Maternal and newborn mortality rates in Indonesia have shown a decline. From 305/100,000 live births in 2015 to 189 per100,000 live births in 2020 for maternal deaths. Neonatal deaths also showed a decrease from 15 in 2017 to 9.3 per 1,000 live births in 2020. Nevertheless, among ASEAN countries there is still much room for acceleration for the decline of these two human development indices.
The USAID-funded MPHD program hypothesis is that if MPHD improves the quality of MNH care delivered by private health facilities; strengthens the enabling environment for private sector engagement; creates a collaborative governance system engaging the public and private sectors; and integrates public-private systems to increase service continuity and efficiencies (with strong political will at the central and provincial levels), then the overall quality of available MNH services will increase, resulting in reduced maternal and newborn complications and mortality.
MPHD achievements reported in FY2023 show that between 2021 and 2023 the program contributed to decreases in maternal and neonatal mortality rates in private healthcare facilities by 36% and 6%, respectively (reduction of iMMR from 61.67 to 39.54 per 100,000 deliveries and of iNMR from 5.68 to 5.32 per 1,000 live births). Regarding the overall obstetric CFR, MPHD reported a reduction from 0,23 to 0,07 percent in obstetric complications including the three main causes of death i.e., pre-eclampsia, hemorrhage, and sepsis. Overall, MPHD observed good progress in achievement of program indicators compared to baseline numbers.
Collaborative quality improvement in MNH services
In line with global evidence and experience across many countries, and the Indonesia MOH’s own national policy for quality improvement, MPHD has recently revised its technical quality improvement (QI) approach to expand from point of care quality improvement (POCQI) as part of hospital mentoring in individual facilities to a collaborative quality improvement approach that engages facilities through a hub and spoke model and provides opportunities for learning and sharing across facilities against a common set of goals. These district-based maternal and newborn health QI collaboratives focus on priority gaps as part of a broader effort to develop sustainable platforms at all levels of the system for sharing lessons learned, evidence generated, and best practices for improving the quality of maternal and newborn care.
MPHD is currently testing this collaborative approach in selected districts and is working with relevant stakeholders to agree on the aim, QI indicators and change package to be addressed under the collaborative, how learning sessions and ongoing support will be provided, and how efforts and achievements will be documented. The design of collaborative QI was tested during year 3 in three provinces i.e. North Jakarta of DKI Jakarta Province, Pasuruan District of East Java Province, and three clusters in East Nusa Tenggara (NTT) Province. Current feedback received from counterparts involved in the implementation is that the short implementation period is one of the challenges for the collaborative QI to showcase a result.
From MPHD’s experience in conducting collaborative QI in the 3 provinces, MPHD together with QI experts observed several interim results that have the potential to promise good results. The results are include (1) MPHD with IHI support has succeeded in strengthening the capacity of the DHO quality team to be able to conduct coaching to health facilities, (2) regular online coaching carried out can help health facilities to improve change ideas, PDSA carried out, and (3) learning sessions which are moments to share experiences and good practices become an encouragement for health facilities that have not succeeded in emulating change ideas elsewhere, and for model facility to be more enthusiastic in implementing the change idea.
Having a collaborative’s improvement packages is one of the essential features that define successful improvement collaborative. MPHD, in close coordination with mentors, develop a collaborative’s implementation packages, specifically focus to improve care on postpartum hemorrhage, severe preeclampsia/eclampsia, and newborn asphyxia. The implementation packages include not only changes to the technical content but also changes in the way services are organized and delivered.
Aside from many promising results, the biggest challenge that the collaborative faced was data management. The main challenges include lack of personnel, different understanding of the data elements and unclear data verification process. Collaborative activities have cultivated greater awareness of the importance of data management. At the moment, MPHD used a stopgap QI platform, based on an available free online platform (Google Site®), to allow for collaborative learning and sharing between all parties in each district/city until the SATUSEHAT platform is fully operational. Going forward, the database for these collaborative QI activities will be one of the critical components. Universities are expected to develop this capacity.
Collaborative quality improvement: from collaborative action to collective impact
In addition to direct support from IHI, the implementation of collaborative QI in Indonesia also adapts several collaborative QI in the United States. One widely adapted resource is the California Maternal (and Perinatal) Quality Care Collaborative (CMQCC). The CMQCC is a multi-stakeholder organization committed to ending preventable morbidity, mortality, and racial disparities in California maternity care. CMQCC uses research, quality improvement toolkits, statewide outreach collaboratives and its innovative Maternal Data Center to improve health outcomes for mothers and infants. CMQCC was founded in 2006 at Stanford University School of Medicine together with the State of California in response to rising maternal mortality and morbidity rates.
