Sistem pencatatan & permantauan Jejaring Transportasi POS Informasi KB Pendonor Darah DESA SIAGA Dana Sosial Kesehatan Desa Siaga Model Supported by SISKES in NTB Rahmi Sofiarini, PhD Advisor CONCEPT PAPER Developed 2006 Reviewed 2007
REVIEW ON THE DEVELOPMENTAL CONCEPT OF DESA SIAGA The word of SIAGA firstly emerged and was used in Maternal Neonatal Health (MNH) Project in West Java. The term itself is an abbreviation from SIAP (ready), ANTAR (bring) and JAGA (take care). According to MNH project documents, Desa SIAGA Siap Antar Jaga was developed originally from GSI (Friendly Mother Movement). The GSI itself was the government s effort to increase participation of people in reducing the number of maternal deaths by encouraging people to focus more attention to mothers especially during pregnancy and delivery by a) widely disseminating information on the dangerous signs of pregnancy and delivery, b) motivating pregnant women to go to Posyandu (integrated post services that exist at hamlet levels) for ANC and c) formation of community groups for organizing transportation, voluntary blood donation and finance in helping mothers during pregnancy and delivery. The concept was familiar with the government and the people of Indonesia because it was widely implemented throughout the country by the State Ministry of Women s Empowerment in 1995. Desa Siaga therefore is not in a development stage but rather has entered a cycle of implementation, evaluation and replanning. The differences between GSI and Siaga MNH were the following: GSI was the channel through government bureaucracy (top down), while Siaga is the social mobilization. GSI was perceived as an assignment from the government but Siaga is mobilizing all components in the community. GSI had bureaucratic channel in all level of government administrative, Siaga does not have this. Lessons learnt from the implementation of SIAGA Concept in MNH Project in changing people s behavior were disseminated in Mini University in Jakarta, May 2004. It was claimed that SIAGA increased people s participation in reducing maternal health. The implementation of this SIAGA concept had raised people s awareness on birth preparedness and readiness in facing complications as people, particularly, the neighbors of pregnant women, are highly participative in assisting the pregnant women in terms of provision of means transportation, provision of blood donations and financial support when facing emergency situations during pregnancy and giving a birth. This approach has empowered the villagers to help each other in saving lives of pregnant women. The approach had been rolled out by the villagers outside the MNH Project. MNH project originally supported the establishment of 53 villages in two districts and at the end of the project, there were 278 villages becoming SIAGA village because it was replicated by the villagers themselves through assisting neighboring villages without provision of support from the project. Looking at the successfulness of SIAGA MNH the Indonesian Women Health and Family Welfare IWHFWP, AusAID supported project in NTB and NTT had adapted that concept into its project. Accordingly, Desa Siaga WHFW concept was developed based on the concepts of Desa Siaga MNH (with some differences in process and approach that can see later through this review). Concept Paper: Desa SIAGA Model supported by SISKES Page 1
WHAT IS DESA SIAGA APPROACH? According to MNH Project documents the SIAGA Approach was developed in response to the following facts: High percentage of maternal death happens within 2 hours, during and after process of delivery. Most of maternal deaths were related to three delays delay in making a decision to refer the pregnant women, delay in providing means of transportation, and delay in getting appropriate medical treatment High percentage of maternal deaths because of hemorrhage. Pregnancy and delivery is still seen as naturally happening to every woman. Pregnancy is not women s affairs only. 85 % of maternal deaths could be avoided because: The three delays is the problem related to technical, social and cultural attitudes, There are still plenty of myths and taboo related to pregnancy and delivery that need to be clarified. Pregnancy and delivery should be not only women s affairs but it should be put as a family or public affair. Looking at those facts, everyone, husband of the pregnant women, her neighbor, community/influential leaders, midwives, health facilities (Puskesmas, hospital), could help pregnant women by taking different roles. The community is not aware what they can do in reducing maternal deaths and what sort of roles they can take in saving a life of pregnant woman. Thus, in principle, people could take a role in saving the life pregnant woman by Promoting Birth Preparedness and complication readiness through: Raising people s awareness that pregnancy is their responsibility, not only women s responsibility. Every pregnancy and delivery has a risk and every pregnancy is unique to each woman. Revitalize the value of assisting one and other in saving a life of woman in a non clinical aspect Involving all stakeholders in the community This approach will increase availability and accessibility of people towards a mechanism of birth preparedness and complication readiness at the community level by forming a system to help each other by and for the members of community themselves in terms of notification of pregnant women, provision of means of transportation, provision of blood donation and financial support. These community actions in saving a life of pregnant women are described as SIAGA, which is abbreviation of Siap (ready), Antar (bring) and JAGA (take a care). In other words, SIAGA is an icon that is used to express promotion of people s participation in saving women s lives. Siaga is used in varied roles in getting participation of people such as Warga SIAGA (community alertness), SUAMI SIAGA (Husband Alertness), Dai SIAGA (religious leader s alertness), Wartawan SIAGA (journalist alertness), Pesantren SIAGA (religious school alertness). This Siaga Approach is also promoting alertness of health providers, Bidan SIAGA (Midwives alertness) as part of promotion of birth preparedness and complication readiness. The campaign on changing people s behavior through Siaga approach was nationally advertised through national television using a popular singer that attracted attention of Indonesian population. Concept Paper: Desa SIAGA Model supported by SISKES Page 2
