HUMAN RESOURCES FOR HEALTH in maternal, neonatal and reproductive health at community level. A profile of Indonesia

Maternal, neonatal & reproductive health HUMAN RESOURCES FOR HEALTH in maternal, neonatal and reproductive health at community level A profile of Indonesia Angela Dawson, Tara Howes, Natalie Gray and Elissa Kennedy HUMAN RESOURCES FOR HEALTH KNOWLEDGE HUB www.hrhhub.unsw.edu.au Indonesia

The Human Resources for Health Knowledge Hub This technical report series has been produced by the Human Resources for Health Knowledge Hub of the School of Public Health and Community Medicine at the University of New South Wales. Hub publications report on a number of significant issues in human resources for health (HRH), currently under the following themes: leadership and management issues, especially at district level maternal, neonatal and reproductive health workforce at the community level intranational and international mobility of health workers HRH issues in public health emergencies. The HRH Hub welcomes your feedback and any questions you may have for its research staff. For further information on these topics as well as a list of the latest reports, summaries and contact details of our researchers, please visit www.hrhhub.unsw.edu.au or email hrhhub@unsw.edu.au Human Resources for Health Knowledge Hub and Burnet Institute on behalf of the Women s and Children s Health Knowledge Hub 2011 Suggested citation: 2011, Human resources for health in maternal, neonatal and reproductive health at community level: A profile of Indonesia, Human Resources for Health Knowledge Hub and Burnet Institute, Sydney, Australia. National Library of Australia Cataloguing-in-Publication entry Dawson, Angela Human resources for health in maternal, neonatal and reproductive health at community level: A profile of Indonesia / Angela Dawson... [et al.] 9780733429767 (pbk.) Maternal health services--indonesia--personnel management. Community health services--indonesia--personnel management. Howes, Tara. University of New South Wales. Human Resources for Health. Gray, Natalie. Kennedy, Elissa. Burnet Institute. Women and Children s Health Knowledge Hub. 362.198209598 Published by the Human Resources for Health Knowledge Hub of the School of Public Health and Community Medicine at the University of New South Wales. Level 2, Samuels Building, School of Public Health and Community Medicine, Faculty of Medicine, The University of New South Wales, Sydney, NSW, 2052, Australia Telephone: +61 2 9385 8464 Facsimile: +61 2 9385 1104 hrhhub@unsw.edu.au www.hrhhub.unsw.edu.au Please contact us for additional copies of this publication, or send us your email address and be the first to receive copies of our latest publications in Adobe Acrobat PDF. Design by Gigglemedia, Sydney, Australia.

Contents 2 Acronyms 3 Executive summary 4 Indonesia: selected HRH and MNRH indicators 5 Key background information 6 Overview of maternal, neonatal and reproductive health 7 Services and cadres at community level 8 Coverage and distribution 9 Competency 9 Supervision and scope of practice 12 Education and training 12 Teamwork 12 Country registration 12 HRH policy and plans 13 MNRH policy and plans 13 Remuneration and incentives 13 Key issues or barriers 14 Key initiatives 15 Critique 16 References 18 Appendix 1: Pre- and in-service education and training in Indonesia 19 Appendix 2: Country registration in Indonesia 20 Appendix 3: Country HRH and MNRH policies in Indonesia List of Tables 5 Table 1. Key statistics 7 Table 2. Cadres involved in MNRH at community level in Indonesia 9 Table 3. Health worker distribution in Indonesia 10 Table 4. Distribution of the health workforce, village maternal huts and community clinics over the districts of Indonesia 1

Acronyms AAAH ANMC AusAID BDD BPK GDP HRH JNPK MDG MNRH MoH PNS PODES PTT USAID UNDESA USD$ WHO Asia-Pacific Action Alliance on Human Resources for Health Australian Nursing and Midwifery Council Australian Agency for International Development bidan di desa (village-based midwife) Badan Pusat Statistik (Statistics Indonesia) gross domestic product human resources for health Jaringan Nasional Pelatihan Klinis (Indonesia s national training network for health providers) Millennium Development Goal maternal, neonatal and reproductive health Ministry of Health pegawai negeri sibil (permanent employee) Potensi Desa (Village Potential Statistics) pegawai tidak tetap (contractual employee) United States Agency for International Development United Nations Department of Economic and Social Affairs United States dollar World Health Organization A note about the use of acronyms in this publication Acronyms are used in both the singular and the plural, e.g. MDG (singular) and MDGs (plural). Acronyms are also used throughout the references and citations to shorten some organisations with long names. 2

EXECUTIVE SUMMARY This profile provides baseline information that can inform policy and program planning by donors, multilateral agencies, non-government organisations and international health practitioners. Accurate and accessible information about the providers of maternal, neonatal and reproductive health (MNRH) services at the community level (how they are performing, managed, trained and supported) is central to workforce planning, personnel administration, performance management and policy making. Data on human resources for health (HRH) is also essential to ensure and monitor quality service delivery. Yet, despite the importance of such information, there is a paucity of available knowledge for decision making. This highlights a particular challenge to determining the workforce required to deliver evidence-based interventions at community level to achieve Millennium Development Goal (MDG) 5 targets. This profile summarises the available information on the cadres working at community level in Indonesia; their diversity, distribution, supervisory structures, education and training, as well as the policy and regulations that govern their practice. The profile provides baseline information that can inform policy and program planning by donors, multilateral agencies, non-government organisations and international health practitioners. Ministry of Health staff may also find the information from other countries useful in planning their own HRH initiatives. The information was collected through a desk review and strengthened by input from key experts and practitioners in the country. Selected findings are summarised in the table below. There are key gaps in the collated information which may point to the need for consensus regarding what HRH indicators should be routinely collected and how such collection should take place at community level. 3

