Stories of Most

Significant Change

from Kinerja USAID March 2016

1

Table of Contents Introduction .................................................................................................................................................. 2

Summary of Findings .................................................................................................................................... 4

Study Process ................................................................................................................................................ 6

1. Method ............................................................................................................................................. 6

2. Site and storyteller selection ............................................................................................................ 7

3. Identification of domains of change ................................................................................................. 7

4. Story collection ................................................................................................................................. 7

5. Selection process .............................................................................................................................. 8

6. Limitations......................................................................................................................................... 9

Most significant changes: stories .................................................................. Error! Bookmark not defined.

Kabupaten Sambas, West Kalimantan Province ................................................................................... 10

Kota Singkawang, West Kalimantan ...................................................................................................... 15

Probolinggo, East Java ............................................................................................................................ 20

Bondowoso, East Java ............................................................................................................................ 22

2

Introduction

After decentralization, Indonesia has made substantial progress in strengthening local

governments, and has greatly increased local budget resources and service delivery

responsibilities. Local democracy and autonomy have been expanded, and capacity for local

governments in management and governance has been steadily increasing.

However, despite this overall progress, there remain some critical gaps in certain sectors local

government capacity. The health sector is one such area, with local service delivery remaining

weak. Roles and responsibilities are poorly defined; the quality of services at health facilities is

low and unpredictable; outreach services are limited; and health facilities are often poorly

equipped and stocked. These are just some examples of the limitations of public healthcare

provision in twenty-first century Indonesia.

Kinerja was a five-year project from United States Agency for International Development

(USAID). It was funded by the democracy and governance program, and focused on improving

service delivery in five provinces in Indonesia. The program was designed to reduce the gap

between targeted performance and actual performance by testing and replicating governance

interventions that measurably improved performances in the education, health, and business

sectors.

The original program worked in the four provinces of Aceh, West Kalimantan, South Sulawesi,

and East Java from 30 September 2010 to 28 February 2015. A no-cost extension was granted

to amend the program end’s date to September 2015. In March 2012, Papua Province was

added to the program, bringing the total number of provinces assisted to five.

Kinerja was designed to address both the demand and supply sides of local public service

delivery. This was done to avoid stimulating demand without a subsequent local government

response, or alternatively, without providing services that remain unused by the public, while

keeping in mind the critical need to maintain a balance and facilitate successful models of

functioning feedback mechanisms.

Kinerja’s M&E Framework emphasizes quantifying the measurable differences the project has

made in health, education and business, but it must be acknowledged that this type of

quantification may not offer practical insights into impact and recommended changes.

The Most Significant Change method was developed in the 1990s by Davies and Dart, and helps

to clarify the changes that occur as the result of a program, project, or intervention. MSC can be

described a storytelling technique, collecting qualitative evidence of changes as perceived by

the various stakeholders (including indirect beneficiaries such as users of public health facilities)

involved in the project.

3

In recent years, storytelling has emerged as an important component of organizational learning,

and a useful tool for monitoring and evaluation (Dart 2000). In fact, stories are an ideal medium

for development practitioners to help them make sense of the array of program impacts and to

better understand the range of stakeholder values – what is important, and why? Taking the

complexity of Kinerja’s interventions into account, it is important that time is allocated for the

various stakeholders to enter into meaningful dialogue about what happened in the field, and

whether these experiences represent the outcomes that were expected (Davies and Dart 2005).

Kinerja chose to undertake a study using the MSC approach due to its highly participatory

nature. MSC engages stakeholders not only in collecting but also in analyzing the data. The

methodology allows for the identification of the important changes that a project brings about,

from the viewpoint of beneficiaries who experienced the impact of the project.

However, MSC should not be the sole technique used for producing conclusive opinion for the

overall success of a project. This technique should be seen as complementary to the other

monitoring and evaluation methods. MSC stories are rather a rich source of hypotheses about

how things did or did not work, as well as identifying changes that were unintended or

unexpected.

The study was carried out by Isma Novitasari Yusadiredja and Rika Setiawati in August and

Septmber 2015. The report was developed in coordination with Kate Walton and Andri

Pujikurniawati from Kinerja in December 2015 and published in March 2016.

Thank you to all who were involved and interviewed during the research, and to all Kinerja staff

who participated in the selection of most significant stories.

For more information, please visit Kinerja’s website at http://www.kinerja.or.id or email

info@kinerja.or.id.

4

Summary of Findings The study showed that positive changes can occur in public service delivery when three sets of actors –

citizens, service providers, and governments – interact well and work together. By supporting and

building the capacity of both the supply side (the government and service providers) and the demand

side (the community and service users), Kinerja has shown that the availability, accessibility, and quality

of health services can be improved. Improvements can be identified as having occurred by the fact that

there are now less complaints from the community about service quality, users are more satisfied, and

services are more frequently accessed.

Service providers

The readiness of service providers to employ innovative tools and initiatives in Kinerja’s partner districts

was identified as a key method of improving services. By being willing to re-assess programs and moving

beyond ‘doing things as they have always been done’, service providers have shown that small changes

can have big impacts. For example, by genuinely involving both midwifes and traditional birth

attendants (TBAs) in midwife-TBA partnerships, the partnerships become much stronger and more

women give birth at health facilities, compared with the traditional top-down, government-led style of

partnerships. When all partners feel appreciated, listen to, and properly involved, health programs

become more likely to succeed and to have a positive impact on health outcomes. Two health centers in

West Kalimantan, for example, said that before they had governance-based midwife-TBA partnerships,

around 50% of births in their catchment areas had been with TBAs; now, only one or two births per year

are assisted by TBAs.

