rapid assessment of bidan delima program

RAPID ASSESSMENT OF

BIDAN DELIMA PROGRAM

USAID Jalin December 2019 – January 2020

This report is made possible by the generous support of the American people through the United States Agency for

International Development (USAID). The contents are the responsibility of DAI Global LLC and partners and do not

necessarily reflect the views of USAID or the United States Government.

USAID JALIN RAPID ASSESSMENT OF BIDAN DELIMA PROGRAM | ii

RAPID ASSESSMENT OF

BIDAN DELIMA PROGRAM

USAID Jalin December 2019 – January 2020

Cover photo: A Bidan Delima midwife in her private practice.

© Oscar Siagian/USAID Jalin

This report is made possible by the generous support of the American people through the United States Agency for

International Development (USAID). The contents are the responsibility of DAI Global LLC and partners and do not

necessarily reflect the views of USAID or the United States Government.

USAID JALIN RAPID ASSESSMENT OF BIDAN DELIMA PROGRAM | iii

FOREWORD

USAID/Indonesia’s Jalin Project supports the Ministry of Health (MOH) to achieve an accelerated

reduction in maternal and newborn deaths – a priority recently reconfirmed by the President of

Indonesia. The maternal and newborn mortality rates are among the highest in the region; are far

above Indonesia’s Sustainable Development Goals (SDG) targets; and have stagnated in recent years.

The overarching problem that Jalin strives to resolve is that the quality of care accessible to mothers

and newborns is uneven across the country in both public and private facilities and at both primary

and secondary levels of care.

USAID Jalin Project focuses on working towards two results: 1) Improved maternal and newborn

health quality of care in public and private, and primary and secondary facilities, at scale; and 2)

Improved efficiency and effectiveness of the emergency referral system at community and facility

levels, at scale.

Recognizing the significance of private midwives’ contribution in maternal newborn health services in

Indonesia, the Project works with the Indonesian Midwives Association (IBI) to sustain the

improvements in quality of care by private midwives. One of the project strategies is to revive and

strengthen Bidan Delima Program, the flagship private midwives’ quality improvement program

initiated by IBI in 2003 with support from USAID. The project undertook a Rapid Assessment of

Bidan Delima Program to understand the constraints and strengths in reviving and strengthening the

Bidan Delima Program. Results and findings from the rapid assessment are presented in this report

and have guided IBI and the Project to co-create an enhanced business model of Bidan Delima

Program and the implementation plan which documented as the Bidan Delima Program

Enhancement Recommendations.

On behalf of USAID Jalin, I would like to extend our appreciation tothe team who carried out the

Bidan Delima Program Rapid Assessment diligently and gathered valuable insights regarding the Bidan

Delima Program and to all key informants (DHO, provincial and district chapters of IBI and Bidan

Delima Program Executive Unit/UPBD, and midwives) in the study areas who generously shared

their time, experience and thoughts for this assessment. I am also very grateful for the leadership,

support and valuable input from Dr. Emi Nurjasmi, MKes., the President of IBI, and team of central

level IBI and UPBD leadership during the review and finalization of this report.

We hope that this document will be used as a reference for the continuous improvement of private

sector engagement in the maternal-newborn health services, particularly by private midwives.

Ella Hoxha

Chief of Party

USAID Jalin

USAID JALIN RAPID ASSESSMENT OF BIDAN DELIMA PROGRAM | iv

ACKNOWLEDGEMENTS

Rapid Assessment Implementation Team:

▪ Dr. Bimo, M.D., MPH (Team Leader)

▪ Dr. Esty Febriani MKes (Field Assessment Lead)

▪ Abigail Wohing Ati, SPsi, MA (Assessor and qualitative data analyst)

▪ Dr. Asmuyeni, Dra. MKes (Assessor)

▪ Eli, AMKeb, SKM (Assessor)

▪ Fransiska Mardiananingsih, M.D., MPH (Assessor)

▪ Julie Rostina, SKM, MKM (Assessor)

▪ Santi Deliani R, SST, SKM, M.Epid (Assessor)

▪ Dr. Wayan Aryati. SKM. MKes (Assessor)

▪ Yusti Amalia, SKM (Assessor)

Reviewer Team from the Indonesian Midwives Association (Ikatan Bidan Indonesia-IBI):

▪ Dr. Emi Nurjasmi, MKes (President of IBI)

▪ Nunik Endang Sunarsih, SST, SH, MSc (First Vice President of IBI)

▪ Sri Poerwaningsih, SST, SKM, M.Kes (Manager of Central Level Bidan Delima Program

Executive Unit)

▪ Ike Kurnia, S.Keb. Bd (Technical Staff)

▪ Innana Mardhatillah, SST, MKM (Technical Staff)