Indonesia: SELECTED HRH AND MNRH INDICATORS Maternal mortality ratio in 2008 240 deaths per 100,000 live births Skilled birth attendance: 75% of births attended by a skilled birth attendant (2005-2009) Human resources for health policy reference to community level HRH in MNRH YES Neonatal mortality ratio in 2009 19 deaths per 1,000 live births 20 nurses and/or midwives per 10,000 people 54.5% Government spending on health as a percentage of total expenditure on health (2007) Maternal, neonatal and reproductive health policy reference to community level HRH in MNRH YES 2 doctors per 10,000 people Key to acronyms HRH human resources for health MNRH maternal, neonatal and reproductive health (Adapted from MoH Indonesia 2005; Rokx et al. 2009; UNICEF 2010; WHO 2010) 4

KEY BACKGROUND INFORMATION Table 1. KEY STATISTICS (Adapted from Hogan et al. 2010; UNDESA 2005; UNICEF 2010; WHO 2010) population Total thousands (2008) 227,345 Annual growth rate (1998 2008) 1.3% Health expenditure (2007) Total expenditure on health as a percentage of GDP 2.2% General government expenditure on health as a percentage of total expenditure on health 54.5% Private expenditure on health as a percentage of total expenditure on health 44.5% MDG 5 status Insufficient information MORTALITY RATIO Number of maternal deaths for every 100,000 live births: UNICEF 2010 Hogan et al. 2010 240 229 (133 379 Number of neonatal deaths for every 1,000 live births (in the first 28 days of life; 2009) 19 Skilled birth ATTENDANCE (2005 2009) Percentage of births covered by a skilled birth attendant 73% A note on health expenditure Government spending on health as a percentage of total expenditure has increased from 40% in 1995 to 50.4% in 2006 (as seen in Table 1). Expenditure on health as a percentage of gross domestic product (GDP) has also increased slightly from 1.9% in 1995 to 2.2% in 2007 (WHO 2010). Most health care workers earn the majority of their income from private practice. For example, in Banten Province, West Java, private practice was found to make up 58% of midwives annual salary (Ensor et al. 2009). Private practice is actively encouraged by the government. Since decentralisation, provinces have been required to raise a third of the income needed to manage HRH (Hennessy et al. 2006b). Key to acronyms GDP gross domestic product MDG Millennium Development Goal 5

OVERVIEW OF MATERNAL, neonatal AND REPRODUCTIVE HEALTH Although 70% of Indonesian women receive a postnatal check-up within two days of birth, 16% of women receive no postnatal care. In 2007, 73% of births were attended by trained personnel in Indonesia (Rokx et al. 2009). The majority of births take place in either the woman s home (64%) or a midwife s home (28%) 1, with home births more common in rural areas (Thind and Bannerjee 2004; Makowiecka et al. 2008). Following decentralisation in 2001 the management of puskesmas (community health centres) and public hospitals was transferred to the provincial governments. Training institutes are currently producing more nurses and midwives than can be absorbed by the system, with places only being available for about 10% of midwifery graduates. The Healthy Indonesia Plan calls for a tripling of the total health workforce; this is not a major concern for nurse training, as large numbers are already in training (Rokx et al. 2009). There has been a general increase in facility-based births, with these increasing from 20% in 1997 to 46% in 2007. Amongst the poor, only 11% of women give birth in a facility, with two-thirds of these women choosing private clinics. There is currently an aim to reduce the maternal mortality ratio to 125 for every 100,000 live births by 2010 (Thind and Bannerjee 2004). Midwife densities in Indonesia are 2.2 for every 1,000 people. This is comparable with countries such as Malaysia (3.4) and Sri Lanka (1.6), who have achieved high rates of coverage by a skilled birth attendant (Ronsmans et al. 2009). However, referral facilities have lagged behind these other countries (Shankar et al. 2008). There is a high coverage of antenatal care, with 82% of women attending at least four antenatal visits. The majority of women (79.3%) receive antenatal care from a nurse, midwife or village midwife. Although 70% of Indonesian women receive a postnatal check-up within two days of birth, 16% of women receive no postnatal care (BPK and Macro International 2008). The majority of public service providers are also employed in the private sector (between 60% and 70%). Dual practice was introduced in the 1970s to allow health care staff to supplement their low incomes. Currently, there is a health information system in place to record public workforce data, but not information about private providers (Rokx et al. 2009). In 2001, the government started the process of decentralisation. This created some issues concerning health workforce planning and distribution how it is carried out and who is responsible for different aspects of this planning. Decentralisation has led to a greater focus on district-based training and the opening of new training institutes. 1 In the 2007 Demographic Health Survey, the rate of home births was recorded as lower, with 53% of births taking place at home. 6