Community members identified four key changes that occurred in health centers following Kinerja’s

program: 1) improved interpersonal relations between patients and health workers; 2) improved

availability and adequacy of resources and services, including reduced waiting times; 3) increased

comfortability of the health center; and 4) better medical care. Health workers were said to be better

listeners and treated the patients more kindly and respectfully, and now tended to give more detailed

information on pregnancy, ante-natal care, childbirth, and breastfeeding. Health workers also were

perceived to arrive at work on time, and stay later into the afternoon than before. They were also more

enthusiastic and worked harder to handle more patients in a day than they used to, which led to shorter

waiting times. Many physical changes were also identified by patients as having taken place at the

health centers since Kinerja began working there – patients reported that centers were generally

cleaner, more comfortable, and better organized. Medical care was also seen to have improved,

following the implementation of service standards.

Crucial to all of these changes was the occurence first of a change in thinking. Heads of health centers

across Kinerja’s sites said that they had been huge changes in what they called their staff’s mindsets.

Since being introduced to principles of good governance such as transparency and public participation,

health center staff were identified as having become willing ‘agents of change’ once they realised how

much of an impact they could actually have on service quality. Staff stopped simply following habits and

routines, and started changing how they worked, which resulted in staff not only becoming more

enthusiastic, happy, and friendly, but in improved customer satisfaction and better health outcomes.

5

Governments

The willingness of governments to support service providers in improving healthcare services and in

involving community members was also shown to be crucial. By reinforcing existing policies and

regulations, and developing new regulations to cover gaps, governments are able to demonstrate to

citizens that they are committed to the principles of good governance. When governments genuinely

listen to their citizens and commit to fulfilling their rights, problems are more easily identified and

service quality improves.

Patients, service providers, and government staff all identified that new local policies and regulations

had been central to the improvements they saw at health centers. This was particularly the case for local

government-level regulations on immediate and exclusive breastfeeding, which government staff

believed acted as a strong push factor to changing policies on breastfeeding at health facilities.

Community

Finally, in Kinerja’s partner districts, the enthusiasm of the community has been vital to service

improvement. When acting as an oversight mechanism by joining a community forum (in this case,

Kinerja’s multi-stakeholder forums), community members are able to push for change by identifying

problems, finding solutions, and advocating for fixes. Budgets and plans become more relevant and

more capable of solving health issues when the community is involved, and service providers are more

likely to follow standard procedures when they are aware that service users know their rights and are

capable of demanding them.

Community members in Kinerja’s partner districts report believing that their governments now

genuinely listen to them and have realized that services will be better implemented if communities,

service providers, and governments work together rather than individually as they used to. Members of

multi-stakeholder forums said that they are also able to act as a bridge between service providers and

the community, and can solve problems that would previously have gone unresolved because of poor

relationships. Many multi-stakeholder forum members also stated that they felt they now have

important roles to play in the community as a conveyer of information from the health centers, and that

this was improving health outcomes in areas such as safe delivery and breastfeeding.

Conclusion

The study of the most significant changes coming out of the Kinerja program shows that incorporating

and strengthening key good governance principles – transparency, accountability, responsiveness, and

public participation – in public service provision has a positive impact. Patients are more aware of their

rights; medical professionals are more aware of their responsibilities; and governments are more aware

of what is needed to provide high-quality, reliable health care. Over a longer period, these changes will

lead to improvements in health outcomes, the beginnings of which can already be seen in many of

Kinerja’s partner districts. Through good governance, less women and babies will die, more women will

have positive birth experiences, and more children will have a good start to life.

6

Study Process

1. Method The Most Significant Change (MSC) tool was originally designed to involve ten steps of

implementation:

1. Finding champions and raising interest in using the approach

2. Establishing domains of change

3. Defining the reporting period

4. Collecting stories of change

5. Reviewing stories within a predetermined structure

6. Providing stakeholders with feedback about the review process

7. Putting in place a verification process for the stories collected

8. Quantifying the data

9. Conducting secondary analysis

10. Revising the MSC process

Although every step plays an important role, it is not mandatory to follow all ten steps in order

to successfully implement the MSC approach. Kinerja took into consideration the available time

and resources (financial and human), and focused on what we considered to be the

fundamental steps to the process, as depicted in the following diagram.

7

2. Site and storyteller selection In consultation with Kinerja’s staff and management, the following sites were identified for

evaluation:

Province District

East Java Probolinggo

Bondowoso

West Kalimantan Sambas

Kota Singkawang

Based on Kinerja’s MSC study objectives, the stories were collected from a group of pre-

identified types of respondents. In general, the respondents were decided that they should be

stakeholders who had witnessed and/or experienced the situation both before and after

Kinerja’s intervention. The following roles were identified as targets for interviews:

1. District Health Office staff: Head of the Office, or staff of the MCH department, who had

at least 2 years’ experience with Kinerja.

2. Community health centre (puskesmas) staff: Head of Centre, Head Midwife, or staff

midwife who had at least 2 years’ experience with Kinerja.

3. Community members: Pregnant mothers who receive ante-natal care for their current

or recent pregnancies, and had also been pregnant before. The women must have used

the local community health centre for their previous pregnancy or deliver, as well as for

their current or most recent pregnancy or delivery.

4. Multi Stakeholder Forum (MSF) members: Members who have been active for at least 2

years during the Kinerja assistance period.

5. Community journalists (CJs): CJs who have been active for at least 2 years during the

Kinerja assistance period and who received training from Kinerja.

3. Identification of domains of change Domains of change are general categories that are used to group the stories collected during

the MSC research process. Before grouping the stories into different domains of change, Kinerja

staff and the research consultants decided that the stories would aim to capture and illustrate

changes that occurred on the supply side (that is, the service provider side), with a particular

focus on the community health centres called puskesmas. It was expected that the stories

would convey changes in service quality, governance, and community participation.

