Bidan Delima Accreditation: The Implementation of a Franchise Model in Regulating Performance of Private Midwives in Indonesia A Case Study Anna Cynthia Maharani, MPP Tanti Liesman, MPA dr.Sri Hartani Kusuma 1 Glossary List of Acronyms Definition Askeskin Health Insurance Scheme for Poor BD Bidan Delima BPS Bidan Praktik Swasta DHO District Health Office HSP Health Services Program IBI Indonesian Midwives Association J&J Johnson and Johnson JPS Social Safety Net Jamkesmas Health Insurance for Public MMR Maternal Mortality Rate MoH Ministry of Health MCHN Maternal Child Health and Nutrition Puskesmas Community Health Post Pustu Health Sub Centers Posyandu Integrated Health Post Program Pendidikan Bidan Midwifery Education Program SSM Sentrong Sigla Management UPBD Bidan Delima Implementation Unit QA Quality Assurance QAP Quality Assurance Project 2 Table of Contents 1. Overview of CHMI .................................................................................................... 4 2. Executive Summary .................................................................................................. 5 2.1 The Study ......................................................................................................... 5 2.2 The Findings .................................................................................................... 5 3. Background and Country Context ............................................................................ 8 3.1 Era of Health Innovation ................................................................................. 8 3.2 Health System ................................................................................................. 8 3.3 Assuring the Quality of Midwives in Indonesia ............................................... 9 3.4. Health Financing ............................................................................................ 10 4. Model Overview of BD (Table) ................................................................................. 11 5. Accreditation Model of BD ....................................................................................... 12 5.1. Background/History..................................................................................... 12 5.1.1. Birth of Bidan Delima ....................................................................... 12 5.1.2. Management and Scope Reconstruction .......................................... 13 5.1.3. Franchising Model ............................................................................. 14 5.2. Business Model............................................................................................ 15 5.2.1. Accreditation Tools: The Standards .................................................. 16 5.2.2. Activities: Memberships, Trainings and Monitoring of Compliances... 17 5.3. Human Resources ...................................................................................... ... 18 5.3.1. Management Team at District, Province and Central Level ............. 18 5.3.2. Implementing Facilitators and Assessors .......................................... 19 5.3.3. Volunteering System ......................................................................... 19 5.4. Target Population ........................................................................................ 20 . 5.5. Challenges ............................................................................................... 21 6. Impact ...................................................................................................................... 23 7. Growth Plans ....................................................................................................... 24 8. Financials ................................................................................................................. 25 Annex 1 – List of Interviewees (Primary Research) ........................................................... 25 Annex 2 – References: Secondary Research ................................................................... 26 Annex 3 - Research Methodology and Normative Framework ........................................ 27 Annex 4 - Lesson Learned ................................................................................................. 27 Annex 5- BD Program, Innovation or Adaptation?............. ...................................... ……….. 30 Annex 6 - List of Questions ..........................................................................................…. 31 3 1. OVERVIEW OF CHMI The Center for Health Market Innovations (CHMI) is a global network of partners that seeks to improve the functioning of health markets in developing countries with large numbers of private health care providers. CHMI works to accelerate the diffusion of Health Market Innovations that lead to better health and financial protection for the poor. CHMI focuses on identifying, analyzing and disseminating information about the vast expanse of Health Market Innovations operating in developing countries. Health Market Innovations are programs and policies— implemented by governments, non-governmental organizations (NGOs), social entrepreneurs or private companies—that have the potential to improve the way health markets operate. These programs and policies enable the transactions that occur in the health care marketplace to lead to better health and financial protection, especially for the poorest and most vulnerable. CHMI categorizes programs according to five distinct program types – organizing delivery, financing care, regulating performance, changing behaviors, and enhancing processes. CHMI’s first level of program documentation consists of a standardized web-based template capturing key data points about each program (such as geographic coverage, target population, health focus, numbers served, etc.) In addition to map the Health Market Innovations globally, CHMI is conducting in-depth case studies designed to give readers a deeper look at the structures, activities, and impact of innovative programs. In Indonesia, CHMI through Mercy Corps, works together with partners from the government, local and intercentral NGOs, for-profit and not-for-profit private sectors, and the community to facilitate knowledge sharing between donors, implementers, policy makers and researchers. The BD program was selected from a scan conducted over three months (Nov 2010-Jan 2011) of more than 100 innovative health programs in Indonesia. The program was selected to assess the adoption of a franchise model in regulating the performance of private midwives. 4 2. EXECUTIVE SUMMARY Despite the recent economic growth in the country, maternal mortality in Indonesia remains amongst the highest in the world at 228 per 100,000 live births.1 In addition to the barriers to free access of care and transportation, unsafe pregnancy and delivery methods also contribute to the high rate of maternal mortality. The high percentage of births assisted by unskilled attendants and insufficient emergency obstetric care are the major contributors to unsafe pregnancy in Indonesia. Overall, there has been an increased percentage (from 75.4% to 82.2%)2 of births assisted by skilled birth attendants (SBAs) from 2007 and 2008, with the majority taking place in private facilities or with private midwives. In 2008, there were 68,772 midwives in Indonesia, about half with their own private practices3. By contrast, in the same year, there were 46,926 physicians in Indonesia4. The number of private midwives keeps increasing as midwives continue opening private practices as soon as they receive licensure (D’ambruoso, 2009). 2.1. The study The BD Accreditation study was conducted by the Mercy Corps CHMI Team from January to March 2011 to research the adoption of a franchise model of the BD Program and to uncover how the model affects compliance with standards of care, and improves the quality of services delivered by private midwives. The team conducted interviews and reviewed reports on the program published by USAID-HSP and Johnson & Johnson. The Team conducted a field visit, in-person and phone interviews involving 11 participants consisting of donors, implementers, and the beneficiaries, representing public health, business, and midwifery professionals from BD, Ikatan Bidan Indonesia (IBI), StarH of USAID, HSP-USAID, and Johnson & Johnson. 2.2. The Findings The decision-making process and types of incentives applied within the BD system are greatly affected by the Indonesian concept of “Organisasi Profesi “or “Professional Organization”. The concept implies that as health professionals, midwives provide quality health services to the public, and that in itself has its own “pride”. Hence, being a public servant should be the key factor driving the midwives’ intrinsic motivations to perform well5. BD program is run with the assumptions that the BD midwives have the intrinsic motivations and therefore, the 1 See http://www.measuredhs.com/pubs/pdf/FR218/FR218%5B27August2010%5D.pdf (accessed on 1 March 2011) 2 Badan Penelitian dan Pengembangan Kesehatan Kementrian Kesehatan RI (2010) Riset Kesehatan Dasar. 3 See Indonesia Demographic and Health Survey, Badan Pusat Statistik, 2007 4 See www.idionline.org (accessed 1 March, 2011) 5 Akademi Kebidanan Stikes Cut Nyak Dien Langsa, “Kelompok Etika dan Profesi,” working paper, 2010 5 program should work with or without the monetary incentives. Currently, most BD implementers remain working on unpaid voluntary basis. The Study Team found that this