Indonesia A Situational Analysis on Newborn Health Composition of Country Team Dr Mujadid, Child Health Directorate, MoH Dr L Daisy, Child Health Directorate, MoH Dr A Riskiyana, Maternal Health, MoH Dr Karina Widowati, UNICEF Ms Rustini Floranita, WHO Dr M Bateman, Senior Health Advisor, USAID Ms Mildred Pantouw, MCH Specialist, USAID Dr Pancho Kaslam, EMAS, JHPIEGO Dr Ardi Kaptiningsih, Consultant Good morning! I would like to present A Situational Analysis on Newborn Health in Indonesia. We have a strong partnership in Maternal and Newborn Health Programme, which is reflected in the composition of the Country Team.

Country profile Total pop* 237.6 m Women 15-49 years* 131 m U5* 22.7 m TFR** 2.6 Total live births 4.3 m MMR *** 228 NMR** 19 Neonatal deaths* 95 301 Stillbirths (2009) 62 300 Preterm babies (2010) 65 700 Indonesia, located in South-east Asia, consists of more than 180 000 islands. The total population of 237 million are unevenly distributed among islands. The total live births are 4.3 million/year. This slide also shows the number of provinces, districts and municipalities, health facilities and midwives. 33 provinces, 399 districts, 98 municipalities, 6 994 subdistricts, 81253 villages 2162 hospitals, 9557 health centres, 212 629 integrated health posts 104 060 midwives (65 475 community midwives – deployed at village level) Source: *Population census 2010; **IDHS 2012; *** IDHS 2007

Trends of U5MR, IMR and NMR, 1991-2015 Proportion of newborn deaths contributing to child mortality 30% 43% 48% This graph shows the trends of under-5, infant and neonatal mortality rates from 1987 to 2012. During the last 10 years, the decline has been slowed down, while NMR was stagnant. As a result, the proportion of neonatal mortality to under-5 mortality is increasing from 30% in 1991 to 48% in 2012. Source: IDHS 1987-2012

Correlation between proportion of skilled care at birth, facility birth and MMR MMR target Although the proportion of skilled care at birth has been significantly increasing to achieve 83% in 2012, and facility-based delivery 63%, the MMR has been decreasing slowly to achieve 228 per 100 000 live births in 2007. It is likely that the MDG 5 target of 102 per 100 000 live births cannot be achieved by 2015. Source: *IDHS; ** MoH routine reporting

Causes of neonatal mortality, 2010 The major causes of neonatal deaths are preterm birth complications (45%) and asphyxia (21%), while congenital anomaly was 13% and sepsis was 11% in 2010. Source: Countdown to 2015 report

NMR disparity among regions, 1990-2010 Widening the gap There are disparities in NMR among island groups in Indonesia. Java-Bali island group is the most developed region, while East Nusa Tenggara, Maluku and Papua island group is the most lagged behind region. While NMR in Java-Bali is declining, that of ENTMP and Kalimantan island groups are increasing. These create a widening gap among those island groups. Source: KH Nguyen et al. Indonesia equity report. University of Queensland, 2011.

Continuum of care – wealth quintiles There are disparities among rich and poor people along the continuum of care of MNH interventions. The widest disparities are in the coverage of institutional delivery: only less than 20% for the poorest, while it is more than 80% for the richest. Source: MoH, 2012

Coverage of key MNH interventions The coverage of MNH intervention is increasing. Institutional delivery coverage has been increased from 46% in 2007 to 63% in 2012. The MoH is currently promoting institutional delivery as the proportion of skilled care at birth has reach 83% and this has not been translated to a faster reduction of MMR and NMR. Source: IDHS 2007-2012

Targets for MCH improvement, 2009 and 2014 Strategic goals Target for 2009 Target for 2014 Maternal mortality ratio (per 100 000 live births) 226 118 Infant mortality rate (per 1 000 live births) 26 24 Neonatal mortality rate (per 1 000 live births) na 15 ANC coverage at least 4 visits (%) 90 95 Coverage of skilled care at birth (%) First neonatal visit (%) 84 Household practicing healthy and clean lifestyle behaviours (%) 60 70 These are the targets set for the medium-term development plan of 2004-2009 and 2010-2014. It shows that NMR issue has been given a special attention from 2010 onwards. In the 2004-2009 plan there was no target specifically for NMR. Source: Medium-term development plan 2004-2009 and 2010-2014

Policies related to newborn health Newborn health issues Related policies Focus on main causes of neonatal deaths thru: EmONC, ENC, MPA, quality improvement, supervision Reaching the majority: special attention to 9 provinces (75% of total pop) and 3 most lagging behind provinces Importance of an integrated MCH services: MIP, PMTCT and elimination of congenital syphilis, etc Inequity issues Financial schemes Address inequity issues Early initiation of and exclusive breastfeeding National Program for Community Empowerment (PNPM Generasi) Scaling-up nutrition movement These are policies related to newborn health. Focus is given to the main causes of neonatal deaths, give a special attention to 9 provinces that cover 75% of the total population and 3 most lagging provinces, and facilitate an integrated MCH services and address inequity issues. To address those issues, the GoI launched financial schemes for maternity and newborn care (community health insurance scheme, maternity insurance scheme and conditional cash transfer), address inequity, early initiation of BF and EBF, implement a national program for community empowerment and scaling-up nutrition.