4. Story collection The collection of MSC stories was conducted by two external research consultants. Using

external consultants meant that the stories were, in theory at least, provided as neutral and

8

objective stories, as the storytellers were not influenced by the presence of Kinerja staff. To

ensure consistency in the information recorded in different districts, researchers developed and

used common interview guidelines. As previously mentioned, the researchers intended to

collect stories based on three over-arching domains of change:

1. Changes in quality of public services

2. Changes in governance

3. Changes in community participation.

Data collection was done in the aforementioned four sites, and during the process, over 40

stories were collected. After cleaning data, 30 stories were selected from all districts.

Stories were collected using in-depth interviews with selected respondents. Stories were

collected on 10-15 August 2015 in East Java and on 21-26 August 2015 in West Kalimantan.

Each interview lasted around 30 to 45 minutes. When approaching potential participants, the

study’s objectives were explained before consent was requested to participate. If they

consented to be interviewed, participants were also required to give their consent to be

recorded using a digital tape recorder.

Each interview was named with the real name of the storyteller. Real names were also used to

name audio files and transcripts. All notes and audio files are kept by the researchers and the

Kinerja team in password-locked computers, and will be retained for five years from the

beginning of the study. Recorded data and handwritten notes were transcribed and typed into

a word processing program. After transcription, all transcripts were then summarized into short

stories.

5. Selection process The stories collected from each district were discussed and the final selections made during a

mini-workshop held on 22 September 2015. Current and former Kinerja staff from East Java,

West Kalimantan, South Sulawesi and Aceh were invited to the workshop; the national office

staff also attended. The workshop was held in order to validate and verify the changes

conveyed in the stories collected.

All 39 stories were distributed to the participants. Participants were divided into three groups.

Each group was assigned to select 5 stories that they considered most significant. All stories

considered significant by each group were read aloud by the workshop participants, and the

facilitators took notes. Each group was required to state the background or reasons why they

chose particular stories. After the stories were heard, a process to identify the three stories that

were considered most significant was begun. A long, open discussion was held until the final

selections were made and all participants agreed.

9

At the end of the first stage, there were 15 stories from all groups that were considered

significant. These stories represented 5 stories from Sambas, 5 stories from Kota Singkawang, 3

stories from Probolinggo, and 2 stories from Bondowoso. 3 stories were eventually chosen as

most significant: one from Singkawang, one from Sambas, and one from Probolinggo.

6. Limitations This study was conducted to shed light on the changes that occurred on the supply side,

focusing on the puskesmas. Therefore, stories outside this scope were not able to be captured.

During the collection phase, some beneficiaries from the community level were very shy and

did not find it easy to tell their stories. Therefore, because participation in the interview is

voluntary, the sample of stories collected may be biased towards the stories of more confident

and outspoken individuals.

Another challenge was the difficulty of selecting the final ‘most significant’ stories. Workshop

participants recognized that all stories had some important information within them, and this

made selection tricky.

10

Stories of most significant change

This publication does not include all stories collected during Kinerja’s MSC study. Instead, we have

focused on offering a selection of stories that illustrated what some of the program’s stakeholders

considered to be the most significant changes occurring as a result of Kinerja’s support in West

Kalimantan and East Java provinces.

Kabupaten Sambas, West Kalimantan Province

A Change in Mindset

(Marzini, Head of Semparuk Community Health

Centre)

Photo: Marzini, Head of Semparuk Communtiy

Health Centre, Sambas.

Marzini is the head of the Semparuk

Community Health Centre, one of the 27

government community health centers

(puskesmas) in Sambas District, West

Kalimantan Province. He has been the head of

the Semparuk centre since 2014. Previously he

was the head of Sungai Kelambu Community

Health Centre, also in Sambas. Although he has

only been at Semparuk for a bit over one year,

Marzini has long known about Kinerja through

his previous centre’s involvement with the

program, and since moving to Semparuk, he has

even presented at a number of large events,

including in the provincial capital of Pontianak,

on the changes that have taken place at

Semparuk since working with Kinerja.

Marzini feels that there have been many

positive changes at Semparuk in the last year.

The centre’s staff are performing better and

service quality is improving. Marzini believes

that underlying all this is a change in mindset –

that is, a change in how his staff think.

“With Kinerja’s support, a really

significant change that has taken

place at our centre has been a change

in mindset, in thinking. Firstly, we

don’t just think about doing our

routine tasks anymore; we think of

ourselves now as ‘agents of change’,

that we can bring innovations into

the centre and can make it better.

This has been a big change in how we

think.”

This change in thinking has brought about many

improvements at the Semparuk Community

Health Centre. Marzini nominated the

involvement of all staff in planning as one of the

most significant changes. Before, planning was

done only by the centre’s management team;

the staff below them simply followed orders.

Now, the staff work together with the

11

management to decide on how they want to

improve the centre’s performance and services.

This had led to all staff feeling personally

responsible for making improvements.

One example of the improvements made is the

physical changes the health centre has

undergone. The reception desks and waiting

room have been cleaned up and improved, and

posters are now displayed on the walls. This

makes people more comfortable.

“It’s like in a hotel,” Marzini says, smiling. “If

people come here and are made to feel

comfortable [because of the pleasant

atmosphere], they will immediately feel 50%

better.”

These improvements were all suggested by the

staff of Semparuk, and were jointly carried out

so that everyone played a role.

Marzini believes that another major change in

how he and his staff think is that they are now

open to receiving feedback from the

community. Before Kinerja began working with

the centre, staff felt that feedback was not

helpful and was more like criticism. Now, there

is more willingness to take suggestions and

input from patients.

“Before, if we received feedback from

the community, it was like we were

being criticised in negative way. Like

we had an opposition. But now, we

actually want to receive feedback all

the time!”

