned to use the family-based new-born health monitoring tool prior to being discharged from clinics or hospitals during the first two months.

• 75 per cent of families in West Lombok and 60 per cent of families in East Lombok correctly understand how to use rapid assessment tools.

• The family-based monitoring tool for new-borns increased families’ knowledge and led to technical discussions with village midwives.


• Replication at other puskesmas took place in East Lombok.

• NTB’s Provincial Health Office (PHO) allocated funding in the 2020 budget to support widespread adoption of family-based monitoring tools for new-born health.

• The innovation of engaging families in monitoring became especially essential during the COVID-19 pandemic, when new-borns and children had to remain at home, except in emergencies.

Cost

• Printing the form: IDR 72 million (USD 4,950)

• Distributing the form: IDR 3 million (USD 210)

• Workshop dissemination: IDR 51 million (USD 3,530)

Skills

• Reading

• Observation and analytical skills

• Mentoring

Stake- holders

• Paediatricians Association

• Midwives Association

• PHO/ DHO

• Puskesmas

• DPMD – Village offices

• Family welfare programme (PKK)

• District Development Planning Agency (Bappeda)

Lessons Learned

• PHO commitment to safeguard the innovation is essential.

• The role of the provincial QI team in facilitating regular discussion on how to improve MNCH services at all levels is also important.

• Close coordination with local stakeholders with the ability to reach families is important.

• Rapid assessment is needed to understand families’ challenges.

• Home visits by integrated health staff to mentor families on using the tool is vital.

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Development and Planning Agency media feature: www.bappeda.ntbprov.go.id/monitoring-dan-evaluasi-terpadu-program-kerjasama-pemerintah-ri-unicef-periode-2016-2020-untuk-kelangsungan-hidup-perkembangan-dan-perlindungan-ibu-dan-anak-khppia-di-provinsi-ntb/

Contact details

• Vama Chrisnadarmani, Child Survival and Development Specialist UNICEF ([email protected])

• Bobby Marwal Syahrizal, Health Specialist UNICEF ([email protected])

• Mohammad Abdullah, West Nusa Tenggara Public Health Practitioners Association (IAKMI) ([email protected])

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Technical Support for Cold Chain Equipment Service & Maintenance in East Nusa Tenggara Province General topic area: Immunization – Cold chain equipment technical support Location: East Nusa Tenggara (NTT)

Summary of the

Approach

Every year NTT provides routine immunization services for around 250,000 children under two years of age. In 2016 UNICEF supported the NTT government to conduct mapping of its cold chain equipment (CCE) inventory, which revealed a gap between the amount of cold chain equipment available and actual need. In addition, much of the equipment was broken due to improper maintenance and service.

Districts in NTT have limited numbers of qualified staff to provide technical assistance and conduct CCE routine maintenance and services at community health centres. Budget and human resource constraints have prevented the government from delivering conventional face-to-face training and capacity-building programmes. To address these challenges, UNICEF supported the NTT government to train trainers to conduct routine CCE service and maintenance, who then trained technical staff of the expanded programme on immunization (EPI).

This was the first EPI innovation undertaken in Indonesia. The capacity-building activities involved a blended programme aimed at:

1. Improving EPI staff’s programme management and immunization skills

2. Ensuring that health facilities have sufficient CCE

3. Reducing the amount of broken CCE through routine maintenance and service.

This approach sought to assist districts and health centres with CCE problems through on-the-spot assistance and/or virtual support. On-the-spot support was provided during cascade training at the district level and during routine supervision to districts and health centres. Virtual support was made available through online videos and direct access through WhatsApp. Districts with low fiscal capacity and a limited number of qualified EPI technical staff find it easier to adopt the latter approach.

This programme consists of two main components:

1. Capacity-building programme on immunization management, conducted simultaneously with on-the-spot technical assistance for conducting routine CCE maintenance and service.

2. Provision of virtual technical support for routine CCE maintenance and service.

The programme employed the ‘cascade’ method, with training flowing from the highest (provincial) level down to community-based health centres. For the province, capacity building began at a training of trainers (ToT) workshop that was also attended by district-level EPI staff. Next a series of regional follow-up trainings was conducted in districts in the outer islands. To support the ToT, one module and five video tutorials on routine CCE maintenance and service of were developed in 2019.

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In districts, UNICEF’s field office in Kupang supported the training, along with programme update workshops. These training activities have taken place regularly in all districts since 2016. Participating districts and the NTT government shared the cost. District governments pay to train health centre staff, while NTT Province supports visits by technical staff to districts. District-level activity combines programme updates and review, EPI workshops and supportive supervision to health centres to monitor the condition of all CCE.

A newly developed module on routine CCE maintenance and service is now being used. UNICEF provided full support to NTT for developing and transferring training materials into modules and videos. The provincial EPI team can provide virtual technical assistance through various channels, such as Facebook, WhatsApp and YouTube. The programme uses standardized training materials and EPI supervision checklists.


• Improved capacity of districts and health centre staff to perform service and maintenance has reduced the amount of broken equipment.

• Standardized training materials, supervision checklists and five video tutorials to support distance and online trainings were produced.

• At least five CCE in each district were repaired and are in use by province and district staff. The lifespan of CCE is no longer jeopardized by improper service and maintenance.

• Improved budget efficiency allowed increased funding allocations for new devices needed by health centres.

