1. 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.

2. Country profile Total pop* 237.6 m Women 15-49 years* 131 m U5* 22.7 m
TFR**
Total live births m
MMR ***
NMR**
Neonatal deaths*
Stillbirths (2009)
Preterm babies (2010)
Indonesia, located in South-east Asia, consists of more than 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, subdistricts, villages
2162 hospitals, 9557 health centres, integrated health posts
midwives ( community midwives – deployed at village level)
Source: *Population census 2010; **IDHS 2012; *** IDHS 2007

3. 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 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

4. 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 live births in It is likely that the MDG 5 target of 102 per live births cannot be achieved by 2015.
Source: *IDHS; ** MoH routine reporting

5. 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

6. 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.

7. 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

8. 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 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

9. Targets for MCH improvement, 2009 and 2014
Strategic goals
Target for 2009
Target for
2014
Maternal mortality ratio (per live births)
226
118
Infant mortality rate (per live births) 26 24
Neonatal mortality rate (per 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 and It shows that NMR issue has been given a special attention from 2010 onwards. In the plan there was no target specifically for NMR.
Source: Medium-term development plan and

10. 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.

11. 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.

12. 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

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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

19. 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   

20. Thank You