To deal with feedback from the community,

Semparuk health centre has a feedback process.

Complaints and suggestions can be made

through telephoning the centre, through SMS,

in person (face-to-face), or by filling out a

complaint form. The centre is committed to

receiving and following-up on all feedback as

long as patients follow the proper process for

submitting complaints. This information has

been provided to the community in order to

increase their participation in the system.

For example, the centre once received some

feedback from patients that service was too

slow. The complaints were discussed with all

staff, and the staff decided to make a service

flowchart that would make services run faster.

The flowchart was developed and hung on the

wall by the reception desk, so that all patients

can know exactly what they are required to do

at the centre: register, be seen by a medical

professional, be seen by other staff if required

(such as a dentist), visit the lab if required,

collect medicine if required, then pay and go

home. This sort of flowchart was never

previously displayed at the health centre, so

patients were often confused where to go and

what to do. Now, things are much clearer.

Marzini explained that the health centre deals

with all feedback itself, and tries to solve its

own problems. However, if necessary, he also

takes up patients’ complaints with the District

Health Office to be resolved.

Marzini notes that the community is much more

involved in general now, and not just in

providing feedback. Kinerja supported the

establishment of a Multi-Stakeholder Forum

(MSF), made up of community members, and

provided training for citizen journalists. At first,

the health centre saw the MSF and the citizen

journalists as trouble – they seemed to be

always trying to find problems. But now, says

Marzini, he and his staff have realised that their

contribution is actually important, and helps the

health centre to improve. They act as a conduit

for the community’s aspirations and needs, and

ensure there is smooth coordination between

the centre and the community. Marzini hopes

the MSF and the citizen journalists will continue

to be active in the years to come, even after

Kinerja’s support ends.

12

Now, We Want to Care

(Nurul Fauzah, MSF Sejangkung)

Photo: Nurul Fauzah (left), a member of the

MSF in Sejangkung, Sambas.

Nurul Fauzah is a member of the Multi-

Stakeholder Forum (MSF) in Sejangkung Sub-

District, Sambas District, West Kalimantan. She

has been part of the MSF since 2011. Nurul is

also a member of the Community Health Board,

a volunteer at the integrated health services

post that provides healthcare for mothers and

babies, and a volunteer at an early learning

centre.

There are 10 members in the Sejangkung MSF,

around half of whom are very active. They come

from a wide range of backgrounds: the local

religious affairs office, blood donation

organisations, youth groups, and many more.

The members attended multiple types of

training from Kinerja, including training on

advocacy and writing, before they began

regularly attending the local health centre’s

meetings and monthly mini-workshops.

Nurul sees her role as an MSF member as a way

of supporting interactions between the

community, the government, and health

services.

“One of our most important tasks has been

about government regulations and policies. You

know, ‘Oh the regulation is like this because the

service flow has to be like this.’ So we share that

information with the community, with our

neighbours, our friends, the mothers and

babies’ service post. We tell them ‘So the

process at the health centre is like this.. you pay

this to get insurance..’ and so on. We tell people

that with their health insurance that they should

give birth at the health centre, not [with

traditional birth attendants], and we tell them

about the importance of breastfeeding.”

Nurul has seen a lot of changes in the

community and at the health centre since she

joined the MSF. The health centre’s opening

hours are now followed, for example, and they

don’t open late or close early. The health centre

also displays a service flowchart so that patients

better understand how to get a checkup. Nurul

says that the community itself feels like the

health centre has improved a lot – a simple

example that has made a difference has been

replacing the waiting room chairs with more

comfortable ones, so that everyone feels happy

while they are waiting to be seen.

Before, Nurul says, the community didn’t have

sufficient access to information on government

policies. For example, when the previous

pregnancy insurance scheme was replaced with

the national insurance scheme, the MSF was

able to explain the changes to the community.

Previously, the community may have not

received this sort of information.

Nurul learnt that maternal and neonatal deaths

can actually be avoided when she attended a

workshop run by Kinerja’s local partner, PKBI.

The facilitators told the participants that in East

and West Nusa Tenggara, part of Eastern

Indonesia, a program there was able to reduce

the number of neonatal deaths from 20 to zero.

Nurul was surprised to learn this, and was

fascinated that through working with all the

13

different stakeholders, the lives of mothers and

babies can be saved.

Nurul is happy to be a member of the MSF. She

likes working with friends who have the same

goals, and feels that their work is more effective

when they work together rather than

individually. Nurul feels that the MSF has been

very successful so far in sharing information

that is needed by the community. She feels that

she has changed a lot since joining the MSF:

“I didn’t used to pay that much

attention to pregnant women, for

example. Women would die giving

birth, and we would just say that that

was God’s plan for them. That was

our understanding of it. But it turns

out that humanity plays a big role [in

what happens to someone], too. So

now, we want to care.”

Nurul would like to see the MSF formalised by

the government through the legalisation of the

forum’s status. If they are formally recognized

by the government, they will be allocated a

small budget to use for their activities. Nurul

hopes this can be achieved in the near future.

Photo: The new

delivery room at

Semparuk

Community

Health Centre,

the land for

which was

donated by the

village as a result

of the local MSF’s

advocacy.

Safe Childbirth

(Narti & Eliah, midwives at Semparuk

Community Health Centre)

Photo: One of the midwives at Semparuk

Community Health Centre, Sambas.

Narti and Eliah are midwives at Semparuk

Community Health Centre in Sambas District.

They themselves did not attend Kinerja’s

activities in the region, because the centre’s

management normally attended instead, and

later shared the information with other staff.