All of those community actions (financial support, notification, blood donations and means of transportation) are actualized in a form of agreement that describes provision of assistance to the pregnant woman when giving birth. The form describes following points: where to give a birth, who will assist her to give birth, who will deliver her, who will provide blood if needed and availability of finances for the cost of delivery, then it was signed by the pregnant woman, husband/family members, midwife and village facilitator. This form was termed as AMANAH PERSALINAN. Desa Siaga can be defined as the village that has an alertness system for overcoming emergency situations of pregnancy and delivery. The alertness system consists of notification, blood donation, transportation and financial support. The effort of facilitating the villagers to establish alertness or emergency systems not only deals with establishing a system only but the process also takes into account other issues such as behavior change techniques: An effort to trigger social mobilization in order to alert people in emergency situations, especially in helping the pregnant woman during delivery An effort to gather people s participation in reducing maternal health in non clinical aspects. An effort to gather resources owned by the people in helping women during pregnancy and delivery. An effort to initiate behavior change so delivery assisted by health professional. A process of empowering people so they are able to solve their own problems An effort to integrate all stakeholders in solving health problem. The Desa Siaga approach stands on following concepts: Revitalization of social togetherness practices and values in helping women during pregnancy and delivery. Shifting a paradigm; delivery is a public issue, it is not only a women s issue. Shifting a paradigm: health issues are not only government issues but they belong to the community also. Involving all stakeholders in the community. Using participative approaches Taking action and advocacy Concept Paper: Desa SIAGA Model supported by SISKES Page 3
REVIEW ON DESA SIAGA MODEL OF MNH AND IWHFW PROJECT Conceptually, both SIAGA MNH and IWHFP are the same but with some differences in number of community actions and characteristics in its implementation. The differences can be seen as follows. Number and kind of Siaga systems Relation to Posyandu Coverage of the network Relationship to government institutions Cost of establishment Siaga network A form of birth plan Siaga MNH 4 systems: notification, saving /social fund for delivery, blood donor and transportation There are no technical operational guidelines for each system No relations to posyandu, indeed it was avoided. Siaga network works in parallel with posyandu activities and cadre of posyandu were not necessarily involved in the Siaga networks In each village, the network exits in one or two hamlets Avoided during establishment phase. Now days, Siaga network is coordinated by Dinkes. But, BPM and FP institution was not involved at all in the process of establishment. 53 villages in 2 districts/cities, it cost around Rp 200 million per village The form was termed as AMANAH PERSALINAN Siaga WHFW 5 systems: notification, saving/social fund for delivery, blood donor, transportation and FP centre There are technical operational guidelines for each system Posyandu and Siaga networks are integrated operationally and structurally, they are not parallel. Almost 70 % of members of the networks are cadre of posyandu. In each village, the network exists in every hamlet/posyandu. Coordinated by BPM, and involving Dinkes and FP institution as technical resources. 54 villages in 10 districts, It cost around Rp.150 millions per village. The form was termed as RENCANA PERSALINAN These differences could be affected by the structure of each project. The differences of the project s structures, MNH Project and WHFW are: The structure of the project at the district level: the MNH project has a District Coordinator who has responsibility for the implementation of behavior change component of Desa Siaga. Whereas WHFW in its structure had a District Facilitator for coordinating all activities of the project in district level (4 components). The main technical project counterpart: MNH Project has counterpart of PHO and DHO with additional BKKBN. Whereas WHFW has 4 main technical counterparts: PHO/DHO, Provincial/district BKKBN, provincial/district Bappeda and Provincial/district BPM. The differences in the structure and the technical counterparts have affected the process of establishing Desa Siaga. Here some differences: At provincial level Siaga MNH The development of concept and the implementation of all activities at provincial level were done by the project itself without involving PHO. PHO was involved later when the Siaga had been established and had been functioning. Siaga WHFW Provincial BPM has played roles in organizing all activities that took a place at provincial level, was involved in the development of the concepts and monitoring, taking a role as source persons for the activities at district level. Concept Paper: Desa SIAGA Model supported by SISKES Page 4