• The gap between the actual and needed quantity of CCE in districts and health centres has narrowed.

• The MoH’s vocational health college adapted CCE service and maintenance modules into its curricula.

• A PHO staff member was named as “best innovative health staff” by the NTT governor for his contribution to CCE service and maintenance.


The innovation was acknowledged by the MoH immunization sub-directorate and adopted by all districts in NTT and NTB provinces, especially following the earthquake.

Cost • Technical skills on CCE service and maintenance

Skills

• Workshops, as needed

• Printing of modules, as needed.

• Video production - no cost (free videos available online)

• Off-line training IDR 1,4 million (USD 100) person/day

• Online training: IDR 150,000 (USD 10) / person

Stake- holders

• National team: Technical assistance and supportive supervision

• Provincial team: Resource person, technical assistance and supportive supervision of CCE service and maintenance

• Districts: Technical assistance and supportive supervision related to CCE at health centres and hospitals

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Lessons Learned

• Capacity building of district stakeholders is important to enable independent technical support for CCE maintenance.

• Routine workshops are essential to upgrade the skills of technical staff, as new versions of CCE become available every year.

• Regular support from the national level is important to building capacity among provincial and district technical staff.


• Blog Article: Cold Chain Expert from East Nusa Tenggara www.indonesiaunicef.blogspot.com/2017/05/sang-ahli-cold-chain-vaksin-dari-ntt.html

• “I want Children in East Nusa Tenggara to be Healthy”, BaKTINews No. 139 July-August 2017 www.bakti.or.id/sites/default/files/files/baktinews/BaKTINews%20Edisi%20139.pdf

• Cold Chain video tutorials:

− Video 1 : www.youtube.com/watch?v=AJU0ZQz8yS8

− video 2 : www.youtube.com/watch?v=CK8_1ivNw_U

− Video 3 : www.youtube.com/watch?v=hhoWpFXyH5I

− Video 4 : www.youtube.com/watch?v=PQC4O1hqYaQ

− Video 5 : www.youtube.com/watch?v=X9mo7sgTcyw

Contact details

• Ermi Ndoen, Chief Field Office - Surabaya ([email protected])

• Kenny Peetosutan, Health Specialist UNICEF ([email protected])

• Moh Ruhul Amin, Immunization Specialist UNICEF ([email protected])

• Yosef Kupertino, East Nusa Tenggara PHO ([email protected])

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Combining On-the-Job-Training for Malaria Microscopist with Microscope Services and Maintenance to Improve Malaria Diagnostic Quality Assurance in East Nusa Tenggara General topic area: Malaria elimination - diagnostic quality assurance Location: East Nusa Tenggara (NTT) – province-wide and focus districts

Summary of the

Approach

The programme aimed to tackle the high number of malaria cases in NTT Province. In 2015, NTT contributed to 20 per cent of nationwide cases. Several factors contributed to this trend, including weak malaria diagnostic capability, poor quality of malaria laboratories, inadequate number of frontline lab technicians and limited supporting facilities and compliance procedures. Together, these factors posed a serious challenge to meeting the 2023 malaria elimination target.

UNICEF supported an NTT Province initiative to address these problems through two main areas of activity:

1. Microscope service and maintenance

• In 2018 a training-of-trainers workshop was conducted and accredited by NTT Province for all districts, as well as specialists and technicians from private laboratories, on microscope service and maintenance.

• The following year three modules and videos tutorials were developed • Centre for Microscope Service and Maintenance was established at the provincial

health laboratory.• The province provided routine technical assistance through its health laboratory.• Districts adopted a similar approach.

2. On-the-job training for lab technicians

• Microscopists from NTT participated in the QA Malaria field study in Aceh, facilitated by UNICEF.

• In Kupang, UNICEF supported collaboration between the Provincial Health Office and its laboratory, the MoH-owned vocational health college and the NTT professional association of laboratory experts (PATELKI) to jointly conduct training and workshops for microscope technicians.

• A customized on-the-job training curriculum was developed to improve the capacity of front-line lab technicians.

• Combined on-the-job training for malaria diagnosticians and microscope services and maintenance is now conducted regularly.

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In addition, virtual support was provided to districts and community health centres using three video tutorials. The provincial malaria elimination team also provides remote technical assistance via social media platforms.

This is the first innovation in Indonesia’s malaria programme that combines supply side (ensuring the availability of good quality microscopes), skills improvement (innovative training for malaria diagnosticians), along with the added benefit of preventing human and technical errors. The programme is designed to be easily adaptable by districts with low fiscal capacity and a limited number of qualified laboratory technicians (level 1 and 2).


• 50 microscopes repaired annually since the activities began, leading to a reduced procurement budget.

• Number of staff qualified to identify malaria in focus districts increased through on-the-job training: the number of districts with a qualified lab technician increased from two to 22.

• One health laboratory staff member was named as ‘innovative health practitioner’ by the NTT governor for his contribution to technical support for routine microscope service and maintenance.

• Quality assurance has become far more reliable, as reflected in the low error rate, down from 48 per cent to less than 5 per cent.

• The number of annual malaria cases declined in Lembata, previously the most malaria-endemic district in NTT province.


• The innovation was acknowledged by the MoH’s malaria sub-directorate and adopted by districts in NTT.

• The MoH’s vocational health college incorporated the malaria service and maintenance modules in their curriculum.

• Professional organizations and district governments adopted this approach to maintain their members’ skills and competencies through independent and regular training and professional supervision support.