The two midwives believe there were lots of

changes that occurred because of the Kinerja

program. One was the new style of partnerships

between midwives and traditional birth

attendants, which was more transparent and

participatory than before. Other changes

identified by Narti and Eliah as important

included the addition of a breastfeeding room;

improvements in carrying out immediate

initiation of breastfeeding for new-born babies;

the pregnancy tracker map; and the complaint

system. They also felt that the Multi-

Stakeholder Forum (MSF) was an important

addition to their sub-district, although they

weren’t entirely sure what its real role was

supposed to be.

Narti and Eliah especially like the new feedback

system their health centre has set up. When

14

pregnant mothers come to the centre for a

check-up, they are given a feedback form to fill

out. The form includes questions on all parts of

their check-up, from the moment they enter

the building to the moment they leave. Once

filled out, the forms are put into the suggestion

box, and the box is opened by the head midwife

once a month.

For example:

Semparuk Community Health Centre

once received suggestions asking

them to improve the healthcare

available at the mothers’ and babies’

health post (posyandu). The requests

wondered if the weighing of babies

and the provision of antenatal care

for mothers could be separated in

order to speed up and provide more

clarity. The midwives liked the idea

and agreed to implement it.

Narti and Eliah feel that there have also been

significant changes in safe childbirth in their

sub-district. Before, many women still gave

birth assisted by traditional birth attendants,

who lack proper medical training and

equipment. Now, they say, because of the new

partnerships between midwives and traditional

birth attendants (TBA), more and more women

are choosing to give birth at the health centre

with the help of a trained midwife.

“Sometimes, women still want to give birth with

a TBA. Before, TBAs used to say that they hadn’t

had enough time to refer the woman to us –

that she had arrived and the baby was born

immediately. It was just an excuse [to justify

their helping of the woman]. But now, it’s been

made clear to the TBAs that they have to

encourage women to give birth at a health

facility. It’s really helped a lot. We used to get

called to assist births at homes, which was hard

because we often couldn’t bring a lot of

equipment of medicines, but now [they come to

us] and it’s made a big difference.”

Narti and Eliah say that there have

always been partnerships between

midwives and TBAs in their sub-

district. But they argue that Kinerja’s

program was different, because it

clearly and simply laid out all of the

steps to developing a strong,

sustainable midwife-TBA program.

Kinerja helped the Semparuk Community Health

Centre to hold meetings at the neighbourhood

and village levels about the importance of

delivering babies in facilities and assisted by

midwives. Community members, midwives, and

TBAs were all invited. After a number of

meetings, memoranda of understanding were

signed between midwives and TBAs, and

witnessed by village heads. Now, TBAs work as

assistants to the midwives, providing non-

medical support to delivering mothers and new-

born babies. TBAs receive an incentive of

Rp.30.000 (US$3) every time they refer a

pregnant woman to their midwife partner.

According to Narti and Eliah, almost all births in

Semparuk are now attended by midwives. The

few that are assisted by TBAs usually occur

when a woman arrives at a TBA’s house in

advanced labour.

“If a woman gives birth with a TBA, it’s risky for

the mother. Anything could happen. She could

haemorrhage, for example. But if she was giving

birth with us [midwives], we know what the

signs are. Or if the birth wasn’t advancing, for

example, we would know to refer her [to a

hospital]. This is important.”

15

We Don’t Need to Wait All Day

Anymore

(Ria, a mother from Semparuk)

Ria is 25 years old. She lives in Semparuk Sub-

district, in Sambas, and is a regular user of the

Semparuk Community Health Centre. She is

currently seven months pregnant with her

second child.

Ria married in 2011, and had her first child the

following year. Her ante-natal care for both

pregnancies has been from the Semparuk

Community Health Centre. She remembers

having her blood pressure checked, her height

and weight measured, and her baby’s heart

beat checked. The centre also gave her vitamins

and iron tablets to take, and milk to drink. The

midwives also advised her to get enough rest

and to eat nutritious food so that her child is

healthy.

In Ria’s perspective, the Semparuk Community

Health Centre has changed a lot since she had

her first baby in 2012. The building itself has

been improved, and there are more staff than

there used to be. The staff are even present at 8

o’clock in the morning, when before there was

nobody. The centre is also cleaner than before.

For Ria, the most important change has been

the staff attendance and punctuality:

“If you want to go [to the health

centre] now, you can even go at 8am.

There will be staff there. So you can

go early in the morning, and you

don’t have to wait until midday, or

the afternoon anymore.”

Kota Singkawang, West Kalimantan

Patients’ Rights

(Head Midwife, North Singkawang Community

Health Centre)

The head midwife of North Singkawang

Community Health Centre, located in

Singkawang City, West Kalimantan, has been

working there for 25 years. She says she has

noticed a number of important changes since

Kinerja began supporting the health centre.

The smaller changes include the addition of a

breastfeeding room at the centre, and extra

focus by the staff on performing immediate

breastfeeding after births and on supporting

exclusive breastfeeding.

But she believes that one of the most significant

changes has been that patients are now more

aware of their rights. The staff at the centre

decided to hang information on patients’ rights

on the walls so that they could be easily read

and understood. For example with regards to

antenatal care, there are now posters that

describe the 10 types of care a woman is

supposed to receive during her check-ups.

Previously, she says, the women would just

accept whatever was given to them, and there

was no information on what standard services

they should receive.

Before Kinerja assisted the staff at North

Singkawang to develop better understanding of

patient rights, staff used to separate mothers

and babies immediately after delivery. The

women just used to accept this and not

question it, because they assumed that what

the midwife was doing was best practice and

that they weren’t allowed to be with their baby.

16

But now, through awareness raising programs

and promotional materials such as posters, she

says the women in North Singkawang now

request not to be separated from their babies

because it is their right to be together.

The head midwife considers this to be the most

significant change at North Singkawang

Community Health Centre since Kinerja began

supporting them.

“We as midwives, as service

providers, need to be more

introspective. We need to learn where

our deficiencies are, and how we can

improve the quality [of our services],

too.”