At district Level At village level Siaga MNH There was District Coordinator (DC) (the project staff and a District Facilitator DF (community member, recruited and trained by the MNH project then called as District Facilitator). The District coordinator and Facilitator worked together in the process of establishing Desa Siaga. The district facilitator had played roles in writing TOR of the activities at the village level (together with the village facilitator), took a role as facilitator and coordinates all activities related to Desa Siaga. The District Facilitator received financial support such as transportation fee from the project. Village Facilitator/VF, a villager that is recruited and trained by the project. The VF, DF, DC worked together with village midwife in establishing Desa Siaga. Siaga WHFW There is a District Facilitator (DF) that is responsible for all project components and District Organizer (DO), a field staff recruited by the project especially for implementing Desa Siaga. In addition the project has District BPM as the leading sector in implementing Desa Siaga. Roles of district BPM: organizing meetings and workshops at district level, as resources person for activities at village level and in monitoring and evaluation. District BPM together with DO also have coordination roles for other relevant institutions/administrative levels, such as kecamatan/sub district, village government, blood transfusion unit, red cross, district hospital. DO has responsible for technical process in the village level together with advisor. DO also responsible for administrative affairs together with District Facilitator/DF. Village Organizer/VO, a village activist that recruited and trained by the project and district BPM. VO together with DO have responsible for all activities at village level in establishing Desa Siaga, such writing TOR of the activities at village level, organizing and facilitating the activities. District BPM utilized the VO for other programs; the VO received financial incentive for transportation fee from district government channeled through district BPM. It amounted around Rp.100.000 to Rp.300.000 per month per person varied to district based on the financial capability of the district government. Concept Paper: Desa SIAGA Model supported by SISKES Page 5
If we draw, Siaga MNH and IWFFW development roadmap would look like this: Pregnant Woman Notification Giving Birth Social Finance Transport Blood Donors Figure 1: Siaga System in MNH Project Pregnant Woman Notification Giving Birth Family Planning Post Social Finance Transport Blood Donors Figure 2: Siaga System in IWHFW Project PROCESS OF ESTABLISHING DESA SIAGA A process of establishing Desa Siaga in MNH and WHFWP can be seen as follows: The main process carried out in MNH project as following: Recruit Village facilitator, who has roles to organize all activities at village level in establishing Desa Siaga. IMP (Identifikasi Masyarakat Partisipatif participatory identification) Training, the training aims to train the village facilitator to be mover or organizer of people in their village. This has been done with trial and error. Formation of Village facilitator forum. The purpose of the forum is strengthening the action of the village facilitator. District meeting for facilitator. The aim is to establish a network in establishing Desa Siaga Neighborhood meeting, to establish Siaga system Village meeting. Concept Paper: Desa SIAGA Model supported by SISKES Page 6
Establish a network with related institutions for getting political support. More activity in Capacity building for the village facilitator: advocacy. Strengthening legal status of the forum to be independent institution as like a Non governmental Organization. In the context of WHFW, the Desa Siaga model WHFWP was developed during the process of the implementation of the prior developed project design. The main processes carried out under the WHFW are: Several meeting for developing Siaga concept and strategy at various levels. Dissemination of Siaga concepts, such as orientation meeting (provincial and district level) Selection of the village as the site of the project Recruitment of District Organizer (DO) DO Training on the nature of the project, Desa Siaga and administrative roles for DO Recruitment of VO Training workshop on the Participatory Learning and Action for the VO and DO Participatory Learning and Action at village level Training workshop on Organizing the Siaga systems for the VO and DO Presentation on the results of PLA at district and provincial level Formation of Siaga system through conducting workshop at village and hamlet level. Provision of support in establishing Siaga network and its function (FP training was carried out in other project components) Regular coordination meeting amongst the DOs and Adviser Regular provincial meeting Regular coordination meeting at district level Training workshop for the VO and DO on data collection for monitoring and evaluation purposes Regular Monitoring and evaluation at provincial and district level In terms of detailed processes of establishing Siaga it very much depends on the nature and characteristics of the project, a mechanism of provision of the project support and the project counterparts. All of these determined the process of establishing Desa Siaga in both projects. Essentially, the process of establishing Desa Siaga requires the main following activities: Recruitment of village facilitator Training for the village facilitator in order to be able to facilitate people to establish Siaga system Facilitating the villagers in establishing Siaga system, and the function of the Siaga systems Monitoring evaluation. Prior to and along with these essential processes there is a requirement for processes for dissemination of information, raising awareness of people, promotion of behavior change and advocacy. Importantly, these Concept Paper: Desa SIAGA Model supported by SISKES Page 7
