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Anisia Ivona has delivered hundreds of babies in her 22 years as a midwife in the capital of Nusa Tenggara Timor province (NTT), Indonesia. But the job is not as straightforward as it may seem – even if midwives have the required clinical skills, many women don’t end up giving birth at a local health facility.

“Even though Kupang is the provincial capital, cultural barriers still get in the way of safe deliveries,” Ivona explained. “Sometimes family members prevent us from getting a woman with complications to give birth in the hospital, because her husband or uncle hasn’t approved the decision.”

Dr. Dian S. Arkiang, Head of Puskesmas Pasir Panjang, describes the facility’s improvements to Australia’s Ambassador to Indonesia, Mr. Greg Moriarty, during his visit to Kupang. Puskesmas Pasir Panjang has been acknowledged as an example of a successful Puskesmas Reformasi program, where improved services and facilities have contributed to more safe births at the clinic.

But over the last couple years, the health clinic where Ivona works as the Senior Midwife, Puskesmas Pasir Panjang, has seen an increase in deliveries and a shift in patients’ attitudes. In addition to improving the clinical skills of health staff, the Australia Indonesia Partnership for Maternal and Neonatal Health Program (AIPMNH) is currently implementing Puskesmas Reformasi in 42 health centers, or puskesmas, in 14 districts of NTT.

Through this program, health staff are trained on non-clinical service delivery (including standard operating procedures, ethics, transparency and team-building) and support for the formation of a Puskesmas Community Board, or BPP, which serves as an advocate for patients rights and for the puskesmas within the community.

The community-centered Puskesmas Reformasi program complements AIPMNH’s work in Clinical Services, which aims to improve the skills of puskesmas staff to handle emergency obstetric and neonatal complications (PONED). In a cultural context where women may lack decision-making power or confidence, the Partnership recognizes that clinical skills are not enough. Women and their families must feel that health centers are welcoming, trusted spaces in which to bring a new life into the world.

Adriana Asbanu, with her second child, whom she delivered at Puskesmas Pasir Panjang. In 2009 gave birth at home because she felt unwelcome at the puskesmas, but said that the staff “are much more friendly now” with much improved facilities.

 Adriana Asbanu, 23, has been going to Puskesmas Pasir Panjang since she was a little girl. But she wasn’t always happy to do so.

“When I was pregnant with my first child at 19, I went to the puskesmas for my pregnancy check up,” she explained. “But the midwife was more interested in my personal life than the pregnancy – and I left feeling so embarrassed that I asked my mother to find the traditional birth attendant (TBA) from another village to deliver my baby.”

Fortunately, Adriana’s first baby was fine, but giving birth at home with a TBA is one of the leading factors in NTT’s high maternal and neonatal mortality rate.  But Adriana just chose differently for her second child based on the improved customer service at Puskesmas Pasir Panjang.

“The puskesmas staff are much more friendly now,” she said. “Even though I used jamkesmas (health insurance for the poor), I was treated very nicely.”

“When my husband and I left the puskesmas, we got some supplies for the baby and a card. I also got information about family planning and breastfeeding,” she explained. “I asked lots of questions about maternal and newborn stuff, something I wouldn’t have done before.”

“I’m very happy with the puskesmas service,” Adriana said. “I wish the service was as good in 2009 when I was pregnant with my first child.”

Since AIPMNH support began in January 2012, the puskesmas staff and Community Board have responded to complaints identified in a Complaint Survey of more than 600 patients, including: facilitating better access to free health insurance; clearly displaying official costs of treatment; providing more seats in the waiting room; providing free drinking water at the puskesmas; and clearly displaying directions for patients.

The puskesmas has also taken a novel approach compared with other health centers in the area by partnering with private companies to improve their facilities and services, with the BPP playing an active role.  “The BPP has been actively searching for companies whose themes match health issues,” explained Dr. Dian Arkiang, Head of Puskesmas Pasir Panjang.

“We now separate our medical and non-medical waste, thanks to support from Kalbe Farma [a Jakarta- based pharmaceutical company and the largest of type in Southeast Asia], who donated this equipment to us,” she said. “Not to mention, this was at the request of the community, whose feedback we received from our new suggestion box.”

Similar achievements can be seen at nearby Puskesmas Bakunase, where AIPMNH has also implemented Puskesmas Reformasi.

The Puskesmas Pasir Panjang Community Board, or BPP. AIPMNH supports the formation of BPPs at Puskesmas throughout NTT to act as an advocate for both the community and the puskesmas. The BPP at Puskesmas Pasir Panjang has successfully garnered support from a number of private companies to improve facilities and make the puskesmas more comfortable for patients

“Patient feedback was not really something we paid attention to before Puskesmas Reformasi,” explained the Head of thePuskesmas, Dr. Maria Ivonny Ray. “Health promotion is much better now too – we are working more actively to get women to give birth here.”

“AIPMNH support through this program has been very important,” she said. “And another puskesmashere in Kupang has begun to replicate this program on their own - which makes me very proud.”

In fact, Kupang’s District Health Office, Kupang, Dr. Ari Wijana, has been a strong partner of AIPMNH in making Puskesmas Reformasi successful and issupportingreplication throughout the city. According to Theresia Bano, Senior Midwife, who has delivered babies in the area for the last 23 years, “the most obvious achievement is the increased number of deliveries since AIPMNH support began through the Puskesmas Reformasi program.”

Compared to the 849 women who gave birth at Puskesmas Bakunase in 2011, 1,346 women delivered there in 2012.  “The puskesmas management is much better and more transparent,” Dr Dian explained. “All staff are managing their units better than before.”

“Now we try to help patients from the moment they step into the puskesmas,” she said. “And most importantly, we let them know that their feedback counts.”


AIPMNH is managed by Coffey on behalf of the Australian Government

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