To Save Lives

(Hatijah, Yeti, Alusia, Waldi, and Mayuri –

members of various MSFs in Singkawang)

These five MSF members – three women and

two men – had just finished disseminating the

results of a satisfaction survey when they were

interviewed. They told the team that they were

members of different sub-district level MSFs,

from North Singkawang, South Singkawang, and

West Singkawang, and that four of them had

been involved since 2012. One woman, Alusia,

had just recently joined her local MSF in East

Singkawang, as it was only formed during the

local government’s expansion of Kinerja’s

program in 2015.

Each of the five MSF members were also active

in other social welfare activities, such as the

District Social Welfare Office’s Community

Social Workers program, where they became

used to talking to the community and sharing

information. They are happy to now be working

on issues of maternal and child health in

addition to the topics they previously covered,

such as HIV/AIDS, tuberculosis, and domestic

violence.

Hatijah, Yeti, Alusia, Waldi, and Mayuri stated

that they had seen a number of positive

changes in their communities and at their

community health centres since Kinerja began

working in Singkawang. The centres have all

developed service improvement charters, with

detailed promises on how they will improve

staff performance and healthcare quality. For

example, the MSF members note that now the

staff are more friendly than before, and that

there are clear service flowcharts on display, so

that all patients know where to go and what to

do. The centres have also improved physically,

with more chairs in the waiting rooms and

more-organised reception areas.

The MSFs in Singkawang have also

helped to spread information to the

community. Mayuri and Yeti say that

patients were previously sometimes

tricked by staff about how much they

needed to pay, whereas now there is

a clear service flowchart and a

transparent fee list. The MSFs have

ensure this information is displayed

at the health centres.

Mayuri says that since Kinerja, his local

community health centre has a new referral

procedure in place for when patients need

transferring to hospital. The procedure is public

knowledge and has been explained to the

community, so that all community members

17

now understand how and when patients are to

be referred to the hospital.

Hatijah notes that there has also been an

increase in people’s knowledge of

breastfeeding, especially on the importance of

exclusive breastfeeding. She tells a story of how

she successfully encouraged one mother to

overcome her fears of breastfeeding and to try

it with her first child. Hatijah explained to the

woman how if she took good care of herself

from the first trimester of her pregnancy, both

physically and nutritionally, she should be able

to breastfeed her child.

Alusia agrees that there has been an

improvement in people’s knowledge, not just

with regards to breastfeeding but also in terms

of maternal health more generally. She says she

once succeeding in convincing a man to take

better care of his pregnant wife, who had

previously miscarried and was worried about

losing the pregnancy. During her first

pregnancy, her husband had still let her

perform hard physical tasks such as carrying

sacks of rice in from the field after harvest.

Alusia and other members of the MSF

contacted the man and spoke to him; she

believes that he really had no idea that women

should not perform heavy physical work during

pregnancy. Following their intervention, the

man no longer lets his wife work in the fields,

and she is now happily seven months pregnant.

Alusia notes that if she wasn’t a member of the

MSF, she would never have given such

information to people before. She feels

empowered now.

All of the five MSF members agree that

knowledge is incredibly important. They each

strive to build their own knowledge so that they

can share it with their local communities, which

they have recently started doing through a

door-to-door awareness raising program.

Each person identifies a different change as the

one they considered most significant. Mayuri

selects the fact that the MSF can access

information that was previously unavailable or

hard to access (such as a list of fees) as most

significant. Yeti thinks that the creation and

display of the patient referral procedure was

most important, but also nominates the District

Health Office’s support for the MSF as a

significant development. Waldi agrees.

Alusia picks her own improvement of maternal

and child health knowledge as the most

significant change for her. She can now explain

the importance of things like delivering in a

health facility to members of her community,

and feels this brings big benefits. Hatijah agrees,

saying that her knowledge has also grown, and

she likes being able to share that with others.

When asked why they had chosen these

changes as the most significant, Hatijah

immediately responds: “Because they save

lives! What else would be the reason?” The

others smile in agreement.

Photo: Health centre staff and MSF members

take part in a training supported by Kinerja.

18

Communication between Health

Professionals and Patients

(Sri Sumiati, Head of North Singkawang

Community Health Centre)

Photo: Some of the staff at North Singkawang

Community Health Centre.

Sri Sumiati is the Head of North Singkawang

Community Health Centre in Singkawang City.

She has been head since April 2015, and was

previously the head of West Singkawang

Community Health Centre (2013-2015). She has

been involved with Kinerja at both centres.

One of the biggest changes Sri Sumiati has seen

since working with Kinerja has been the impact

of developing and signing service charters.

These service charters are created based on

feedback fielded from community members

during a complaint survey, and are made up of

a number of specific promises for

improvements. Sri says that some of the

changes that have happened include the

development and display of SOPs and patient

service flows, the improvement of the waiting

room, and a positive change in staff attitude.

Staff are also arriving at work earlier and leaving

later – average work hours were from 9am to

12pm, but now most staff arrive at 8am and

leave around 1.30pm. This means more patients

can be seen and waiting times are decreased.

Before Kinerja’s support, West Singkawang

Community Health Centre did not have many

patients. Sri nominates a few reasons as to why

this may have been the case: the staff were

rude and unfriendly, and the waiting rooms and

inspection rooms were uncomfortable and

unclean. But after the service charter was

signed, the staff realised that their job was to

serve patients, and that they should be more

friendly and welcoming. The rooms are now

cleaner and more organised, which makes

patients feel more comfortable and thus more

likely to use the health centre’s facilities.

Sri thinks the existence of the multi-stakeholder

forum (MSF) is one of the biggest influencing

factors. The MSF frequently passes on

complaints and feedback from the community

to the health centre.