essential processes have to be implemented using participatory approaches and in an empowering manner. Thus, all the detailed processes on establishing Desa Siaga can be adapted into the SISKES project. DESA SIAGA MODEL SUPPORTED BY SISKES: Background The success of the Desa Siaga Models of both MNH and WHFW in gathering participation of people in improving maternal health in non medical aspects as well as change in behavior has raised attention on the model itself. Such a model could be improved and modified in order to gather participation of people not only in the issues of maternal health but also in broader health issues such as reproductive health as well as newborn and infant health. This extension is possible by extending the roles and coverage of the Siaga system, especially the FP center and notification, or it could be done by adding other Siaga system. This extension is needed in order to respond to the fact that mortality of newborns and infants remains high and the monitoring of new born health is required. Reproductive health education is still limited, especially for adolescents (girls and boys) outside of the formal educational institutions. Many poorer village adolescents tend to drop out of school even before this information can be conveyed. This lack of knowledge perpetrates the high numbers of early age marriage and birth in NTB. The existing Siaga model could be modified into a model that could cover education activities for Reproductive health as well to monitoring Post Natal Care included newborn cares. The Proposed Model Under the IWHFW model of Desa Siaga the notification system only focused on monitoring and recording the existing pregnant women, linked them to social finance, transportation and blood donor systems to ensure those women give a birth safely. During pregnancy the women also had been linked to the FP Post for counseling on FP methods that will be chosen after delivery and linked them to the FP service facilities (as seen in Figure 2). Under the proposed model, the notification system will be broadened not only on surveillance of pregnant women but also surveillance of other major health issues in the village. Thus, the notification system will be called a surveillance system instead of notification system. This Surveillance System will monitor and record major health issues, for example: pregnant women, delivery (where delivery takes place and who assisted), maternal death, infants (weight when born and infant death), nutrition of children under five years, members of the community who get communicable diseases, usage of health subsidy card or Askeskin, and population change (death, married, migration, birth).this system will assist the villagers to monitor their own health condition, so they may take actions to solve the conditions if there is a problem. In this proposed model, the first system is surveillance and this is very important for the community as well as other relevant institutions in order to do any action on improving health condition. In addition, the surveillance system could cover any condition that need by the villagers so its coverage is depended on the need of the villagers or it could be adapted into situational context of the village. There is potential that this surveillance system will Concept Paper: Desa SIAGA Model supported by SISKES Page 8
change people s behavior. Initially, when someone who has a particular health condition that is going to be monitored, they come to report their condition to the recording volunteer in their neighborhood. The cost is book and pen to record the information. This system is different with current system in which someone goes around the village to identify people who are pregnant and record them in the book. The FP information center will not only provide information about FP but it will also provide information on reproductive health for adolescents and it could be also extended for information of HIV/AIDS. The FP Post also will organize reproductive classes for adolescents. A module of education will be developed in a participative manner for allowing the participants to have interactive discussions and learn amongst themselves as a peer group. The adolescent class needs special training in FP and RH knowledge as well as training in facilitation skills for those who are responsible in managing the FP centre. The organization of RH classes also needs to get acceptance from the community /religious leaders in order to avoid any controversy emerging on the content of discussion in the classes. The proposed model could be drawn as follows: Pregnant Woman Postpartum & infant health Reproductive Health for Adolescents Maternal & infant deaths, nutrition, communicable diseases Surveillance Social Finance Giving Birth Family Planning Post Transport Blood Donors Figure 3: Proposed Model Siaga Supported by Siskes /HSS/NTB The surveillance system is a tool for the community to monitor their health condition and if there is a problem or an emergency situation they may take an action, and their action will be supported by the availability of transportation system, financial support system and blood donation system. All these systems are basic systems that should be available at community level in order to be able to take an action if emergency situations happen, especially for Birth Preparedness and Complication Readiness. Establishment of Desa Siaga is not only dealing with activities of facilitating the community to establish all the systems but it involves the following activities: partnership between midwives and traditional birth attendant, the birth planning program, reproductive health education, and revitalization of posyandu. Because all these activities are a complement to each other with activities of establishing Desa Siaga and all of these activities is Concept Paper: Desa SIAGA Model supported by SISKES Page 9