Cost• Offline training: IDR 1,5 million (USD 100) /person/day

• Online training: IDR 150,000 (USD 10) /person/day

Skills• Microscope services and maintenance

• Skill assessment

Stake- holders

• Ministry of Health (MoH)

• District and provincial health offices

• District health laboratory

• Community health centres

• Hospitals

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Lessons Learned

Extending the duration of on-the-job training from three to five days led to improved understanding of the material by participants.


• Helping Each Other through Microscope, BaKTINews No.144 January-February 2018 (https://bakti.or.id/bakti-news/baktinews-144-januari-februari-2018)

• Video Tutorials:

− Video 1: www.youtube.com/watch?v=6glUyyUhuys

− Video 2: www.youtube.com/watch?v=QTHfYGUm6gg

− Video 3: www.youtube.com/watch?v=xErhoqr7sP8

Contact details

• Ermi Ndoen, Chief Field Office - Surabaya ([email protected])

• Maria Endang Sumiwi, Health Specialist UNICEF ([email protected])

• Dece Mery Natalia Pay, East Nusa Tenggara PHO ([email protected])

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Improving the Quality of Hospital Care for Mothers and Newborns through Point-of-Care Quality Improvement (POCQI) at District Hospitals General topic area: Maternal and neonatal health Locations: West Nusa Tenggara (West Lombok, East Lombok, and Central Lombok)

Summary of the

Approach

West Nusa Tenggara (NTB) Province had the third highest number of neonatal deaths in the country, and was ranked 32nd for neonatal health (Bappenas, 2017). As part of UNICEF support to NTB’s efforts to address neonatal death, UNICEF partnered with public health association (IAKMI) in selected districts of East and West Lombok to improve the quality of new-born and maternal health and referral services.

In July 2019, POCQI was introduced at Patut Patuh Patju Hospital (West Lombok) and Dr. Soedjono Selong Hospital (East Lombok). POCQI was developed by the WHO as a method to improve the quality of health services through systemic improvements. This problem-solving methodology highlights finding solutions using existing resources. No additional funding is needed. The goal of POCQI was to support quality improvement in maternal and new-born health at referral facilities. The three hospitals are located in focus districts of UNICEF’s MNCH programme and were selected based on consultation with local governments.

To ensure that the POCQI approach would work required a process including:

• Secure commitment from the provincial quality improvement (QI) team to utilize the approach in pilot districts and scale-up to other hospitals.

• Conduct assessments using WHO tools and discuss findings with district hospitals. The assessments showed that the main causes of death in new-born were hypothermia and asphyxia, in addition to the retention of placentae in mothers giving birth.

• Establish a QI team within the maternal and neonatal unit at target hospitals and obtain a commitment to improve quality services in the units.

• Conduct training for both provincial and district/hospital teams on POCQI. The provincial QI team also attended a session on coaching methods.

• Facilitate district QI hospital teams to develop a QI project in the unit with clearly defined outputs, outcome indicators and timelines. Continuous self- assessments were conducted by the QI hospital team to identify progress and challenges to meet targets.

• Mentoring and monitoring were conducted by the provincial QI team to identify progress in unit performance and discuss challenges with the hospital team and management.

• Celebrate and document POCQI progress achieved and share at the provincial level.

• Scale-up to other district hospitals.

In early July 2020, MoH, PHO and UNICEF conducted monitoring and evaluation of the progress made and found that considerable progress had taken place.

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• Hypothermia cases in new-borns declined from 15.29 per cent to 6.45 per cent within 11 months of POCQI implementation

• No deaths occurred due to hypothermia

• Improved quality of early initiation in delivery room

• Decreased cases of placental retention (from 15.6 to 3.18 per cent) within 11 months of POCQI implementation

• No maternal death due to postpartum haemorrhage or placenta retention was recorded where POCQI was being implemented

• No re-admission due to late postpartum haemorrhage or retention of the placentae occurred

• The POCQI approach is continuously used by QI teams in maternal /neonatal units and being introduced to other units at district hospitals

• In East Lombok, the district hospital developed a POCQI project to reduce asphyxia cases in delivery rooms and to increase the weight of low birthweight babies using Kangaroo care (a technique that keeps babies in skin-to-skin contact with mothers or fathers) to keep the babies warm and promote/support breastfeeding.


• In West Lombok, scale-up to two other hospitals is ongoing and another four hospitals received training on POCQI in October 2020.

• In mid-2020 Praya Hospital of Central Lombok District was selected for POCQI training due to high numbers of neonatal and maternal deaths in the district. Central Lombok is one of 120 focus districts targeted by UNICEF due to its high rates of infant and maternal mortality.

• In the 3rd quarter of 2020, four other district hospital teams were trained on POCQI using a combination of off-line and online methods.

Cost• Off-line training: IDR 585 thousand (USD 40) / person

• Online training: IDR 870 thousand (USD 59) / person

Skills

• Understanding of WHO-UNICEF POCQI guideline

• Simple data analysis

• Related clinical knowledge


Stake- holders

• Paediatric Association

• Obstetrics and gynecology (OB/GYN) Association

• Midwife Association


• Provincial and district hospitals

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Lessons Learned

• Commitment from provincial health authorities and hospital management to safeguard the interventions is essential.

• Mentoring and monitoring visits by provincial and national health authorities increased team spirit among QI teams.