SERVICES AND CADRES AT COMMUNITY LEVEL The cadres working in MNRH at the community level and the tasks they perform are outlined in Table 2. Table 2. Cadres Involved in MNRH at Community Level in indonesia (Adapted from Makowiecka et al. 2008; Ronsmans et al. 2009; Utomo, et al. 2006) Base or place Home Staff involved (name of cadre) Bidan di desa, pegawai tidak tetap (BDD PTT): village-based midwife, contractual government employee Bidan di desa, pegawai negeri sibil (BDD PNS): midwife, permanent government employee Petugas lapangan keluarga berencana: family planning volunteer Dukun terlatih 2 : trained traditional birth attendant Dukun tidak terlatih: untrained traditional birth attendant Private midwife Possible service in the community Skilled birth attendance, antenatal care and postnatal care Although usually located in government clinics, this cadre of permanent employee often also assists women with home births, antenatal care and postnatal care Organises meetings, promotes family planning, provides information and contraception, organises income-generating activities and records uptake by couples Birth attendance and referral Birth attendance Antenatal care, birth attendance and postnatal care Outreach centre Nurse May provide midwifery care in villages along with health centre nursing duties Aid post or basic clinic Health centre midwife Family planning volunteer Health centre midwives BDD PNS: midwife, permanent government employee BDD PTT: village-based midwife, contractual government employee May provide village-based midwifery care Works in posyandu (sub-village integrated health post), often runs monthly services for baby weighing, family planning, nutrition and diarrhoea control Skilled birth attendance and postnatal care Works in clinics, skilled birth attendance, antenatal care and postnatal care Often located at puskesmas pembantu (satellite community health centre), provides maternity care and often emergency health care services to the community 3 2 Reviewer comment: Most villages have traditional birth attendants. 3 Reviewer comment. 7

COVERAGE AND DISTRIBUTION There are two main cadres of midwives. The first midwife is the pegawai negeri sibil (PNS; permanent) midwife. They are employed by the government on a permanent contract, are usually more experienced and work in clinics and villages. Due to their greater level of experience they often run their own private practice. The cadre of pegawai tidak tetap (PTT; contract) midwife emerged from the government Village Midwife Program. PTT midwives are employed by the government on a temporary (but renewable) three-year contract. They are often recent graduates with little experience (Hull and Mosley 2009; Makowiecka et al. 2008) 4. There are no job descriptions attached to either cadre of midwives (Hennessy et al. 2006c). Of all village-based midwives, 46% are PTT and 54% are PNS. On the other hand, of those working in health centres, only 3% are PTT and 97% are PNS (Makowiecka et al. 2008). One study based in Serang and Pandeglang found that the largest group of midwifery service providers was village midwives (49% of the midwife workforce), followed by health centre midwives (26%), nurses (9%), public hospital midwives (7%) and other hospital midwives (4%). Irrespective of numbers in each cadre, most women prefer to use midwives operating from their own private practice as they are considered to be more experienced (Makowiecka et al. 2008). There is a maldistribution of staff between rural and urban areas. For example, in urban Java there is 1 doctor to 3,000 people, compared with 1 doctor for every 22,000 people in rural Java. 5 This trend is changing with an increase in the ratios of doctors to population in rural and remote areas and decreasing ratios in urban areas. This could be the result of rural-urban migration (Rokx et al. 2009). Table 4 (pp.10 11) outlines the provinces of Indonesia and the numbers of doctors, nurses, midwives, village maternal huts and community clinics in each province. There is uncertainty about the number of health workers due to different methods of reporting. The PODES Survey (Potensi Desa; Village Potential Statistics) asks village leaders about the number of health professionals serving in their area and the Governance and Decentralisation Survey relies on information from district health offices. However, this was restricted to 139 out of 400 districts (Rokx et al. 2009). There is no central register of nurses which makes determining their number difficult (Hennessy et al. 2006b). Midwives typically serve one or more villages, catering for 3,500 people, and attend 36 deliveries a year (Ensor et al. 2009). Midwives working in rural areas often have a large workload, with one midwife being responsible for up to five villages. Only 29% of villages have their own resident midwife (Immpact 2007). While this means that there is a higher ratio of midwife to population, it also means that midwives working in rural areas have the potential to bring in a higher income as they have a greater patient load (Ensor et al. 2009). This section provides an overview of the numbers of health workers who may be engaged in MNRH at community level. Table 3 describes the distribution of this workforce according to gender and employment in the public and private sectors where available. 4 Reviewer comment: Village midwives may sometimes work in areas where there is a low population density and will therefore only care for a very small number of women each year, making it difficult to maintain professional skills. 5 Reviewer comment: There is also a great difference in health outcomes between different provinces, with eastern Indonesia having the highest burden of maternal and child mortality. For example, in Papua Province the maternal mortality ratio is 1,025 for every 100,000 live births. 8