an integrated model. The establishment of Desa Siaga systems surveillance, finance, transportation, and blood donor and PF Post, will support the birth planning to take a place from the side of mother and family. In addition, the function of surveillance systems and all Siaga systems will be discussed and centered at Posyandu, so, it will improve the value of the existing posyandu. This model could be developed adding more activities based on identified need of the villagers, since the approach applied in the establishment of Desa Siaga triggers people, to think, to analyze their condition so that a new awareness arises. Based on this new awareness, people will plan new action together and take action based on the new emerging awareness. The Desa Siaga activity could be developed into an effort of improving sanitation condition, more interventions on promoting changing behavior such as washing hands, healthy life, parenting class, nutrition class, pregnant and post partum class and so on. The proposed model that could possibly develop: Community system for emergency situations: Transportation and communication system Neighborhood financial support system Community Based Surveillance System More community actions, such as: Drainage & sanitation improvement Waste management More development activities such as: RH Class for adolescents Parenting class Nutrition class Pregnancy and post partum class Healthy life class HIV/Aid Class Communicable disease Health Provider Polindes Pustu Puskesmas RS Red Cross Related institutions: DHO PHO FP BPM Women s organization NGOs Local Government Figure: 4. Possible development model of Desa Siaga Concept Paper: Desa SIAGA Model supported by SISKES Page 10
PARTICIPATORY LEARNING AND ACTION AN APPROACH APPLIED IN THE PROPOSED MODEL A process of establishing the Siaga systems is very much dependant on community participation and to gather participation of people it is necessary to put them as the subject of what they doing. Thus, how is to make them the subject? To be able to be the subject, they have to be aware that they have a problem that can affect their health condition; they have to be aware that they have their own resources to overcome the problem, so that they do an action to solve the problem. In order to raise people awareness, it is important to facilitate them to think and to analyze their own health condition and problems critically. By facilitating them to think, re think and analyze their own health condition and problem, people will be able to have new awareness, have sensitivity and awareness that trigger them to have intention to act, in order to change their current condition. Their new emerging action, then will be observed, re thought and re analyzed, in order to have further awareness based on lessons leant from previous actions and used for forging new actions. Thus, this is a cyclic process: Figure: 5. Cycle of process in establishing Desa Siaga This cycle process, that allows people to comprehend their condition, and take an action in solving their problems, is called Participatory Learning and Action (PLA). This approach is not only facilitates people to explore and manage various components, strengths and differences, so that everyone has the same view on solving problem, but it is also a process of organizing people so that they are able to think, to analyze and take action to solve their problem. This is also a process of empowering people so that they are able to carry out actions to improve their condition. In the context of establishing Siaga system, people firstly need to understand and analyze their current health condition such as maternal; neonate, infant health, health services, and various relations and powers that affect those conditions in order to be able to take an action to improve their current condition based on their analysis on potencies that they have. In order to facilitate people to think, to analyze and to take an action a Concept Paper: Desa SIAGA Model supported by SISKES Page 11
facilitation process and facilitator are required. In addition, the facilitator needs to not only understand the Desa Siaga concept but needs the knowledge and skill of facilitation using participative method and tools. Accordingly, this approach applied here is then determines the processes and activities in establishing Desa Siaga supported by Sikes Pus//HSS/NTB. A STRATEGY OF ESTABLISHING THE PROPOSED DESA SIAGA MODEL UNDER SISKES Learning from the prior model that has been piloted in NTB by the AusAID project, the pilot activity had shown us that the process of establishment of Siaga system was intensive work with high costs. Siskes will not do any piloting any more but will support a number of villages based on the availability of the project money supplemented by GOI funding. Siskes will offer support to counterparts to support the establishment Desa Siaga to all five districts of Making Pregnancy (MPS) program by putting them in a batch. Each batch of support will take 5 villagers for each district by considering number of hamlet, geographical areas of the villages, and the intensive work and process of establishment of Siaga. The batch then will be grouped based on geographical areas, Lombok and Sumbawa Islands for the purpose of logistics and management. The villages will be selected using following criteria: Having village midwives and polindes is functioning The village midwives have attended an APN training The village is also the site of the birth planning program Having low deliveries attended by professional health personnel The villagers have openness to the idea of establishing RH class for adolescent. Having good quality service of Puskesmas The core process in Desa Siaga is facilitation of establishment of Siaga system because the Siaga system does not yet exist in the community. Once the system is formed its function depends on the people. In this context, the process of establishing Desa Siaga can be described as like putting an electric installation at a house. The project will help the villagers to install the installation and when it was done, the villagers should take a care and maintain the work and provide the operational of the system. As like electricity, after installation of the hard ware, it is up to the owner or those who stay in the house, to keep the light on. It is up to the villagers to maintain the activities of each system for their better health. Regarding the selection of the project support site, consideration is also given to