Availability of essential drugs and supplies in delivery room This are the results of assessment on quality of MNH care that was carried out last year. The availability of essential drugs and supplies in delivery room in hospital, health centres and midwifery clinics are inadequate. This condition will influence the quality of care in all facilities.

Performance on implementation of Breastfeeding These are performance indicators related to essential newborn care, especially breastfeeding. Information on breastfeeding was given less than 50% at hospital, health centres and midwifery clinic. The initiation of early BF and information on pumped breast milk are also not well covered, while the other four indicators reach more than 70%. Source: Assessment on quality of MNH care 2012

Performance on selected newborn care procedures Routine Newborn Care Neonatal Resuscitation These are the performance on routine newborn care and neonatal resuscitation. The coverage of the procedures needs a lot of improvement. Source: Assessment quality of MNH care, 2012

Major bottlenecks in newborn care by health system building blocks Leadership (including partnerships) Strategies and solutions Insufficient management capacity and skills at provincial and district/municipality level Lack of skills for health planning and budgeting at district/municipality level Collaboration with and regulation of the private sector needs strengthening Unclear roles and responsibilities at different administrative levels Risks of desentralisation on health priorities Local action plan to accelerate MDGs achievement in 33 provinces Advocacy and technical/ managerial supports to provinces and districts Health financing Strategies and solutions Financial barriers: referral is not widely incentivized for institutional delivery Maternal and newborn services and care are covered for all Indonesians by health insurance (tax-based)

Health information system Strategies and solutions Neonatal and perinatal death audits are not regularly performed Poor capacity and skills at provincial and district level to collect, analyse and interpret data which impacts the quality of data Newborn mortality and healthcare data are included in the NHIS and the DHS Human resources Strategies and solutions Unequal distribution of HR (15% of rural area without villages midwife) Limited technical and managerial supports to decentralized provinces and districts Poor retention of HR especially in remote and rural areas Shortage of pediatricians and obstetricians Problem in competency (skills, knowledge and attitude) on routine newborn care, emergency care and management of complications Poor HR planning and no adequate HR data collection system in DHO and PHO Poor monitoring of training institutions Quality and adequate midwifery, nursing and medical schools Encourage training of local/ indigenous people to enhance staff retention Involving professional associations in HR management and ensure competency  

Access to essential drugs and commodity Strategies and solutions Stock-outs of essential drugs and BEmOC commodities at PHC level are common Lack of knowledge of correct storage and use of drugs and commodities among health facility staff at PHC and referral facilities All drugs needed for maternal and newborn care are included in essential drugs list Service delivery and organisation Strategies and solutions Lack of policy to enforce certification and accreditation of CEmONC (24 hrs-7 days) function in all hospitals Uneven/substandard policy for private hospitals Limited access to hospitals with CEmONC: rural: 51%; urban: 91%; Papua 18%, the Moluccas 37%, Nusa Tenggaras 51%, Kalimantan 53% Human resources: 83% public hospitals with obstetrician, 75.5% with pediatrician, 49% with anesthesiologist Continuity: only 59.1% ready for obstetric operation within 30 minutes Quality: 21% can do all 9 signal functions Address those issues locally, according to local situation and needs

Next plan for development of INAP Continue with more detailed bottleneck analysis : starts in early September 2013 Key partners involved : related programs in MoH, province representatives, partners, e.g. WHO, UNICEF, EMAS, USAID, AusAID, professional organizations Monthly technical meetings of TWG: from Oct 2013 – March 2014 First draft of INAP will be ready by December 2013 and final draft by March 2014 Piloting the ENC component in selected districts (remote): January 2014 Final review of INAP document by mid-2014

Strategies and solutions BEmONC Priority bottlenecks Strategies and solutions No policy supporting for sustainability of BEmONC (such as mutation, availability of drug and equipment and lack of facilitative supervision) Inadequate competency level of BEmONC functions in pre-service education of doctors, midwives and nurses Location of BEmONC sometimes inappropriate Only 47.4% of PHC BEmONC can provide 24-hour services Clarity on policy related to BEmONC sustainability Support provinces to identify and address local issues

Prevention and management of preterm birth Priority bottlenecks Strategies and solutions Limited actions in identifying maternal and other factors that lead to prematurity MoH has been promoting institutional delivery, although it is not written yet in the national policy Policy and guidelines for antenatal corticosteroids are not stated clearly Administration of corticosteroids for women with suspect premature labour has been implemented at hospital level Access: ineffective system of referral and emergency transfer of the mother from home to hospital in many areas of Indonesia, especially those with a low population density, such as Papua Lack of knowledge of the community regarding premature babies care Identify those factors and facilitate relevant actions accordingly Elaborate on task shifting in administering antenatal corticosteroid at primary care level Disseminate relevant guidelines on the subject to relevant health providers Address local situation and needs Individual, family and community education on the care of premature babies   

Thank You