Table 3. Health worker distribution in Indonesia (Adapted from Rokx et al. 2009) Cadre Number gender Male Female Ratio to 1,000 people Doctors 44,564 0.19 Registered nurses 308,306 1.35 Registered midwives 79,152 0.35 Community health workers 1,800 trained to date 100% 0.008 COMPETENCY Often in remote areas, with no other health care staff, nurses perform midwifery services for which they are not trained (Rokx et al. 2009). They have also performed badly in technical skills assessments (Rokx et al. 2009). There is a lack of technical capacity amongst nurses who are often relied upon in rural and remote regions (Rokx et al. 2009). SUPERVISION AND SCOPE OF PRACTICE Once a month, bidan di desa, pegawai tidak tetap (BDD PTT) take part in staff meetings where they present reports and are able to discuss technical matters with more senior midwives. 6 In some districts there are issues with dual reporting, with BDD PTTs being required to report to a local clinic doctor and also the head of the village (Hull et al. 1998). Family planning volunteers are supervised by family planning field workers who are responsible for educating, training and supervising the volunteers (Utomo et al. 2006). In a district in East Java, traditional birth attendants are being encouraged to escort pregnant women to facilities to deliver their babies and are given small monetary incentives to do this. Deliveries assisted by a traditional birth attendant alone have dropped from 86% in 1984 to 1% in 2007. It is still, however, more realistic for the poor to use a traditional birth attendant as the cost of one is about USD$7 compared with USD$23 for a midwife (Immpact 2007). Midwives work with facilities to organise referrals in cases of complications. They often encourage women to seek emergency obstetric care at facilities by organising feeexemption documents, thereby removing family fears about the cost involved (Immpact 2007). The scope of practice for midwives is set out by the Ministry of Health decree 576/1996 and decree number 1239/2000 for nurses and midwives (ANMC 2009). Medical doctors are often required to manage the puskesmas (community health centres) although they have received no training for this task (Rokx et al. 2009). Similarly, nurses often run the outpatient clinics in more remote areas, often performing tasks they have not been trained to do (Rokx et al. 2009). 6 Reviewer comment. 9

Table 4. Distribution of the health workforce, village maternal huts and community clinics over the districts of Indonesia (Adapted from Rokx et al. 2009; MoH Indonesia 2005) Province Population Doctors Nurses (000 s) Number Ratio to 1,000 people Number (private only) Ratio to 1,000 people Aceh 4,073 820 0.20 2,400 0.59 Bali 3,432 1,378 0.40 1,049 0.31 Bangka-Belitung 1,075 187 0.17-0.00 Banten 9,244 1,069 0.12 874 0.09 Bengkulu 1,568 311 0.20 1,074 0.68 Gorontalo 941 173 0.18 910 0.97 Irian Jaya (Papua) 2,662 463 0.17 1,652 0.62 Jakarta 8,963 2,893 0.32-0.00 Jawa Barat (West Java) 39,649 5,531 0.14 6,177 0.16 Jawa Tengah (Central Java) 32,179 5,356 0.17 15,230 0.47 Jawa Timur (East Java) 36,592 6,410 0.18 11,035 0.30 Kalimantan Barat (West) 4,118 445 0.11 1,595 0.39 Kalimantan Selatan (South) 3,346 520 0.16 1,568 0.47 Kalimantan Tengah (Central) 1,938 317 0.16 1,362 0.70 Kalimantan Timur (East) 2,936 711 0.24 2,252 0.77 Lampung 7,212 710 0.10 1,657 0.23 Maluku 1,271 176 0.14 1,930 1.52 Maluku Utara (North) 919 146 0.16 829 0.90 Nusa Tenggara Barat (West) 4,257 502 0.12 2,207 0.52 Nusa Tenggara Timur (East) 4,355 494 0.11 1,341 0.31 Riau 6,101 1,190 0.20 3,109 0.51 Sulawesi Selatan (South) 8,622 1,659 0.19 4,373 0.51 Sulawesi Tengah (Central) 2,349 360 0.15 1,670 0.71 Sulawesi Tenggara (South-east) 2,002 306 0.15-0.00 Sulawesi Utara (North) 2,161 937 0.43 1,203 0.56 Sumatera Selatan (South) 6,900 1,002 0.15 4,190 0.61 Sumatera Utara (North) 12,643 2,761 0.22 3,660 0.29 Yogyakarta 3,389 1,307 0.39 805 0.24 10

Number Midwives Ratio to 1,000 people Total ratio of human resources to 1,000 people Number of village maternal huts Number of community clinics 4,475 1.10 1.89 1,929 4,875 1,156 0.34 1.04 221 4,588 346 0.32 0.50 197 1,071 2,018 0.22 0.43 259 8,648 1287 0.82 1.70 716 1,695 374 0.40 1.55 257 943 2,084 0.78 1.58 279 71,160 907 0.10 0.42-3,882 8,615 0.22 0.51 691 41,231 9,973 0.31 0.95 4,068 43,607 10,294 0.28 0.76 4,807 43,672 1,367 0.33 0.83 1,198 3,781 1,778 0.53 1.16 1,135 3,257 1,125 0.58 1.45 661 2,069 1,152 0.39 1.40 364 4,100 2,302 0.32 0.65 1,062 7,116 1,009 0.79 2.45 83 1,360 712 0.77 1.84 353-1,096 0.26 0.89 395 520 3,077 0.71 1.13 1,253 8,003 2,052 0.34 1.04 226 3,826 3,242 0.38 1.08 185 8,579 1,541 0.66 1.52 901 2,642 1,431 0.71 0.87 349 2,096 1,273 0.59 1.58 368 2,055 3,048 0.44 1.19 636 5,676 7,142 0.56 1.07 2,744 14,974 792 0.23 0.86 133 5,373 11