the commitment of the village government/sub district government/puskesmas/dho to maintain the participation of people by providing consultancy work and supporting operational costs of the system after the project pass through, such as providing administrative books for the system and holding regular meeting at each village level to keep the Siaga system working. In the facilitation process, the core actor in establishing the Siaga system in the village is the village facilitators. The village facilitator needs to be backed up technically and administratively. In this context, the project support will be delivery directly to the village, the project needs someone to provide technical support to the village facilitator and bridge the project with the villagers. This role is needed temporarily during the process of formation of the Siaga system. Therefore the project will recruit local NGOs staff that plays the role as Concept Paper: Desa SIAGA Model supported by SISKES Page 12
coordinator of village facilitator as well as manager of the activities at each district. The role of local NGO staff in this context will last till the Siaga system established and functioning. The local NGO staff will be supervised and managed as well as technically supported by the SISKES adviser. Besides involving local NGO, Puskesmas staff whose role as coordinator posyandu will be involved for two reasons. Firstly, the Puskesmas staff are included in Siaga system at sub district level and these staff monitor the function of the system through the posyandu as their role as coordinator of posyandu. Secondly, the village midwife is involved in every meeting of establishment of Siaga in the village as part of the system at the village level. The main process of establishment of Siaga System: Recruitment of local NGO staff as District Facilitator. Orientation meeting at provincial level on dissemination of Siaga concepts. Output: the concept understood and the criteria of project site agreed, DHO selected the village Orientation meeting at district level, agreed on village facilitator selection, and selection of village facilitator by the team of village (head of village, village midwives, village parliament). Training on PLA (Participatory Learning and Action) and concept of Desa Siaga for Siaga Facilitator. Conducting Situational Health Analysis at village level Village Meeting on Situational Analysis and dissemination of Siaga concept Training on Organizing for Siaga Facilitator Village/hamlet meeting for formation of each Siaga system Provision of support for the functioning of each Siaga system. (recording books, white board, flag etc) Training on Family Planning for cadre whose role is informant on Family Planning. Bi monthly monitoring and evaluation meeting at village level. Quarterly monitoring and evaluation meeting at district level Conducting other complementary activities such as Training for FP Post Information, Running RH Class for adolescents, Meetings for partnership between midwives and traditional birth attendants. An explanation on the process can be found later on attachment. DESA SIAGA MOH In 2006, Ministry of Health of RI launched Desa Siaga as a national program for the strategy of Health Department to achieve Healthy Indonesia 2010. According to the decree of Ministry of Health of Republic of Indonesia, 564/Menkes/SK/VIII/2006, Desa Siaga is defined as a village that has prepared resources on the alert, the determination, as well as the capacity to prevent and respond to emergencies, including natural disasters which may cause health emergencies or epidemic diseases which may cause public health threats. An approach applied in developing Desa Siaga is to facilitate people in learning from their own learning process and cycle through organizing them, with following steps: Problem identification Diagnose and develop option of solving the problems Decide a feasible solution, plan and implementing the solution. Concept Paper: Desa SIAGA Model supported by SISKES Page 13
Monitor, evaluate, sustainability. Steps of the process: Formation of health personnel team Formation of a team at community level, that consists of community members from varied components such as community leaders, decision makers, community members. Undertaking Community Self Survey which is done by community with assistance of health personnel. The aims are to raise awareness of the villagers about their health problems so that they have intension to find out a solution to overcome the problems. Output of this survey is identified problems and potential ownership by the villagers in solving their problems including in establishing Poskesdes community managed health facility. Village meeting to discuss option in solving health problems as well to discuss a plan in establishing Poskesdes. Implementing activities : o o o o o Formation of structure and cadre of Siaga Orientation/ training Development of Poskesdes and community base initiatives Running the Poskesdes Further assistance and improvement LINKING SIAGA MODEL SISKES with Desa SIAGA MOH Desa Siaga is a government effort to redevelop the capacity and reawaken the motivation of village communities to help themselves in the field of health. This is also an endeavor to empower and increase the role of community at the village level in health sector issues to achieve Indonesia Sehat 2010. In the context of community empowerment, if we are talking about capacity to prevent and overcome health problems and emergencies, the villagers should have their own surveillance system that may tell them what s going on in their village. Secondly, the villagers should have an emergency system of assisting each other when emergency situations happen. What is basic emergency system at the community level? First is surveillance system reporting and recording on their changed health condition that is managed by, from and for themselves. By having this system, people will know and inform each other on what health conditions is happening so that they may prevent or help or to take action to help each other. This could be called as community base surveillance system. Resources available in the village communities are ownership of means of transportation and communication, blood and money or in kind. These resources are important when taking an action if emergency situations happen. These resources are needed to be organized and utilized by the villagers and linked to the health provider. Accordingly, people should have health surveillance system in order to know health condition in their environment and supporting system (transportation/communication system, blood donation and financial support) in order to be able to take an action in preventing or overcoming their health problems. Concept Paper: Desa SIAGA Model supported by SISKES Page 14
