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Attracting and Retaining Village Midwives in Indonesian Remote Postings: ‘Success Cases’ from West Nusa Tenggara

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Attracting and Retaining Village Midwives in Indonesian Remote Postings: ‘Success Cases’ from West Nusa Tenggara ATTRACTING AND RETAINING VILLAGE MIDWIVES IN INDONESIAN REMOTE POSTINGS: ‘SUCCESS CASES’ FROM WEST NUSA TENGGARA BY ENDAH SETYANINGSIH A thesis submitted to the Victoria University of Wellington in fulfilment of the requirements for the degree of Doctor of Philosophy in Health VICTORIA UNIVERSITY OF WELLINGTON 2017 ABSTRACT “When midwifery is in place, there is much less need for emergency interventions.” - Petra ten Hoope-Bender at Bulletin WHO (Shetty, 2013) Accessing health professionals, such as midwives, is essential reducing the maternal and child mortality rates. However, attracting and retaining midwives to remote areas of Indonesia is not a simple task. Many midwives in Indonesia prefer to work in cities due to better facilities, incomes, and proximity to families. In order to increase their numbers in remote areas, policy-makers and other related stakeholders must better understand those factors that attract them to, as well as retain them in, these remote areas. This study explored key success factors that influenced midwives to work and stay in remote areas of Indonesia, and the policies of the Government of Indonesia (GoI) which influenced their attraction and retention to such areas. The ‘Success Case’ evaluation method was used with Appreciative Inquiry. This combined approach has not been used before in the field of public policy to study health professionals in marginalised areas. However, it enabled the identification of key success factors from the best performing cases in order to obtain better evidence, thus assisting policy-makers and other related stakeholders to craft better strategies for attracting and retaining midwives in remote areas of Indonesia. The West Nusa Tenggara (Nusa Tenggara Barat or NTB) Province was chosen as the study location because it provided an excellent opportunity to examine the ‘success cases’ (six districts) and the ‘less success cases’ (two districts) which were determined based on the coverage of midwives from 2010-2014. Fifty-seven participants from the ‘success cases’, fourteen participants from the ‘less success cases’, and four other relevant participants were interviewed. These included civil servant midwives, nationally- and regionally-contracted midwives, volunteer midwives, and national and local government officials. Thematic analysis included the voice of the government officials, and documents analysis as part of data triangulation. A multifaceted framework which consists of personal, organisational and societal factors was used as the conceptual framework for this study. While some of the results were similar to previous studies, this study revealed some unique factors. Economic stability attracted midwives to remote areas in both the ‘success cases’ and the ‘less success cases’. Community support played a major role in their retention. Personal, family and individual prestige were identified as other important factors influencing midwives to stay in remote areas. Cultural and religious beliefs constructed midwives’ viewpoints about their work and life in general, which influenced their motivation. It was found that many government programmes focus only on a limited number of policy initiatives, such as monetary incentives, to influence workers’ behaviours, and neglect the potentially important role that other, non-monetary factors may be playing. Policy-makers need to consider a broad range of motivational determinants which could potentially improve programmes and policies for attracting and retaining midwives in remote areas of Indonesia. This study concludes by offering recommendations for the GoI in order to improve the recruitment and retention of midwives in remote areas of Indonesia, and suggests further areas for research. Key words: Village Midwives; Success Cases; Remote Areas, Multifaceted Approach 2 ACKNOWLEDGEMENTS This dissertation has developed not just out of my own hard work but also out of the goodwill of others. First of all, I would like to express my special appreciation and thanks to my supervisors: Prof. Jacqueline Cumming for her support and valuable advice in this thesis process; Dr. Lynne Russell for her encouragement and faith in me throughout which have been extremely helpful; and Dr. Jenny Neale for always being available for my questions and giving generously of her time and vast knowledge. She always knew where to look for answers while leading me to the right perspectives. I also would like to express my sincere thanks to all my research participants. My fieldwork would have been impossible without the support of my travel buddy, Wulan Septianingsih. She supported me with important information and