“We receive the complaints in their

raw form. Then we investigate, are

the complaints accurate? Who was

involved? We identify them and ask

them about the complaints. If they’re

quiet or only try to make excuses for

their behaviour, yeah, that’s normal.

We know what that means.. [laughs]”

Sri Sumiati summarises the most significant

change at West Singkawang Community Health

Centre as improved two-way communications

between medical staff and patients. Both staff

and patients are now more honest and open,

and Sri rates this as very important. She says

that patients now frequently offer feedback and

complaints about services, and much more

often ask questions about their pregnancies and

their children than they used to. Sri believes

that if the centre makes improvements that

solve patient complaints, then the patients will

feel that they are receiving better care and they

will have less complaints.

19

Exclusive Breastfeeding

(Muwati, staff member in Maternal and Child

Health Section, District Health Office,

Singkawang City)

Muwati works in the maternal and child health

section of the District Health Office in

Singkawang City. She has taken part in a

number of Kinerja-supported activities, and is

keen to talk about the changes she has

witnessed in Singkawang.

In addition to supporting safe delivery, Kinerja

also supports immediate and exclusive

breastfeeding. Muwati says that Kinerja helped

the city’s government develop a regulation that

encourages women to breastfeed and requires

offices and other places of work to provide

breastfeeding rooms. With a government

regulation in place, the District Health Office

and other departments now work much harder

to support the city’s mothers and ensure their

children grow strong and healthy.

Muwati also nominates the establishment of

the city and sub-district MSFs as a positive

change. She explains that the MSF members are

representatives of all the different groups in the

city and sub-districts. Muwati thinks that the

health staff at the community health centres

appreciate the help the MSF gives them, and

likes that the MSF assist them in sharing

information with the community. It makes their

work easier, Muwati explains, especially

because a lot of awareness raising activities

used to fall on the shoulders of the village

midwives, who were already very busy and

overburdened. Now, with the MSFs, there is a

much smoother two-way flow of information,

and relationships between the community and

the health centres have become stronger –

midwives can pass important information on to

community members, while community

members can easily give feedback and make

suggestions for improvement.

According to Muwati, the MSFs also help from a

social work aspect. For example, if there is a

patient who needs medical assistance, MSF

members often take them to the health centre

themselves. Or when a blood donor is needed,

MSF members frequently offer to donate

themselves or to find someone with the correct

bloodtype. This greatly helps the health centres.

The MSFs of the three sub-districts supported

by Kinerja are in fact considered to be so

successful by the local government that new

ones will be established in the two remaining

sub-districts of the city – Central and East

Singkawang.

But, after considering everything, Muwati still

nominates the establishment of the pro-

breastfeeding government regulation as the

most significant change. For example, she says

that midwives previously didn’t have sufficient

knowledge of immediate initiation of

breastfeeding – maybe they did when the

graduated, she says, but since then, perhaps

they have forgotten. Now, after being assisted

by Kinerja, the quality and rates of immediate

breastfeeding have improved throughout

Singkawang. The minimum period for

immediate breastfeeding is now one hour;

previously, it was just half an hour.

Muwati says that the pro-breastfeeding

regulation has also improved understanding of

the importance of exclusive breastfeeding in

Singkawang. Before Kinerja, many health

centres and hospitals used to sell or provide

formula milk to new mothers, and didn’t

encourage them to breastfeed. Since the

regulation came into place, this is no longer

allowed.

20

Probolinggo, East Java

The Contribution of the Community

(Dr Wahyu, Head of Sumberasih Community

Health Centre)

Photo: The new fingerprint registration system

at work at Sumberasih Community Health

Centre, Probolinggo.

Although Dr Wahyu has only been the head of

Sumberasih Community Health Centre for a

little more than one year, he has noticed many

things that are different at Sumberasih if he

compares it to the health centre he worked at

previously. The service quality is better, and the

community is more involved at Sumberasih. He

puts this down to Kinerja’s support; his last

workplace wasn’t assisted by Kinerja, unlike

Sumberasih Community Health Centre.

At Sumberasih, Dr Wahyu is constantly

surprised by how much the community

contributes to the centre’s activities. Every

three months, the centre holds a meeting with

health volunteers and the local multi-

stakeholder forum (MSF) to discuss problems

and receive input from community members.

He says the MSF acts as a bridge between the

health centre and the community, because they

support a two-way flow of information.

The MSF at Sumberasih also helped carry out a

complaint survey in the local community. The

survey aimed to get feedback regarding the

performance of the health centre and on the

general health status of the community. Dr

Wahyu appreciates the MSF’s contribution in

running the survey, and says that his staff didn’t

feel ‘watched’ or ‘investigated’ at all:

“For me, I see the MSF’s active role as

a positive one. We don’t feel judged!

We are actually happy to receive their

suggestions. They aren’t like some

NGOs that just try to find problems or

mistakes all the time.”

One of the big changes that occurred after the

implementation of the complaint survey was

the establishment of a fingerprint registration

system at the centre’s reception desk. Patients

can now register for an appointment much

faster than previously, and waiting times have

been significantly reduced. The amount of

paperwork performed by staff has also

lessened. The centre now plans to introduce

touch screens for patients, like those used in

banks, that provide information on how

services work at the centre.

SOPs and service standards have also been

improved and displayed on the walls of the

centre since the complaint survey. Patients are

now better aware of their rights and of what

services they are supposed to receive.

Dr Wahyu believes that Kinerja’s assistance has

also helped his health centre improve its staff

performance. They now have a Manager on

Duty position, which is rotated between staff,

to ensure that the services the centre provides

run smoothly and are the best they can be.