These surveillance, transportation/communication, blood donation and financial supporting community based system are the Siaga systems in Siap Antar Jaga. Thus, development of Siaga MOH can start from Siap Antar Jaga in the context of community empowerment then developed and linked into management of Poskesdes. In other words, Siap Antar Jaga system is community action that will be met in the Poskesdes with the provider. Thus it is obvious that Siap Antar Jaga is as basic of the community action in Siaga MOH, and it could be developed into possible model as described earlier in this concept. In terms of process of establishment, Siaga MOH and Siap Antar Jaga Supported Siskes plus/ in principle are the same. They focus on learning processes and community organization to take action. Siaga SISKES work at community level to facilitate the community to build systems for surveillance their health condition and systems for supporting their action when emergency situations happen. The Siaga MOH works on developing Siaga Siskes Plus into having linkage and managing health situation with health provider at health facility that termed as Poskesdes, as well as facilitating people to take more community action to improve their health condition (sanitation improvement, nutrition, healthy life style, so on). Concept Paper: Desa SIAGA Model supported by SISKES Page 15
ATTACHMENT 1: Recruitment of District facilitator (DF) The District Facilitator s (DF) role is to provide technical support as well as management of project support in each district, except district in Lombok Island (Mataram City and West Lombok District are geographically close so need only one DF for 10 villages at these 2 districts. These roles will last until the Siaga systems are established and functioning. This time is about one year. These roles cannot be given to staff members of DHO or Puskesmas because these roles require intensive inputs and it is preferred to be given to NGO staff as we know that NGO is very popular with participative approaches and community organizing, so the NGO staff only need to be equipped with Desa Siaga concept so they may play their roles. For this role: the project offers 3,000,000IDR for managing 10 villages that geographically close to each other or 2 2,500,000 IDR for managing 5 villages considering geography. Desirable criteria are: Graduated from university, social science is preferred Having at least 3 years in community empowerment and organizing Familiar with participative approach and having experience in using participative methods and approach such as PRA and PLA. Having knowledge about community health Having gender perspective Able to work under pressure to reach dead lines Having good communication skills Having experience in working in teams and managing others Having experience in administrative and financial accountability Orientation meeting at province level The aim of this meeting is to disseminate concept of Siaga, including its approach, process and discussion on village selection and criteria, to the DHO where the project support is provided and provincial counterparts and related institutions ( such as Bappeda; BPM; BKKBN;DPR;IBI;Red Cross; Religious Leader) This is a one day meeting only and organized by PHO. Outputs: The concepts are understood Criteria on village selection is agreed Support/commitment from relevant institutions is gathering, such as providing local budget for maintaining the established Desa Siaga specifically when the project is over. Concept Paper: Desa SIAGA Model supported by SISKES Page 16
Orientation meeting at district level DHO selects village that propose to be supported by the project. The selected village and Puskesmas and subdistrict office are then invited to attend the orientation meeting at district level. The aim of the meeting is to disseminate concept of Siaga, including its approach, process and discussion on village facilitator. This is one day meeting and organized by DHO. Participants of the meeting are: From District : DPR; IBI, PKK, Red Cross, Hospital, Blood Transfusion Unit, Private maternal clinic From Sub district: Camat, Head of Puskesmas, Puskesmas midwives, PKK sub district From Village (as the site of the Desa Siaga): Head of the village; village parliament; Village PKK, Village midwives; Influential religious/community leader. Output of the meeting: The concepts are understood Criteria for village facilitator agreed Support/commitment from relevant institutions is gathering, such as providing local budget for maintaining the established Desa Siaga specifically when the project is over. Training workshop on the concept of Desa Siaga and PLA for Siaga Facilitator This activity is called a training workshop because the participant are not only trained on concept of Siaga and PLA approach but the participants also work on developing their guidelines for facilitating the villagers in analyzing their health condition. Modules of the training workshop can be seen in separate document. Output of the training: Participants understood the concept of Desa Siaga Participants equipped with skills of PLA Participants are able to facilitate the villagers to analyze their health condition