accompanied me from the top of Lombok Island to the bottom of Sumbawa Island with her motorbike. Wulan and her family (Om Mulyono, Tante Sujiati and Uli) patiently taught me the basic local language and kept the journey safe, joyful and memorable – thanks to you. I am especially indebted to Ministry of Foreign Affair for granting me a doctoral scholarship; to the Health Services Research Centre of the School of Government, Faculty of Commerce, Victoria University of Wellington (VUW) for providing me with grants to carry out data collection in Indonesia, attend conferences, and take English for Speakers of Other Languages (ESOL) courses; and to the SurfAid team (Andrew Judge, Anne Wuijt, and Bang Lamhot) for the great support. My gratitude also goes to the New Zealand Aid team at VUW, Dr. Helena Cook and Linsell Richards for their hands on and amazing support during my study; to the Student Learning Support Services team, especially Dr. Xiaodan Gao for her extraordinary support throughout this difficult writing process; my ESOL teacher, Prue Walker, for her expert comments on producing a better kind of English academic writing; Victoria International office for their invaluable support in organising my visa and other administration; and to the Faculty of Graduate Research team, especially Dr. Lizzy Towl, for providing brilliant workshops during my study. 3 Thank you also to the Indonesia Students Association, especially to Jazz and Pak Zaki who have patiently listened and helped make my crazy ideas come true; and the Indonesia Embassy in New Zealand, especially Pak Ferry, Pak Wanton and Pak Budi for allowing me to take part in many cultural activities here in Wellington. Special thanks also to the ‘the quiz gang’ at the Old Government Building: Jenny, Maggy, Janet, Megan, Lesley, Ausaga, Marianna, and Emma. I know that I am going to miss the morning quiz time as it has been my other learning source about general knowledge, particularly about New Zealand. In addition, during the long process of my writing this thesis, I believe the support from my friends both emotionally and academically was undeniable. Their true friendship and kindness has sustained me through this rollercoaster journey of completing this difficult task. So, big thanks to: Railway West Wing crews, Aftab, Cherry, Jessica, Ha, Vy, Ali, and Mphahy; and office mates, Emma – for the fun walk and talk during the day so we both could release the stress – and Tara and Molly for the company. You guys have contributed immensely to my personal and professional time at VUW. It was great pleasure to share this long journey with my partner in crime and flatmate, Tenri (Bu Direktur). Thanks for all the joyful moments that we have shared together. It was also a great pleasure to share the experiences of living in Wellington with Mbak Asih, Lydia Blue, Cikgu, Avi, Mbak Anita Anas, TJ, Jill Fernandes, Mas Tomo, Teh Lya, Richard, Lina, Finn, Alex Hill, Pakjira Leelerphan, Shih Min Loo, Matthew Book, Mbak Restu, Ghifary, Syva, Sila, mbak Ruly, Mas Nino, Mbak Endang, Bu Shinta, Bu Ella, Kia, Andre, Mbak Wiwin, Jacq and Alan. One of the reasons I did this PhD was because of my nieces, Olga, Dita, and Dinda. I hope by my example you know that you can achieve your dream if you work hard. To my sisters (Mbak Wati and Mbak Indri) and my brother (Mas Bimo), thank you for the support. My deep thank you to Ibu (mother) and Bapak (my Dad in heaven). Words cannot express how grateful I am for all of the sacrifices and allowing me to grow to be a person that I want to be. Your prayer for me was what sustained me this far. To my Melbourne family, Linda, Leighton, Kerry, Claire, Gordon and Ethan – thank you. Finally, I cannot express sufficient gratitude to Chris for his amazing support and providing great insight into my decision-making. Thank you. 4 TABLE OF CONTENTS ABSTRACT ...................................................................................................................... 1 ACKNOWLEDGEMENTS .............................................................................................. 3 TABLE OF CONTENTS .................................................................................................. 5 LIST OF TABLES ............................................................................................................ 9 LIST OF FIGURES ........................................................................................................ 10 LIST OF BOXES ............................................................................................................ 11 LIST OF ACRONYMS................................................................................................... 12 CHAPTER 1. INTRODUCTION ............................................................................... 1 1.1 Introduction .......................................................................................................
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