EDUCATION AND TRAINING TEAMWORK There has been an increase in the number of medical training schools, especially since the process of decentralisation began. The regulation of education is still unclear. Current legislation is covered by Law 20/2003 (Law on the National Education System) and Law 29/2004 (Law on Medical Practice; Rokx et al. 2009). Law 20/2003 gives The Indonesian Medical Council responsibility for curriculum development, registration and certification of graduates. The Ministry of Health Centre Workforce Education oversees all publicly owned nursing education above high school level which is often carried out through the poltekkes (polytechnic schools). Privately owned and other nursing and midwifery educational institutes are overseen by the National Accreditation Board for Higher Education. These two different agencies have different accreditation processes which are not in line with international standards (Rokx et al. 2009). A new curriculum was introduced for medical students in 2005. The aim is to train doctors for work in primary health care clinics. The new curriculum outlines seven semesters of general teaching, followed by three semesters of clinical teaching. There is currently a plan to include a one-year internship at a primary health care clinic at the completion of training (Rokx et al. 2009). There are 682 nursing schools throughout the country offering a Diploma III in Nursing, with approximately 34,000 graduates each year (Rokx et al. 2009). Currently 39% of nurses have obtained a Diploma of Nursing, 1% have a degree and 60% have only secondary school education with on-the-job training (Hennessy et al. 2006b). Between 1989 and 1996, under the BDD Program, one-year midwifery training was provided for graduates of the junior high school nursing program. Seventy-nine percent of public midwives currently working were trained under the one-year diploma program (Makowiecka et al. 2008). This was replaced in 1996 with a three-year diploma for high school graduates. Posyandu (family planning volunteers at the village healthpost level) are often invited to participate in monthly village coordination meetings and advise leaders when issues about family planning arise in villages (Utomo et al. 2006). COUNTRY REGISTRATION There is no registration system for nurses and midwives which makes establishing numbers difficult (Rokx et al. 2009). HRH POLICY AND PLANS Human resources for health in Indonesia are set out in the Policy for HRH Development 2000 2010 (MoH Indonesia 2000). Challenges of HRH and HRH plans are also set out in the country s health strategy, Healthy Indonesia 2010 (Moh Indonesia 1999). This plan aims to decentralise health services so that issues, including those faced by human resources, can be addressed at their source and to create a health workforce with ethical training standards and an improved structure of accreditation and legislation. There are currently 465 midwifery schools throughout the country offering a Diploma III in Midwifery with approximately 10,000 graduates a year (Rokx et al. 2009). In 1997, an in-service training in the core competencies of maternal health was run. It covered topics such as care of normal birth, basic emergency obstetric procedures and post-abortion care (Hennessy et al. 2006c). For more information on education and training, please refer to Appendix 1. 12

MNRH POLICY AND PLANS KEY ISSUES OR BARRIERS MNRH priorities and plans have been outlined in the Making Pregnancy Safer Plan (MoH Indonesia 2001). This has three key principles: every delivery should be attended by a skilled birth attendant, every complication should be referred and managed appropriately, and all reproductive-age females should have access to contraceptives and post-abortion care. The Indonesian government has set a target to lower the maternal mortality ratio to 125 per 100,000 live births by 2010. Maternal child health and reproductive health is also included in the Healthy Indonesia 2010 strategy with a goal of one midwife to every 1,000 people (MoH Indonesia 1999). REMUNERATION AND INCENTIVES The incentives structure of the workforce is overseen by the national civil service agency, Badan Kepegawaian Negara (BKN). They oversee guidelines on hiring, firing and promotions, as well as policies on salary, retirement, transfer and management (Rokx et al. 2009). In May 2006, the Ministry of Health implemented a plan to provide incentives for serving in remote and very remote posts, such as increasing financial incentives and shortening service periods to six months in very remote areas and one year in remote areas (AAAH 2008). Incentives to keep doctors in puskesmas were deemed to be insufficient, and doctor numbers in these areas dropped by 30% between 1994 and 1998 (Rokx et al. 2009). The BDD Program (for village midwives) was more effective at keeping midwives in remote areas, and now midwives and nurses provide the majority of health services. Midwives earn approximately USD$364 a month, while midwives in Banten province, Java, can earn USD$4,368 a year (including income from private practice). The top 10% of midwives earn USD$11,000 from private practice. Midwives with more than 15-years experience can earn twice as much as midwives who have less than five-years experience (Ensor et al. 2009). In Banten province, a survey found that, although the reason for becoming a midwife was almost evenly distributed between career/income (21%), community (27%) and family (25%), the main reasons for remaining a midwife were for career and/or incentives. Of the respondents, 71% listed career and incentives as the primary reason to remain in the profession (Ensor et al. 2009). Skill level of midwives trained under the Village Midwife Program (Shankar et al. 2008). Lack of emergency obstetric care system to back up referrals from the community level. Absenteeism of doctors during work hours (Rokx et al. 2009). Lack of midwives in very remote areas. Studies have found that the greatest hindrance to midwives moving to more remote areas is not income, as in many instances they are able to increase their income levels in remote areas due to lack of competition. Reluctance to move has been found to be related to the relationships that midwives have established through marriage and building a family. They are reluctant to separate their ties with the community and move their family away from schools and work. The solution may therefore be to attract midwives to work in these areas early in their careers before they have married and established ties in communities (Ensor et al. 2009). Lack of community confidence in young, recently trained BDD PTTs, who may be viewed as outsiders, combined with lack of training for midwives in building good relations with the community. 7 Doctors have inadequate skills in basic emergency and obstetric care. 8 Poor supportive supervision provided by district health officers to maintain health worker skills in remote areas. 9 7 Reviewer comment: Some community midwives who have had excellent interpersonal skills have managed to engage with communities in areas where there had been low levels of community participation and interest in health care projects. This highlights the importance of including community engagement and interpersonal communication skills as a part of pre-service training. 8 Reviewer comment. 9 Reviewer comment. 13

