In the years leading up to 2012, women and children in Indonesia faced a significant risk of dying during childbirth. Countrywide, infant mortality was 32 deaths for every 1,000 births, while maternal mortality was 359 for every 100,000 live births.
In Aceh Singkil, one of 23 districts in Aceh province where maternal deaths remained common despite improved access to medical care, the threat of mortality was compounded by cultural norms that compelled women to seek out non-medically trained traditional birth attendants rather than medically-trained midwives. More than 40 percent of births in 2012 were assisted by traditional birth attendants without the help of a midwife from one of the 11 community health clinics.
This low demand for health services was just one example of the challenges facing Indonesia in its efforts in recent years to strengthen service delivery.
Building Capacity at the Local Level
In an effort to close critical gaps in service delivery at the local level, in 2010 the U.S. Agency for International Development launched a program known as Kinerja—drawing its name from the word for “performance” in Bahasa Indonesia. Between 2010 and 2015, Kinerja worked in four Indonesian provinces to improve government service delivery in three critical areas—health, education, and business licensing.
As the lead implementing partner of Kinerja, we managed all aspects of the program, which supported activities across the country to:
- Strengthen demand-side entities for better services;
- Build on existing innovative practices and support local governments to test and adopt promising service delivery approaches, and
- Expand successful innovations nationally and support Indonesian organizations to deliver improved practices to local governments through replication.
Building Partnerships to Encourage the Use of Medically-Trained Midwives
In one example of Kinerja’s success, we initiated a program in 2012 to directly address the crisis of maternal mortality in Aceh Singkil—building partnerships between traditional birth attendants and midwives to provide pregnant women with antenatal care and childbirth services that were both safe and culturally appropriate.
Our approach in fostering these partnerships included involving both midwives and traditional birth attendants in all steps of the process, from program design through implementation and monitoring. To boost program success, we employed a tactic uncommon in Indonesia: namely, ensuring that the local government provided traditional birth attendants with financial incentives for participating in the partnerships. To build cultural acceptance, we facilitated public events for the signing of partnership documents, which helped to raise awareness among local communities.
Dramatic Increase in Antenatal Care and Rate of Midwife-Assisted Births
As a result of this innovative intervention, Aceh Singkil saw a marked decrease in societal pressure to exclude medically-trained midwives during childbirth, coupled with an increase in the number of women choosing to give birth in health facilities with the assistance of both traditional birth attendants and midwives.
Initially piloted in two villages, the two-year intervention achieved remarkable results in that all births that took place in the villages were attended by medically-trained midwives. More importantly, all mothers who gave birth in the villages during the intervention survived.
The success of the pilot program inspired the District Health Office to replicate the intervention in other sub-districts. Today, 29 villages have implemented partnerships between midwives and traditional birth attendants.
Recognizing the significance of this success in changing behaviors around pregnancy and childbirth, in May 2015 the United Nations named Aceh Singkil as a second-place winner in the Asia-Pacific region at the UN Public Service Awards. The government of Aceh Singkil has since committed to establishing partnerships throughout the entire district.
Nationwide Impacts in Public Service Delivery
Beyond Aceh Singkil, Kinerja has helped improve public service delivery in other sectors across Indonesia. For instance, we helped District Education Offices to distribute teachers more proportionally, providing badly needed resources to understaffed rural schools. We also helped local governments simplify business-licensing processes.
Other accomplishments include:
- 216 new district-level regulations were passed to improve governance and services in the health, education and business sectors.
- 781 schools and community health centers adopted good governance practices.
- 371 Kinerja-trained citizen journalists reported on the performance of local governments in Indonesia, directly contributing to public service improvements in health centers, schools, and One-Stop Shops (institutions providing business registration services).
- 257 multi-stakeholder forums were established at district level and at schools/health centers in Kinerja’s original 20 core districts.
- More than 600 teachers in four districts were reassigned to under-served schools.
- In cooperation with the provincial government, the program held a mass business-licensing event in South Sulawesi that resulted in the successful distribution of more than 40,000 business permits in just one day.
In total, Kinerja reached more than 70 districts, 500 schools, and 250 health centers—building the capacity of local governments to meet the needs of citizens.
The success of program efforts continues to be felt in the original four provinces— Aceh, East Java, South Sulawesi and West Kalimantan—where the program has concluded. Under a follow-on effort launched in 2012, our experts continue to provide program leadership and technical assistance in Papua, transferring successes achieved under Kinerja, with a focus on improving service delivery in health and education.
Under the Kinerja model of fostering innovation, an increasing number of Indonesian local governments are able to deliver services that are both more accountable and responsive to local needs.