• Team celebrations of progress also boosted QI team spirit to continue working to achieve better outcomes.

• Recognition from management (even as simple as providing an opportunity to present progress during meetings) motivated the QI team

• Regular discussion creates solid teamwork for improving systems and services to achieve targets.


Bappeda NTB official news:

www.bappeda.ntbprov.go.id/monitoring-dan-evaluasi-terpadu-program-kerjasama-pemerintah-ri-unicef-periode-2016-2020-untuk-kelangsungan-hidup-perkembangan-dan-perlindungan-ibu-dan-anak-khppia-di-provinsi-ntb/

Contact details

• Vama Chrisnadarmani, Health Specialist UNICEF ([email protected])

• Bobby Marwal Syahrizal, Health Specialist UNICEF ([email protected])

• Mohammad Abdullah, West Nusa Tenggara Public Health Practitioners Association (IAKMI) ([email protected])

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Acceleration of Malaria Control in Endemic Villages through Community Engagement and Utilization of Village Funds General topic area: Malaria Location: Maluku (Maluku Barat Daya)

Summary of the

Approach

Malaria endemicity was mapped from the district to the village level. Mapping activity was held in highly endemic areas within the geographic/ administrative boundary (such as sub-district or island). A field team consisting of health staff from the provincial, district and community levels was deployed to observe potential breeding sites and local customs or habits that could result in malaria transmission in these villages. The observation was conducted together with community and religious leaders. A transect walk provided the opportunity to assess local knowledge on malaria’s host-vector environment and inter-linkages. Prompt diagnosis and treatment was also emphasized as vital to reducing transmission and mortality.

At the end of the visit, meetings were conducted to discuss findings. Leaders were asked to present their village map and identify potential breeding sites. Challenges shared included local customs, seasonal activities (nutmeg/clove harvest) and access to healthcare. Solutions were formulated from the bottom up, including potential funding from the Village Fund, which allows for use in malaria-control although village leaders were not aware of this, as allowed usages of Village Funds change yearly. A memorandum of understanding between the District Health Office (DHO) and Community Village Empowerment Office was developed to accelerate malaria control.

This approach was adapted and implemented by a civil society organization (PERDHAKI) carrying out malaria interventions in the same district. The DHO then assigned areas of work based on level of endemicity, and support was provided to highly endemic villages.


• Accelerated malaria control in Maluku Barat Daya, a highly endemic district with an annual parasite incidence (API) of 14.09 per cent in 2017, led to its classification as moderately endemic district, when the API dropped to 1.8 per cent in 2018 and just 1 per cent in 2019.

• 27 participants from all seven villages in Damer Island and Maluku Barat Daya District partook in the activity. This led to strengthened cross-sectoral commitment to controlling and eliminating malaria on the island through increased knowledge and ownership.


The approach could be adapted for use in quarterly mini-workshop at community health centres, inviting head of villages or representatives from PERDHAKI’s programme to train ‘malaria cadres’.

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Cost

• Facilitator (four-day visit): IDR 1 million (USD 68) /person/day Meeting (20-30 participants): IDR 9 million (USD 615)/ meeting

• Flight/boat ticket – based on location (may include rental car and chartered boat).

Skills• Knowledge about malaria transmission and vector control

• Malaria treatment guidelines

Stake- holders


• Provincial and district development planners

• Community-based health centres

• District Community Village Empowerment Office

• NGOs and professional associations

Lessons Learned

• The strategy of targeting highly endemic areas, identifying problems and developing needs-based solutions proved to be effective.

• The programme improved local knowledge about malaria transmission, control and prevention.

• Coordination and collaboration among stakeholders were strengthened through a clear division of tasks and commitment to the elimination goal.


• Guideline for cadres in special risks areas, MoH, 2020 www.malaria.id/p/buku-tahun-2020.html

• Malaria Case Management Pocket Book, MoH, 2020 www.malaria.id/p/buku-tahun-2020.html

• Village Minister Regulation No 7 of 2020 www.kemendesa.go.id/berita/view/publikasi/376/permendes-no7-tahun-2020

Contact details

• Sisca Wiguno, Malaria/EPI Officer UNICEF ([email protected])


• Risa E. Lating, Malaria Officer PHO Maluku ([email protected])

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Community Empowerment and Mobilization through Participatory Learning and Action for Malaria Elimination General topic area: Health – Malaria, community-based approach Location: North Maluku (all 10 districts)

Summary of the

Approach

Given its rural and remote setting, low fiscal capacity and limited human resources North Maluku Province required a unique approach to malaria control. The national roadmap for malaria elimination categorizes provinces into five regions for certification. North Maluku Province is grouped with provinces in Kalimantan Island (one level above other eastern provinces), which were expected to eliminate malaria by 2027.

In 2008 Indonesia adopted a village-based ‘participatory learning and action’ (PLA) approach, stressing community-based malaria control. UNICEF, the Ministry of Health and the Provincial Health Office provided training for village facilitators to support PLA activities. The training focused on key issues such as: (1) enhanced malaria awareness through mapping of malaria cases and deaths; (2) understanding the malaria lifecycle, symptoms, transmission and conditions conducive to exposure and infection; (3) identifying breeding sites through a village transect walk; and (4) development of village action plans using available resources.