The collaboration begins with hospital quality improvement efforts – which is a collaborative action at the level of health care facilities. To get collaborative impact, where there has been a state-wide action, an adequate data center is needed. From there, the information or evidence collected can then have an impact on other policy makers, such as UHC, even to formulate a national policy.
Indonesia perinatal collaborative quality improvement framework
In the 4th year of intervention, MPHD wants to ensure that the collaborative efforts that have been initiated can be continued to show collective impact and ultimately improve the quality of MNH services in Indonesia. One institution that has the capacity and flexibility to build an innovative approach such as collaborative QI is the university.
University with its three main purposes in the educational, research and society services field, is the right agency to continue this collaborative effort. It will also strengthen the university’s position in contributing to determining the direction of health development, by providing practical research-based information.
MPHD envisioned that university would ensure that the cycle of quality improvement continuously propelled. In hospitals, the local quality team will be the main driver for the collaborative quality improvement inside health facility. They not only drive the development of change ideas, but most importantly the have to be able to show an objective result supporting the collaborative. Lessons learned and best practices sharing is critical component of collaborative QI. University will work with local health office to ensure the platform is available. Providing a space to share good experiences and continuous learning is one of the critical drivers. University will also assist health facilities and local health offices with data management. A collaborative tracker will be evaluated regularly in order to immediately adapt and modify so that real impact can be achieved. MPHD will provide technical assistance to university to be able to get sufficient support from global expert such as IHI.
This is a series of cultural changes in interpreting service quality. Adequate time is needed to achieve quality that is equally understood by service providers and service recipients. In the meantime, to accelerate impact, ministry of health needs to provide national level strategy to learn from the collaborative action collected from the initiatives and show a collective impact.
RFP for University partners to manage the Collaborative Quality Improvement Initiatives
The scope of work for university/local organization regarding management of the collaborative quality improvement initiative (involving both public and private health facilities) would include:
- Provide comprehensive and coordinated technical support for the successful implementation of collaborative perinatal QI activities including: 1) coordinate a routine coaching of the hospital QI team; 2) planning and implementing quarterly learning sessions; 3) tracking and analyzing collaborative results across facility-specific and aggregated QI through a shared data platform; 4) synthesis and dissemination of successful interventions, policies, and practice changes both within and outside the intervention area
- Identify and engage other relevant stakeholders, public and private, to support collaborative QI strategies and activities
- Work with districts to coordinate support for individual facilities and QI activities and collaborative learning and implement best practices to improve quality of care across system levels in districts (i.e. FKTP/ puskesmas, hospitals), including actively engaging in learning forums and quality improvement working groups MNH services
- Support mechanisms for regular shared learning across facilities including through virtual mechanisms (e.g. WhatsApp) and regular learning meetings where facilities share results and specific changes, they made to achieve these results.
- To assist local universities/organizations in carrying out these tasks, IHI and MPHD will specifically provide technical assistance and reinforcements needed. For the health facilities involved, the QI coordinator/specialist (MPHD staff located in district/ city) who has been prepared by MPHD and strengthened with adequate knowledge and skills on QI, will intensely accompany and coach the QI process carried out at facility level.
Proposed Timeline and Deliverable
|February 16, 2024
|Review and selection process
|February 29, 2024
|Process and Execute a MoU between the local partners and MPHD
|MPHD and IHI to coach local organization to manage collaborative QI and develop workplan
|March – September 2024
|Preparation, evaluation and dissemination through MPHD Mini Summit in December 2024
|October – December 2024
- University to cover Pasuruan District in East Java Province and 3 cluster in NTT
- University to cover North Jakarta City in DKI Jakarta Province
Required information for the proposal
- The main proposal should include an introduction section, a method section on how the data will be collected and analyzed, detailed activity and timeline, personnel and proposed budget.
- Information on budget line items e.g. for the staff who will be involved in the work (daily rates) etc.
- Previous experiences/research that have been conducted relevant to the topic.
- The research institution profile.
Note that the contracted university, in conjunction with the DHO and MPHD staff, will engage in the following steps to operationalize the implementation activities:
- Develop and submit an IRB protocol and obtain local approval.
- Choose key outcome and process metrics to be tracked and discussed during monthly data review meetings. These indicators will preferentially come from the PMP and will be visualized in dashboards.
- Design Learning Collaborative meetings – the partners to be invited; additional qualitative techniques and information to be gathered
- Develop final report that summarizes the learnings, revised Theory of Change, and recommendations for improving the feasibility and effectiveness of the strategy studied.
Proposal (included budget, timeline, and project team) and Company profile
submissions should be not later than February 16, 2024, and please send to
Contract Committee, Jhpiego Corporation