Every Friday, Dr Wahyu runs a ‘medical staff

class’ where staff share their knowledge with

each other and discuss new information,

21

policies, and programs. Once a week, the centre

also holds a ‘joint reflection day’, where staff

reflect on their recent experiences and share

inspiring and motivating stories.

The impact of these changes on maternal health

outcomes has been notable, says Dr Wahyu.

Almost all women in the centre’s catchment

area now come for antenatal care – a significant

achievement. The percentage of births that take

place at the centre and that are assisted by

midwives continues to increase year on year,

and the percentage of births assisted by

traditional birth attendants is falling.

Overall, Dr Wahyu says that the most significant

change at Sumberasih Community Health

Centre is the increased involvement of the

community. He explains that the MSF’s work

has had ‘extraordinary’ impact on the centre’s

performance and achievements, to the extent

that he now cannot imagine working without

the MSF.

Thumbs Up for Fast Service

(Haji Syukron, member of MSF Sumberasih)

Photo: The ‘thumbs up’ banner at Sumberasih

Community Health Centre, Probolinggo.

Haji Syukron has been involved in the multi-

stakeholder forum (MSF) in Sumberasih sub-

district since 2012, but has been most active

since he retired from the District Education

Office in 2013. He says there have been a lot of

positive changes in the area since the MSF was

established.

According to Haji Syukron, the MSF work as a

bridge between the community and relevant

government institutions such as the District

Health Office. Since receiving training on how to

advocate for change, Haji Syukron says he and

the other members of the MSF have been

active in pursuing problems:

“One example, in the villages there

are always lots of problems with the

Village Funds, especially with regards

to funds being allocated to the

mother and child health post

(posyandu). We took up this issue at

the district level MSF, and it turns out

that it wasn’t just the villages in our

sub-district but other sub-districts,

too, that were having the same

problem. So we worked together to

fix the issue, and the government is

now working on it.”

The MSF also directly works to solve problems

within its local community. One example is

when the MSF worked together with the Sub-

District Intersectoral Committee, after receiving

information from the community that some

traditional birth attendants (TBAs) were still

assisting women in childbirth. The MSF and the

Committee visited the TBAs in question, and

invited them to discuss the issue of safe

delivery. In the end, the TBAs were convinced to

not assist deliveries anymore, and to refer all

pregnant women to trained midwives instead.

Haji Syukron identified another significant

change as an improvement in quality of the

22

health centre’s services. When the MSF and the

health centre carried out the complaint survey,

they received many complaints about long

waiting times, for example. The health centre

responded to this by installing a fingerprint

registration system at the reception desk. Since

then, Haji Syukron says that neither he nor the

MSF have received any more complaints about

waiting times. He also notes that the staff at

Sumberasih seem to have become more

friendly, and explain information much better

to patients than they used to.

Haji Syukron chooses the improvement in

health centre services as the most significant

change. The fingerprint registration system has

greatly reduced waiting times and patients are

very satisfied with the services now.

“Yes, thumbs up, the service is fast. It’s really

been felt by the community.”

Photo: The fingerprint system in use at

Sumberasih.

Bondowoso, East Java

Mums for Reproductive Health

(Dr Titik, Head of Family Health Division at the

District Health Office, Bondowoso)

Dr Titik has been working in the family health

division of Bondowoso’s District Health Office

since around two years ago. She says she has

seen a number of changes in her district since

they were assisted by Kinerja.

One of the most interesting changes for Dr Titik

has been the development of service charters at

each health centre. 14 health centres in

Bondowoso now have their own service

charters, where they promise to make certain

improvements in the following year. The service

charters are developed based on complaints

received from the community during a

complaint survey. Dr Titik notes that the service

charters are useful because they make the

health centres implement complaint

mechanisms, which are actually required to gain

government accreditation. Dr Titik says that

although it’s a national requirement to have

complaint mechanisms in place at all health

centres, many people do not remember this, so

Kinerja has helped them make complaints a

central part of their work.

Another change regarded as important by Dr

Titik has been the creation of two new

government-supported roles: Umi Persamida

and Bunda Kespro. Umi Persamida acts as a role

model for women and encourages them to give

birth at facilities and to breastfeed. Bunda

Kespro are ‘Mums for Reproductive Health’,

and focus on reducing levels of child marriage in

the district. Both roles exist at all levels, from

the district down to the village. Their activities

are funded by the local government budget.

Dr Titik thinks that the creation of the Umi

Persamida and Bunda Kespro roles is the most

important change overall. From the wife of the

district head to the wife of various village

heads, multiple women have been nominated

to take on these important roles and support

the improvement of maternal health in

Bondowoso.

References and other sources Dart, J.J. 2000. Stories for Change: A Systematic Approach to Participatory Monitoring. Proceedings of

Action Reseach and Process Management (ALARPM) and Participatory Action-Research (PAR) World Conference. Ballarat, Australia.

Davies, R. and Dart, J. 2005. The ‘Most Significant Change’ Technique: A Guide to Its Use. Kinerja. 2014. Tata Kelola Inisiasi Menyusu Dini dan ASI Eksklusif [module].

http://www.kinerja.or.id/pdf/889f4355-4828-4272-9612-e02d8d5e68eb.pdf Kinerja. 2014. Tata Kelola Persalinan Aman [module].

http://www.kinerja.or.id/pdf/b583809b-15bf-40b3-9702-1f00804fa7f3.pdf Kinerja. 2015. Berbagi Praktik Baik Tata Kelola Kesehatan.

http://www.kinerja.or.id/pdf/d50dbae5-31a4-4c9a-b081-f154366a75bc.pdf

Kinerja USAID

Sampoerna Strategic Square

South Tower, 18th Floor

Jl. Jend. Sudirman Kav. 45-46, Jakarta 12930

email: info@kinerja.or.id

www.kinerja.or.id

Kinerja USAID

Kinerja is implemented by