In North Maluku, UNICEF provided various forms of supports under the framework of the previous country program document, including trainings and roll out until 2014, supportive supervision, coordination, monitoring and evaluation until 2016, and facilitation of advocacy meeting and refreshment training until 2019.

Village facilitators were responsible for the implementation in partnerships with village leaders. Village mapping is an important part of the PLA approach. PLA does not require sophisticated tools, most of the learning tools are readily available. The approach can be easily adapted to different local conditions. Since mapping relies heavily on local knowledge, participatory techniques such as brainstorming, role play and group discussion were employed to ensure participation by residents.

Gradually, several environmental improvements were observed: latrines were built or renovated to minimize open defecation and reduce malaria risk; drainage systems were introduced to reduce stagnant water and connect a lagoon to the sea, to control salinity; a swamp was filled to reduce larval breeding. PLA also improved community knowledge and awareness about malaria, particularly on symptoms, the importance of health-seeking behaviour and the quality of services.

The project triggered political and financial commitment by local authorities. Local budgets to support malaria control were allocated; district malaria centres were established; local regulations on malaria were issued; and a school curriculum on malaria control was created in cooperation with the District Education Office and implemented at all elementary schools.

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• The first training was for 30 PLA facilitators in South Halmahera District.

• After being replicated in all districts in North Maluku, by 2019 a total of 1,514 facilitators had been trained to carry out PLA.

• The PLA approach to malaria control has been implemented in 537 villages across the province’s 10 districts.

• From 2015 to 2019, the annual parasite index gradually declined (from 2.8 per cent to 0.5 per cent), and the positive slide rate declined sharply: from 12 per cent to 1.2 per cent.

• Overall, North Maluku is now a province with low endemicity status. Nine out of 10 districts have low malaria endemicity with API values below 1 per cent. Only East Halmahera District has moderate endemicity (1.87 per cent).


The PLA approach to malaria control was replicated in all sub-districts of South Halmahera and all districts in North Maluku and Maluku provinces

Cost

• A 6-day district PLA training : IDR 4,500,000 (USD 307) per person

• A 5-day village facilitator training : IDR 2,500,000 (USD 170) per person

• Community meetings: IDR 1.5 million (USD 103)

Skills

• Communication

• Facilitation techniques

• Community participation, planning / organizing

Stake- holders


• Sub-district community health centres

• Private sector and state-owned companies

• Village governments

• Sub-district governments

• Community, religious, cultural leaders

Lessons Learned

• PLA contributed to empowering local communities to undertake malaria control, triggering political and financial commitments; environmental interventions to minimize exposure and breeding sites; enhanced treatment-seeking behaviour and major reductions in malaria incidence and deaths.

• Using the PLA approach creates demand for malaria-control programmes, as well as for access to high quality malaria services. Thus, service providers have to improve service coverage and quality.


Trainers’ guide to PLA

• www.participatorymethods.org/

• www.researchgate.net/publication/288832171

Contact details

• Badwi M Amin, Health Specialist UNICEF ([email protected])


• Sunarty Arsan, Provincial Health Office (PHO) North Maluku ([email protected])

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Promotion of Maternal, New-born and Child Health through Building Health Worker Capacity and Data Management at Community Health Centres General topic area: Maternal, neonatal and child health Locations: North Maluku (Tidore City and North Halmahera)

Summary of the

Approach

During 2018 and 2019 UNICEF supported governments in Tidore City and North Halmahera District to build the capacity of healthcare workers at 26 community health centres. In the remote areas targeted, neonatal infections often go undetected or treatment comes too late due to the long distances to health facilities, resulting in a high number of preventable deaths. UNICEF worked with the two governments to implement integrated management of childhood illness (IMCI) for new-born babies (aged 0-2 months). The main objective was to enhance the capacity of healthcare workers at primary health facilities to carry out IMCI.

The two components of the programme were training and internships. Training modules covered detection and treatment of infectious diseases. Training activities were conducted to produce pool of trainers, who then were assigned to facilitate an internship programme for midwives working in target locations. The programme produced more than 100 trainers, including healthcare workers and provincial and district health office staff.

The internship programme was designed to enhance the skills of healthcare workers to implement IMCI procedures, especially when referral to a larger hospital is not viable. Many of the participating puskesmas are located on remote islands with poor transportation access. In each puskesmas a mentor was assigned to help up to three interns. Internships lasted for up to two months, during which participants were trained to apply all 17 IMCI procedures described in modules sanctioned by the Ministry of Health. The trainees learned various skills, such as how to apply a simplified regimen to treat infectious diseases. UNICEF encouraged this approach, which combines injection and oral treatment for a period of 5-7 days, as it is easier to perform than the approach that calls only for injection.

During the project a mechanism for reporting from puskesmas to DHO was developed. Each case was recorded in a standardized reporting format at puskesmas and reported monthly for monitoring and evaluation and to allow health officials to identify positive or negative trends in new-born infections.

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• Increased capacity of 46 midwives and healthcare workers at two pilot locations to detect and treat bacterial infections among new-borns.

• Improved data collection and reporting to the PHO.

• More than 100 mentors completed formal training and are available to replicate the work across North Maluku Province.

• Throughout project implementation, the PHO’s health promotion section provided active support through campaigns and awareness-raising.

• Partnerships were developed with private firms (BPRS Bank, North Halmahera Mining) and the state electricity company (PLN) to support certain components of the work.