▪ Lukmanul Hakim, SKM, MSi. (Han) (Technical Staff)

USAID JALIN RAPID ASSESSMENT OF BIDAN DELIMA PROGRAM | v

LIST OF ABBREVIATIONS AND ACRONYMS

ANC Antenatal Care

APN Asuhan Persalinan Normal (Normal Delivery Care)

BKKBN Badan Kependudukan dan Keluarga Berencana Nasional (National Population Family

Planning Board)

BLUD Badan Layanan Umum Daerah (Regional Public Service Agency)

BPJS Badan Penyelenggara Jaminan Sosial (Social Security Administration Agency)

BPJS-K Badan Penyelenggara Jaminan SosialKesehatan (Health Social Insurance Administration

Organization)

BPS Badan Pusat Statistik(Central Bureau of Statistics)

CTU Contraceptive Technology Update

DE Developmental Evaluation

DHO District Health Office

FGD Focus Group Discussion

FKTP Fasilitas Kesehatan Tingkat Pertama (Primary Health Care Facility)

FP Family Planning

GP General Practitioner

HSP Health Services Program

HP+ Health Policy Plus

IBI Ikatan Bidan Indonesia (Indonesian Midwives Association)

Jampersal Jaminan Persalinan (Childbirth Assurance)

Jhpiego Johns Hopkins Program for International Education in Gynecology and Obstetrics

JKN Jaminan Kesehatan Nasional (National Health Insurance)

KIA Kesehatan Ibu dan Anak (Maternal and Child Health)

KII Key Informant Interviews

MCH Maternal Child Health

MH Maternal Health

MMR Maternal Mortality Ratio

MNH Maternal and Neonatal Health

MOH Ministry of Health

MU Midwifery Update

NMR Neonatal Mortality Rate

OB/GYN Obstetrics and Gynecology

P2JK Pusat Pembiayaan dan Jaminan Kesehatan (Center for Health Insurance and Financing)

PNC Postnatal Care

PPSDM Pengembangan dan Pemberdayaan Sumber Daya ManusiaKesehatan (Agency for Health

Human Resource Development)

PPJK Pusat Pembiayaan dan Jaminan Kesehatan(Center for Financing and Health Insurance

Puskesmas Pusat Kesehatan Masyarakat (Community Health Center)

RPJMN Rencana Pembangunan Jangka Menengah Nasional (National Medium-term

Development Plan)

SD Sekolah Dasar (Elementary School)

SHP Strategic Health Purchasing

SiBiMa Sistem Informasi Bidan Mandiri- digital application for maternal neonatal information

system in Depok

SiCantik Sidoarjo Mencegah Angka Kematian Ibu dan Anak– digital application for maternal

neonatal information system in Sidoarjo

USAID JALIN RAPID ASSESSMENT OF BIDAN DELIMA PROGRAM | vi

SijariEMAS Sistem Informasi dan Komunikasi Jejaring Pelayanan Kesehatan

SIPB Surat Izin Praktek Bidan (Midwife Practice License)

SMA Sekolah Menengah Atas (Senior High School)

SMP Sekolah Menengah Pertama (Junior High School)

SOP Standard Operating Procedure

SPGDT Sistem Penanggulangan Garurat Darurat Terpadu (Integrated Emergency Response

System in Depok)

STARH Sustaining Technical Achievements in Reproductive Health project.

TWG Technical Working Group

UNFPA United Nations Fund for Population Activities / United Nation Population Fund

UPBD Unit PelaksanaBidan Delima (Bidan Delima Executive Unit)

USAID US Agency for International Development

USAID JALIN RAPID ASSESSMENT OF BIDAN DELIMA PROGRAM | vii

TABLE OF CONTENTS

FOREWORD ...........................................................................................................................iii

ACKNOWLEDGEMENTS ..................................................................................................... iv

LIST OF ABBREVIATIONS AND ACRONYMS .................................................................. v

TABLE OF CONTENTS ....................................................................................................... vii

LIST OF TABLES .................................................................................................................. viii

LIST OF FIGURES ................................................................................................................ viii

EXECUTIVE SUMMARY........................................................................................................ 1

1. INTRODUCTION ........................................................................................................... 4

1.1. BACKGROUND ....................................................................................................................................... 4

1.2. OBJECTIVES OF THE ASSESSMENT ................................................................................................... 5

2. METHODOLOGY ........................................................................................................... 7

2.1. DATA COLLECTION ............................................................................................................................. 7

2.2. DOCUMENT REVIEW AND SECONDARY DATA ANALYSIS ................................................. 8

2.3. CLINICAL OBSERVATION ................................................................................................................... 8