Plan of Situational analysis in each village is developed Participants: Village facilitator from 2 3 districts Puskesmas staff coordinator posyandu under the selected village. District facilitator Staff of DHO Village Meeting on Health Situational Analysis This activity is a process of enabling people to be aware of their situation as well as of empowering people to take action on how to improve their condition especially in maternal and child health. This process is done in two steps. First step is by undertaking a small group discussion based on the determined topics such case of maternal or infant death, discussion on health facilities and services available in the village, access of people to health services, health seeking behavior when maternal /newborn/ infant emergencies happen or when mother/infant/newborns get sick. The focus group discussion is conducted in every hamlet based on selected Concept Paper: Desa SIAGA Model supported by SISKES Page 17
topics. After all topics have been discussed in various small groups, a large village meeting is then conducted. The aims of the village meeting are to facilitate the villagers on analyzing their health condition using the results gathered during the smalls groups discussions, disseminate the concept of Siaga, and gather commitment to establish Siaga systems. Output of the activities: Health picture of the villagers understood. Concept of Desa Siaga understood Commitment to establish Siaga system gathered The health picture of each village is then written in good narrative report then shared to PHO, DHO, Puskesmas, Village midwife and village office and facilitator. Training workshop on Community Organizing for VF and DF This activity is called training workshop because the participant are not only equipped with knowledge and skills of organizing but the participants also work on developing a guideline for facilitation of the people in organizing meetings of formation of each Siaga network. Modules of the training workshop are available in separate document. Outputs of the training: Participants understood what and how to organize people Participants understood steps on organizing each Siaga system Participants equipped with facilitation skills on formation of Siaga system Participants are able to facilitate the villagers in formation of each Siaga system Participants: Village facilitator from 2 3 sub districts Puskesmas staff coordinator posyandu under the selected village. District facilitator Staff of DHO Village/hamlet meeting for formation of each Siaga system Meeting on formation of each Siaga is facilitated by the village facilitator, staff Puskesmas and staff of DHO and supported by District Facilitator. Formation of surveillance, financial support and means of transportation and communication systems are held at hamlet level considering accessibility of people in using the systems, while blood donation system is held in village level. Considering the large number of people that have to know and be involved in each Siaga so it is better to hold each meeting for formation of each system in order to allow more chance of discussion so that behavior change can begin to take place. Detail on the guidelines of formation of each Siaga system is available in separate document. Output of the meeting: Concept Paper: Desa SIAGA Model supported by SISKES Page 18
An agreed system for each system is established (the system includes a rules and functions; a mechanism; rights and responsible, protocols of the system). Who is responsible for each system is defined (including task and responsibilities) Provision of support for the functioning of each Siaga system. (recording books, white board, flag, so on) This is a sort of support provision for each system to start up its activities and function. For example, surveillance system needs some books for recording information of what agreed to be monitored such as pregnant women/newborn and infant. Training on Family Planning for cadre whose role as informant on Family Planning In order to provide nearest access of people to FP information, the project will train one person from each hamlet whose has the capability to share information on FP at hamlet level. The selected person will be trained about FP information and will be equipped with FP information that she/he may share or read together with people in the hamlet. In some cases it is expected that the cadre will be existing FP cadre, therefore in these cases the existing system will be strengthened. Module training is available in separate document. Bi monthly monitoring and evaluation meeting at village level. This meeting is more for capacity building for the villagers as well as the head of the village, head of hamlet, cadre, village midwife in monitoring and evaluating the functioning of the system and how they could use surveillance information to get support from relevant institutions. Additionally, this is capacity building for related institutions on looking after the function of the system as well as advocacy for ownership from the villagers as well as the head village and head of hamlet, and the village midwife. A form of monthly monitoring at hamlet and village level is available in separate document. Quarterly monitoring and evaluation meeting at district level This meeting is more for capacity building for DHO, Puskesmas and related institutions in monitoring and evaluating the functioning of the system and how they can respond to the information from the surveillance system. Also, this is advocacy for ownership in looking after the functioning of the system. Conducting other complementary activities: Running RH Class for adolescents. Modules are available in separate document Meetings for partnership between midwives and traditional birth attendants consistent with MoH guidelines. Guideline is available in separate document. Advocacy meeting for using the information from the surveillance system at the community level. Concept Paper: Desa SIAGA Model supported by SISKES Page 19