A workshop inviting representatives from 10 districts, with a view to scaling up the initiative, was conducted in 2019. Two local governments, Ternate City and West Halmahera District, committed to replicating the project in 2020, but implementation was interrupted by the COVID-19 pandemic.

Cost

• Five-day training of trainers: IDR 800,000-1,450,000 (USD 57 - 98) per person

• Two-month internship programme: IDR 500,000 (USD 35) per person

• Printing of modules: IDR 15,000 (USD 10) per piece

Skills• Application of training modules


Stake- holders

• Provincial health office (PHO)

• District health office (DHO)


• Health workers/midwives

Lessons Learned

• The simplified procedure for addressing neonatal infections was very useful since it allows midwives to combine injection and oral treatment.

• Improved data utilization by the DHO requires timely data collection by puskesmas.


• On-the-job training module on IMCI

• On-the-job training guideline on IMCI in puskesmas

Contact details

• Yuliana Hasim, Health Officer UNICEF ([email protected])

• Badwi M Amin, Health Specialist UNICEF ([email protected])

• Nurhayati Buamona, North Maluku PHO ([email protected])

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Improving Maternal and Neonatal Services through On-the-Job Training for the Integrated Management of Childhood Illness General topic area: Managing childhood illness Locations: Jayapura City and Biak City

Summary of the

Approach

The World Health Organization recommends the integrated management to childhood illness (IMCI) as a cost-effective approach for reducing maternal and neonatal mortality rates, especially in less-developed countries with limited resources.

In Indonesia, not enough health staff were trained to use IMCI, limiting quality implementation. IMCI training for health staff generally demands significant funding and requires that health staff be absent from their post for about two weeks. In some cases, this is not feasible for local governments or District Health Offices in Indonesia.

UNICEF and the Ministry of Health sought to resolve this situation by modifying the training curriculum used for the traditional method into a method using on-the-job training (OJT). Instead of being delivered in the classroom, training took place at the workplace, integrated into daily routine activities. Facilitators and trainees worked together for around two months to ensure the complete transfer knowledge and skills. This initial round of training prepared the participants for facilitating further training for other colleagues at the facility, using the same method. This process continued until all health workers at the facility had received IMCI training.

This method was accepted and implemented quite well by the DHO Jayapura and Biak. One participant noted that the training not only improves health workers’ skills, but also makes a positive contribution to other aspects of the facility’s work, such as the flow of MNCH services and reporting and recording processes.


• Around 150 health workers were trained and certified on the IMCI approach in Jayapura and Biak.

• The capacity of health worker to recognize and manage new-born and child illness has improved.

• Improved service and data management at health centres.


Since most districts in Papua already have trained IMCI facilitators, replication requires a refresher workshop to update staff about the OJT method.

Cost

• Three-day workshop for district IMCI facilitators: IDR 2 million (USD 150) per participant

• On-the-job training: IDR 1 million (USD 75) per participant

• Printing and training material: IDR 580,000 (USD 40) per participant

• Certificate: IDR 125,000 (USD 8.5) per participant

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Skills

• Facilitation

• Mentoring

• IMCI techniques

Stake- holders

• Provincial and District Health Offices


• Health workers

Lessons Learned

• OJT approach is workable and does not reduce the quality of IMCI services

• It is very important that the DHO conduct regular supervision and monitoring

• There is an opportunity to improve MNCH services and data management during the process.


• On-the-job training module on IMCI in Puskesmas

• On-the-job training guideline on IMCI in Puskesmas

Contact details

• Yohan Prasetyo, Health Officer UNICEF ([email protected])

• Bobby Marwal Syahrizal, MNCH Specialist UNICEF ( [email protected] )

• Dr. Leonora Komboy, DHO Biak ([email protected])

• Dr. Farid Yusuf, DHO Jayapura ([email protected])

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UNICEF Support to Polio Outbreak Response in Papua General topic area: Health and well-being Location: Papua

Summary of the

Approach

After being declared polio-free by the World Health Organization (WHO) in 2014, new cases of polio emerged in Papua in January 2019. Three children were confirmed positive with polio virus, one of whom suffered from acute flaccid paralysis (AFP). In response, Yahukimo District, at the centre of the outbreak, declared polio to be an outbreak in a decree issued by the district head. The Ministry of Health quickly responded by conducting two weeks of ‘outbreak response immunization’, followed by two rounds of supplementary polio immunization activities (SIA), as well as increasing surveillance sensitivity and expanding environmental surveillance in Papua throughout 2019.

To ensure that at least 95 per cent of children younger than 15 years were immunized, UNICEF provided comprehensive support in 17 of 29 cities/districts. Several practical steps and strategies were devised to adapt to geographic-, security- and resource-related challenges. Coverage for the first round stood at 77.26 per cent, but the target was eventually met by December 2019 when, after a tremendous effort, over 95 per cent of children were successfully vaccinated in the second round. This represented by far the highest immunization coverage in the province’s history.

A WHO-affiliated outbreak response assessment team confirmed this achievement. A May 2020 letter from the WHO Regional Director concluded that Papua is again free from polio, based on an assessment conducted from April to May 2020.