KEY INITIATIVES Bidan Di Desa Program (for village midwives) Launched in 1989, this program was a push by the government to increase the number of midwives in rural areas to assist with home births (Shankar et al. 2008). At the time, there were approximately 13,000 midwives in the country (Shiffman 2003). The aim was to send 54,000 midwives to rural areas, with each village having at least one midwife. Fifty thousand midwives were dispatched to rural areas as part of the program. Under this program, the births supervised by a skilled birth attendant rose from 22.5% in 1990 to 55% in 2003 (Makowiecka et al. 2008), women who received antenatal care rose from 57% in 1987 to 88% in 1998 (Shiffman 2003). By the end of the program the government reported that 96% of villages had a midwife (Thind and Bannerjee 2004). The government created a new cadre BDD PTT. Those who had completed the three-year nursing course were recruited into the one-year midwife training program and then deployed to rural posts on three-year contracts (with the possibility of renewal) where they would be provided with a polindes (public clinic) which would double as housing for the midwife and a birthing house. As a result, this cadre of workers were young and had little or no practical experience. The training course also included little practical clinical experience, and there were few clinics providing emergency obstetric care to which to refer women (Shankar et al. 2008). There were conflicts in some areas between this new cadre and the existing midwives who, in general, were older, more experienced, receiving lower remuneration from the government, working in clinics and often running their own private practices (Hull et al. 1998). There have also been issues with retention of these midwives (Makowiecka et al. 2008). The MotherCare/Indonesia Project, along with the Ministry of Health and Indonesian Midwifery Association, went on to conduct in-service training for this new cadre between 1995 and 1999 in the district of South Kalimantan. This involved 11 days of training, follow-up workshops, clinical delivery experience and participation in a new peer support and supervision structure. A study found that those who were chosen to be part of the training achieved an average 71% skill score when tested, compared with an average score of 51% for those who did not participate (McDermott et al. 2001). In 1996, the one-year midwifery course was replaced by a three-year specialised midwifery course open to school leavers (Makowiecka et al. 2008). There was strong political support for this movement. President Suharto played an important role in the campaign, opening a number of conferences and seminars on the topic and stating that a seven-year time frame was too long progress would need to be made in shorter time (Shiffman 2003). This was also helped by a very active Minister for Women s Roles who encouraged President Suharto s involvement. Health Insurance for the Poor Program (ASKESKIN) This scheme exempts the poorest families from paying for routine and emergency care. Under this scheme, midwives are paid to manage deliveries either in their own home or in the mother s home. This increases the number of women able to access the service of the midwives and increases the practice and income of the midwives (Ronsmans et al. 2009). Family Planning Program This program started in 1970 with the establishment of the Indonesian National Family Planning Coordination Board. Originally family planning field workers who were employed by the Board and later family planning volunteers would visit villages, educating communities about family planning through meetings and counselling. They would also distribute contraception and record family planning progress in villages. Through this program the attitude towards family planning changed from being a taboo topic to something that was essential (Utomo et al. 2006). Decentralisation in 2004 weakened the program and it no longer receives the political commitment it had before (Hull and Mosley 2009). Partnership between midwives and traditional birth attendants An agreement was reached between midwives and traditional birth attendants in 2007 to work together to improve maternal health outcomes. Traditional birth attendants are now able to carry out their traditional cultural duties during the birth, while midwives are able to oversee the medical processes (UNICEF 2008). 10 Establishment of community health centres During the 1980s, in a push by the government to implement the principles of primary health, Community Health Centres were established throughout the country with the aim of establishing one centre per 30,000 people. They were staffed significantly by medical graduates on bonded placements for up to five years (Rokx et al. 2009; bonded placements were abolished as a result of increasing pressure from the Indonesian Medical Association in 2007 under law 512/2007). 10 Information given by one reviewer. 14

CRITIQUE Documentation There was a wide range of articles published on HRH for MNRH in Indonesia. This made this map less reliant on grey literature. Government reports and policies were less easily accessible, with key documents such as the Human Resources for Health Development Policy 2000 2010 (MoH Indonesia 2000) and the Making Pregnancy Safer Plan (MoH Indonesia 2001) not being located in the public domain. Peer-reviewed journal articles explored the issues of remuneration and incentives, private practice, education and training, cadres, government programs, barriers, supervision and team work (Ensor et al. 2009; Hennessy et al. 2006c; Hull and Mosley 2009; Makowiecka et al. 2008; Ronsmans et al. 2009; Shankar et al. 2008; Utomo, et al. 2006). This provided a much wider scope, compared with the other countries reviewed. There was an even representation of the public and private sector. A study found that those who were chosen to be part of the training achieved an average 71% skill score when tested, compared with an average score of 51% for those who did not participate. The main report used for this map was the World Bank report, Indonesia s Doctors, Midwives and Nurses by Rokx et al. (2009). This gave detailed information about the rate of skilled birth attendance, workforce numbers, education and training and key barriers and issues. Information for this report was gathered using a number of methods, including the records of district health systems and interviews with community members and village and city block leaders (Rokx et al. 2009). Reviewers There were three reviewers for this map. The first reviewer is a representative from the United Nations Population Fund country office and provided updated information about what is currently occurring with programs in the country, provided corrections and highlighted the discrepancy in the maternal mortality ratio reported by different sources. The second reviewer is from the Burnet Institute s country office. They provided some in-depth comments and corrections on the implementation of the BDD Program. Information was also given by a midwifery expert from Indonesia currently undertaking a PhD in Australia who provided feedback on a number of different issues, in particular, the uneven distribution of health workers and the burden of maternal mortality and morbidity between different areas of the country. This reviewer also provided input on other HRH issues faced by the country. 15

REFERENCES AAAH 2008, Annual Review of HRH Situation in Asia-Pacific Region 2006 2007, Asia-Pacific Action Alliance for Human Resources for Health. ANMC 2009, Country Profile Indonesia, Australian Nursing and Midwifery Council, accessed 5 November 2009, <http:// www.anmc.org.au/indonesia>. Ensor, T Quayyum, Z, Nadjib, M and Sucahya, P 2009, Level and determinants of incentives for village midwives in Indonesia, Health Policy and Planning, vol. 24, no. 1, pp. 26 35. Hennessy, D Hicks, C, Hilan, A and Kawonal, Y 2006a, A methodology for assessing the professional development needs of nurses and midwives in Indonesia: paper 1 of 3, Human Resources for Health, vol. 4, no. 1, p. 8. Hennessy, D Hicks, C, Hilan, A and Kawonal, Y 2006b, The Training and Development Needs of Nurses in Indonesia: paper 3 of 3, Human Resources for Health, vol. 4, no. 10. Hennessy, D Hicks, C and Koesno, H 2006c, The training and development needs of midwives in Indonesia: paper 2 of 3, Human Resources for Health, vol. 4, no. 1, p. 9. Hogan, MC, Foreman, KJ, Naghavi, M, Ahn, SY, Wang, M, Makela, SM, Lopez, AD, Lozano, R and Murray, CJL 2010, Maternal mortality for 181 countries, 1980 2008: a systematic analysis of progress towards Millennium Development Goal 5, Lancet, vol. 375, no. 9726, pp. 1609 1623. Hull, T and Mosley, H 2009, Revitalization of Family Planning in Indonesia, Government of Indonesia and the United Nations Population Fund. Hull, T, Widayatun, Raharto, A and Setiawan, B 1998, Village Midwives in Maluku, policy paper, Center for Population and Manpower Studies, Jakarta, Indonesia. Immpact 2007, Indonesia: Resident Midwives Help Avert Maternal Deaths When Financial Barriers are Removed, Immpact International, Population Reference Bureau. Makowiecka, K, Achadi, E, Izati, Y and Ronsmans, C 2008, Midwifery provision in two districts in Indonesia: how well are rural areas served?, Health Policy and Planning, vol. 23, no. 1, pp. 67 75. McDermott, J, Beck, D, Buffington, S, Annas, J, Supratikto, G, Prenggono, D, Ekonomi, D and Achadi, E 2001, Two models of in-service training to improve midwifery skills: how well do they work?, Journal of Midwifery and Women s Health, vol. 46, no. 4, pp. 217 25. MoH Indonesia 1999, Health Development Plan Towards Healthy Indonesia 2010, Ministry of Health Indonesia, Jakarta. MoH Indonesia 2000, Policy of HRH Development 2000-2010, policy paper in Indonesian language, Ministry of Health Indonesia, Jakarta. MoH Indonesia 2001, National Strategic Plan on Making Pregnancy Safer (MPS) Indonesia 2001-2010, Ministry of Health Indonesia, Jakarta. MoH Indonesia 2005, Indonesia Health Profile 2005, Ministry of Health Indonesia, Jakarta. Rokx, C, Marzoeki, P, Harimurti, P and Satriawan, E 2009, Indonesia s Doctors, Midwives and Nurses: Current Stock, Increasing Needs, Future Challenges and Options, World Bank, Jakarta. Ronsmans, C, Endang, A, Gunawan, S, Zazri, A, McDermott, J, Koblinsky, M and Marshall, T 2001, Evaluation of a Comprehensive Home-Based Midwifery Programme in South Kalimantan, Indonesia, Tropical Medicine and International Health, vol. 6, no. 10, pp. 799 810. Ronsmans, C, Scott, S, Qomariyah, SN, Achadi, E, Braunholtz, D, Marshall, T, Pambudi, E, Witten, KH and Graham, WJ 2009, Professional assistance during birth and maternal mortality in two Indonesian districts, Bulletin of the World Health Organization, vol. 87, no. 6, pp. 405 84. Shankar, A, Sebayang, S, Guarenti, L, Utomo, B, Islam, M, Fauveau, V and Jalal, F 2008, The village-based midwife programme in Indonesia, The Lancet, vol. 371, no. 9620, pp. 1226 9. Shiffman, J 2003, Generating political will for safe motherhood in Indonesia, Social Science and Medicine, vol. 56, no. 6, pp. 1197 207. BPK and Macro International 2008, Demographic Health Survey 2007, Marylands, USA. Thind, A and Banerjee K 2004, Home deliveries in Indonesia: who provides assistance?, Journal of Community Health, vol. 29, no. 4, pp. 285 303. UNDESA 2005, The Millennium Development Goals Report, United Nations Department of Economic and Social Affairs, New York. 16

UNICEF 2008, Traditional Birth Attendants and Midwives Partner for Women s Health in Indonesia, <http://www.unicef. org/infobycountry/indonesia_43515.html>. UNICEF 2010, Indonesia: Statistics, accessed 5 May 2011, <http://www.unicef.org/infobycountry/indonesia_statistics. html>. USAID 2007, Health Services Program: 2007 Annual Report, report by JSI Research and Training Institute, Inc. for the United States Agency for International Development (USAID). Utomo, ID, Arsyad, SS and Hasmi, EN 2006, Village family planning volunteers in Indonesia: Their role in the family planning programme, Reproductive Health Matters, vol. 14, no. 27, pp. 73 82. Wang, H, McEuen, M, Mize, L, Cisek, C and Barraclough, A 2009, Private Sector Health Indonesia: A Desk Review, Health Systems 20/20 Project, Abt Associates Inc., Bethesda, MD. WHO 2010, World Health Statistics 2010, World Health Organization, Geneva. 17