UNICEF’s approach to the polio outbreak called for:

1. Technical and managerial support

• Funding support to mobilize the polio SIA team, using air transport to access hard-to-reach areas in Yahukimo

• Support for a logistics consultant and EPI consultant for the Yahukimo special operation

• Provision of a provincial-level communication for development (C4D) consultant and immunization consultant

• Developing print and electronic information, education and communication materials and widespread distribution

• Providing an electronic monitoring and evaluation system through Rapid Pro and ONA tools

• Placing field officers in 15 districts to improve microplanning, vaccine and cold chain management and social mobilization activities

• Deployment of a special high-level team including WHO, the Provincial Health Office (PHO) and Centers for Disease Control to accelerate SIA in remote districts

• Providing special technical assistance and training to health and church cadre in the high-risk security district of Nduga.

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2. Social mobilization

• Facilitating social mobilization activities involving local leaders, church leaders and community leaders

• Involving Papua Province Police, the youth groups, boy scouts and several professional organizations in a series of mobilization activities, through social media

• Using provincial and district commemoration events to promote the polio campaign.

3. Advocacy

• To create an enabling environment supportive of the goals of polio SIA• Advocated with religious, local and community leader and local tribes• Facilitated coordination meetings with local and church leaders• Initiated the establishment of a Papua Health Advisory Group.

Despite no cases of AFP since February 2019, the MoH decide that the second phase of polio response was still needed, since vaccination coverage prior to the outbreak tended to be low. The second phase focused on completing the basic immunization status of children under three years with the aim of:

1. Increasing immunity to polio and other diseases that can be prevented by immunization (penyakit yang dapat dicegah dengan imunisasi or PD3I),

2. Improving the quality and sensitivity of AFP and other PD3I surveillance

3. Expanding the distribution range of IPV (inactivated polio vaccine) and OPV (oral polio vaccine) to all regions in Papua and West Papua

4. Accelerating the implementation of routine immunization programmes.

UNICEF collaborated with WHO and the PHO in the design of a support strategy that involved:

1. Analysis of immunization data targets, including potential coverage and capacity of all available resources (human, access, cold chain, and support from local governments)

2. Conducting intensive technical support by placing field officers and strengthening at least one community health centre to serve as a learning centre for other centres in 15 priority districts

3. Capacity development of immunization programme managers in districts, including in electronic reporting and surveillance systems

4. Involvement by communities and immunization support groups to carry out social mobilization

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• From the total target of 895,886 children under 15 years of age, 77.24 per cent were vaccinated in round 1 and 95.76 per cent in round 2. This is the highest polio immunization coverage in the history of Papua (PHO, 2019).

• In Yahukimo District, the centre of the outbreak, coverage rates for the first and second rounds of bivalent oral polio vaccine were 30.20 per cent and 91.5 per cent, respectively.

• The Yahukimo special operation successfully reached 62 landing spots and delivered polio SIA in 466 villages.

• The Papua Government adopted UNICEF’s social mobilization strategy for use in its COVID-19 risk communication and engagement strategy.


In 2020 UNICEF and three implementing partners (GAPAI, YP2KP and doctorSHARE) committed IDR 6 billion (USD 410,000) to support all activities, including placement of field officers in 15 districts. Districts are required to fund sustainable outreach services, procure equipment, train district immunization officers and establish on-the-job training centres.

Cost

• Immunization in the highlands: IDR 95,000 (USD 6,5) / child • Immunization in the lowlands: IDR 43.500 (USD 3) / child• Training for health workers: IDR 15-20 million (USD 1,000- 1,367)/person/ year. • On-the-job training (two weeks): IDR 2 million (USD 137) /person

Stake- holders

• Provincial Health Office • District Health Office • Community health centres• Local governments• WHO• Professional organizations • Non-governmental organizations/partners

Lessons Learned

• Geographical challenges to expanding immunization coverage were overcome through strategic planning and the allocation of adequate time to manage all resources.

• The strategic plan developed during the polio SIA for reaching hard-to-reach areas - addressing human resources, time, cost and social mobilization and advocacy - will serve as a valuable resource and reference tool for improving routine immunization planning.

• Social mobilization, with an emphasis on local contexts and combining various media, will become a strategic approach for accelerating efforts by immunization programmes to reach areas characterized by high levels of social and cultural diversity and security issues.


• Health Minister Regulation No.12 Year 2017 on Guidance on Immunization

• Polio Outbreak Response Assessment Final Report

Contact details

• Husny Muttaqin, Immunization Officer UNICEC ([email protected])

• Kenny Peetosutan, Health Specialist UNICEF ([email protected])

• Yasman, Papua PHO Immunization Program Responsible Officer ([email protected])

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Use of Human-Centred Design to Increase Routine Immunization Coverage General topic area: Immunization Locations: East Java (Surabaya City, Madiun City, Blitar, Ponorogo, Bangkalan and Probolinggo)

Summary of the

Approach

Despite government efforts to immunize all children, by 2018 the national measles-rubella campaign had coverage of just 71 per cent. Low coverage was partly due to concerns over its safety and general vaccine safety concerns, as well as issues around equity and access to immunization.

Although Indonesia’s health system reaches most children, some 4.9 million each year with immunization and other services, alarming gaps in coverage have emerged. Unvaccinated children put the entire community at risk for disease outbreaks that could be prevented by immunization.

Human centred-design (HCD) helps to enhance strategies focused on how and why people do or do not engage with health services, as a means to achieve optimal results.

The HCD approach assists understanding of the causes, barriers and roots of health-seeking behaviour and what might be done to increase service use. It offers a structured process for working directly with service users and health workers to address challenges related to coverage and quality of care.