APPENDIX 1 PRE- AND IN-SERVICE EDUCATION AND TRAINING IN INDONESIA Cadre Institution/organisation Qualification Length of study Enrolment/graduation Pre service 682 nursing schools 64 nursing schools currently owned by Nurse local governments (Rokx et al. 2009) Diploma III in Nursing 3 years 34,000 nurses a year Polytekkes (polytechnic) schools there are 33 in the country 7 semesters of general teaching Doctor 52 medical schools 5,000 doctors a year 3 semesters of clinical teaching 465 midwifery schools Midwife 14 midwifery schools currently owned by the local government Diploma III in Midwifery 3 years 10,000 midwives a year (Rokx et al. 2009) Community health worker (AAAH 2008) 3 days 1,800 to date in-service Midwifery training in three districts of South Kalimantan. A short training for MotherCare traditional birth attendants also runs at this time In-service training to increase knowledge, skills and confidence, combined with a 11-day course new peer review and supervisory system (Ronsmans et al. 2001) A number of in-service training courses are run by JNPK (national network of training for health providers; USAID 2007) Normal Delivery Care 120 hours Targets: village midwives JNPK (Jaringan Nasional Pelatihan Klinis; national network of training for Basic Neonatal Obstetric Care 70 hours health providers) Targets: puskesmas (community health centre) staff Comprehensive Neonatal Obstetric Care 70 hours Targets: hospital staff 18

APPENDIX 2 COUNTRY REGISTRATION IN INDONESIA Cadre Legislation Responsibility for Registration Licensing and renewal Eligibility Requirements for Registration Doctor (must register in order to obtain a licence to practise medicine) Konsil Kedokteran Indonesia (Indonesian Medical Council) Currently lifelong, will soon have to renew every five years Competency test (for those registering after 2007 with exception of new graduates) Nurse and Midwife (system for registration is still being fully established) Ministerial Decree No 1239 on Nurses Registration and Practice 2000 (Wang et al. 2009) Provincial and District Health Office under the direction of the Indonesian National Nurses Association No Schedule Diploma III in Nursing and 3-years work experience (ANMC 2009) 19

APPENDIX 3 COUNTRY HRH AND MNRH POLICIES IN INDONESIA Name of policy Relevant information for MNRH at community level HRH Policy Policy of HRH Development (2000 2010) This plan aims to decentralise health services further so that issues, including those faced by human resources, can be addressed at their source with a focus on improving moral and ethical standards, training, accreditation and legislation. The plan highlights HRH obstacles such as unequal distribution of resources, inadequate training and unclear promotion paths. (MoH Indonesia 2000) MNRH policy Making Pregnancy Safer Making Pregnancy Safer in Indonesia has three key principles: every delivery should be attended by a skilled birth attendant, every complication should be referred and managed appropriately and all reproductive-age females should have access to contraceptives and post-abortion care. The Indonesian government has set a target to lower the maternal mortality ratio to 125 per 100,000 live births by 2010. (MoH Indonesia 2001) Healthy Indonesia 2010 MNRH is included in this plan under Program 3.6 Reproductive Health. The goal of this program is to improve the health of mothers, children and adolescents in order to create optimal reproductive health. It includes the target of 90% of births overseen by a traditional birth attendant. (MoH Indonesia 1999) 20

The Knowledge Hubs for Health Initiative The Human Resources for Health Knowledge Hub is one of four hubs established by AusAID in 2008 as part of the Australian Government s commitment to meeting the Millennium Development Goals and improving health in the Asia and Pacific regions. All four Hubs share the common goal of expanding the expertise and knowledge base in order to help inform and guide health policy. Human Resource for Health Knowledge Hub, University of New South Wales Some of the key thematic areas for this Hub include governance, leadership and management; maternal, neonatal and reproductive health workforce; public health emergencies; and migration. www.hrhhub.unsw.edu.au Health Information Systems Knowledge Hub, University of Queensland Aims to facilitate the development and integration of health information systems in the broader health system strengthening agenda as well as increase local capacity to ensure that cost-effective, timely, reliable and relevant information is available, and used, to better inform health development policies. www.uq.edu.au/hishub Health Finance and Health Policy Knowledge Hub, The Nossal Institute for Global Health (University of Melbourne) Aims to support regional, national and international partners to develop effective evidence-informed national policy-making, particularly in the field of health finance and health systems. Key thematic areas for this Hub include comparative analysis of health finance interventions and health system outcomes; the role of non-state providers of health care; and health policy development in the Pacific. www.ni.unimelb.edu.au Compass: Women s and Children s Health Knowledge Hub, Compass is a partnership between the Centre for International Child Health, University of Melbourne, Menzies School of Health Research and Burnet Institute s Centre for International Health. Aims to enhance the quality and effectiveness of WCH interventions and focuses on supporting the Millennium Development Goals 4 and 5 improved maternal and child health and universal access to reproductive health. Key thematic areas for this Hub include regional strategies for child survival; strengthening health systems for maternal and newborn health; adolescent reproductive health; and nutrition. www.wchknowledgehub.com.au

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