The initiative used an HCD lens to understand motivations and constraints related to the provision of immunization services in Indonesia, which differ in each province and region and require that solutions be tailored to local problems. The HCD process is suitable for Indonesia: a diverse country with a broad geography, decentralized decision-making and the need for districts, cities and provinces to design effective interventions.


• Collected information on the underlying reasons and obstacles that occur in carrying out routine immunizations.

• Identification of needs, limitations, obstacles and barriers to knowledge and ideas for interventions to implement a good immunization routine.

• Identification of relevant social dynamics, institutions and values that can help implement immunization targeting all children.

• Mapping of concerned caregivers, health workers, decision makers, and community leaders participating in the process

• Mapping of the ongoing immunization service system to identify obstacles and opportunities for immunization officers.

• Developed a plan to reach households whose children have not been immunized, hard-to-reach areas such as slum or remote areas, or areas where immunization faced rejection.

• Active participation from the most relevant stakeholders, both government and non-government institutions.

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A workshop inviting representatives from 32 districts/cities with a view to upscaling the initiative was conducted in 2020. The local governments are now committed to replicate the HCD approach to increase the coverage of routine immunization in 2021.

Cost• Training on HCD

• Printing of module and guideline (optional)

Skills• Application of HCD training modules

• Facilitation and mentoring skills

Stake- holders

• Provincial Health Office

• District Health Offices

• Community health centres

• NGOs and associations

• Target groups representing users and community.

Lessons Learned

• HCD allows for a process of finding solutions to expand immunization coverage by involving the community and considering local community context.

• Community members feels more valued when they can express opinions about how to solve immunization problems.

• People are invited not only to see obstacles but also to look at supporting factors.

• HCD helps to understand the underlying reasons and barriers to immunization, particularly geographic and societal barriers, as well as avoiding generalization of the problem.

• Improve the ability of health services access how and why people are involved, or not involved, and the services to achieve results.


• Human Centred Design Training Module

• Demand for Health Services Field Guide

• Demand for Health Services Workbook

• Companion Workbook & Process Poster for “Demand for Health Services”

Contact details

• Armunanto, Health Specialist UNICEF ([email protected])

• Kenny Peetosutan, EPI Specialist UNICEF ([email protected])

• Dr. Nyoman Anita Damayanti, drg, MS; focal point partnership UNICEF-University of Airlangga ([email protected])

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Optimizing the Triple Elimination Prevention Programme through Private Services in Districts and Cities General topic area: Maternal, neonatal and child health Locations: East Java (Surabaya City, Malang City, Malang, Jember, Banyuwangi), Central Java (Semarang City, Surakarta City, and Brebes).

Summary of the

Approach

Triple elimination is an Indonesian strategy for addressing HIV, syphilis and hepatitis B through maternal and child health services. It is now integrated into maternal and child health (MCH), family planning and adolescent health services. Women seeking these services also receive information about triple elimination. Health personnel are required to test all pregnant women for HIV, syphilis and hepatitis B at least once, as part of antenatal care. Increased access to service providers and timely interventions are expected to contribute to the prevention of mother to child transmission.

UNICEF collaborates with Airlangga University to support the provincial government and five districts/cities in East Java (Surabaya City, Malang City, Malang, Jember and Banyuwangi) in implementing the triple elimination programme. The objectives are to engage private service providers (midwives, clinics, hospitals), to strengthen coordination between the MCH and Diseases Prevention and Control (P2P) units at local health offices, and to increase the capacity of health workers.

PHO decree is issued instructing local government to conduct on-the-job training for health workers and to develop a referral mechanism. Every pregnant woman who tests positive for HIV, syphilis or hepatitis B must receive standard management and follow-up. Logistical planning required for these services is carried out in stages, from the central to the provincial and district levels. The analysis of the results of monitoring, evaluation, and supervision is carried out periodically.


• Increased capacity of health workers and improved facilities, including from private service providers, to implement the triple elimination programme.

• Enhanced participation from private service providers at district level in the triple elimination programme.

• There is an increase in the quality of maternal and child health services according to standards.

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A workshop involving representatives from 33 districts/cities from East Java Province and 32 districts/cities from Central Java Province with the aim of replicating the programme was planned for 2020, but implementation was interrupted by the COVID-19 pandemic, which is consuming the main share of the health budget.

Cost• Budget for training and coaching (local budget allocation)

• Printing of module and guideline (local budget allocation)

Skills• Application of training modules


Stake- holders

• Provincial Health Office

• District Health Office

• Indonesian Medical Association (IDI)

• Indonesia Midwives Association (IBI)

Lessons Learned

• The programme can serve as a reference point for local governments, health workers and other stakeholders implementing programmes to eliminate mother-to-child transmission.

• Networks and cross-program partnerships in districts/cities play a crucial role in enhancing participation from private service providers.


• Triple Elimination Module (PDF).

• Management of pregnant women for early detection (Laboratory Examination) in early management of HIV - syphilis - hepatitis B (PDF).

Contact details

• Armunanto, Health Specialist UNICEF ([email protected])

• Dr. Nyoman Anita Damayanti, drg, MS; partnership focal point UNICEF-University of Airlangga ([email protected])

• Dr. dr. Sutopo Patriajati, MM, MKes; partnership focal point UNICEF-University of Diponegoro ([email protected])

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annex - compendium of good practices - UNICEF

Documents

Transcript of annex - compendium of good practices - UNICEF