2.4. FOCUS GROUP DISCUSSIONS AND IN-DEPTH INTERVIEWS .............................................. 9

2.5. LIMITATIONS ........................................................................................................................................ 10

3. ASSESSMENT FINDINGS ............................................................................................ 11

3.1. FINDINGS FROM DESK REVIEW AND QUALITATIVE ASSESSMENTS .............................. 11

3.2. STAKEHOLDERS’ PERSPECTIVE ON BIDAN DELIMA PROGRAM ...................................... 24

3.3. MIDWIVES’ PERCEPTIONS ABOUT JOINING THE BIDAN DELIMA PROGRAM ........... 27

3.4. FINDINGS OF CLINICAL OBSERVATION ................................................................................... 29

3.5. DOCUMENT AND RECORD REVIEW .......................................................................................... 36

3.6. THE READINESS OF PRIVATE MIDWIVES TO PROVIDE SERVICES .................................... 37

3.7. HEALTH INSURANCE REIMBURSEMENTS FOR BIDAN DELIMA SERVICES .................... 39

4. CONCLUSIONS ............................................................................................................ 47

4.1. THE EFFECTIVENESS OF THE BIDAN DELIMA PROGRAM IN ASSURING QUALITY .. 47

4.2. PROGRAM RELEVANCE AND VALUE .......................................................................................... 48

4.3. BIDAN DELIMA AS A STRATEGIC DIRECTION FOR A BUSINESS MODEL IN THE

FUTURE ................................................................................................................................................... 49

5. RECOMMENDATIONS ................................................................................................ 51

5.1. STRENGTHEN THE QUALITY ASSURANCE MECHANISM OF THE BIDAN DELIMA

PROGRAM .............................................................................................................................................. 51

5.2. STRENGTHEN BIDAN DELIMA MANAGEMENT ...................................................................... 51

5.3. ENHANCE COLLABORATION WITH STAKEHOLDERS TO SUPPORT THE BIDAN

DELIMA PROGRAM ............................................................................................................................. 52

5.4. STRENGTHEN COLLABORATION WITH BPJS/JKN AND INVOLVEMENT IN

STRATEGIC HEALTH PURCHASING DISCUSSIONS ............................................................... 52

5.5. PROMOTING THE BRAND OF BIDAN DELIMA ....................................................................... 52

REFERENCES ........................................................................................................................ 54

USAID JALIN RAPID ASSESSMENT OF BIDAN DELIMA PROGRAM | viii

LIST OF TABLES

TABLE 1: BIDAN DELIMA PROGRAM RAPID ASSESSMENT AREAS .............................................................. 7

TABLE 2: LIST OF KEY INFORMANTS FOR IN-DEPTH INTERVIEWS ........................................................... 9

TABLE 3: DEMOGRAPHIC DATA OF BIDAN DELIMA PROGRAM RAPID ASSESSMENT AREAS ...... 13

TABLE4: PRIVATE MIDWIFE DATA IN ASSESSED DISTRICTS, PER DECEMBER 2019 ........................... 14

TABLE 5: THE CHARACTERISTICS OF PREGNANT WOMEN WHO WERE INTERVIEWED ............ 25

TABLE 6:THE CHARACTERISTICS OF POSTPARTUM MOTHERS WHO WERE INTERVIEWED ...... 26

TABLE 7: THE THOUGHTS AND OPINIONS OF PRIVATE MIDWIVES ABOUT BIDAN DELIMA .... 27

TABLE 8: CHARACTERISTICS OF PRIVATE MIDWIVES SAMPLED FOR THE CLINICAL

OBSERVATION ............................................................................................................................................ 29

TABLE 9: RESULTS OF PARTOGRAPH DOCUMENT REVIEW ...................................................................... 34

TABLE 10: AVAILABILITY OF EQUIPMENT AND SUPPLIES IN PRIVATE MIDWIFE PRACTICES ....... 39

TABLE 11: REASONS FOR NOT EMPANELING AS MNH PROVIDER FOR JKN ...................................... 40

TABLE 12: THE CHARACTERISTICS AND QUALITY OF CARE OF SAMPLE MIDWIVES ..................... 47

LIST OF FIGURES

FIGURE 1: NUMBER OF BIDAN DELIMA MIDWIVES IN THE RAPID ASSESSMENT AREAS FROM

2011 – 2019 ................................................................................................................................................. 16

FIGURE 2: BIDAN DELIMA CERTIFICATION PROCESS AS EXPLAINED BY THE BIDAN DELIMA

MIDWIVES ................................................................................................................................................... 17

FIGURE3: COMPETENCY IN FAMILY PLANNING COUNSELING ............................................................... 31

FIGURE 4 FAMILY PLANNING COUNSELING SKILLS BY INDICATORS ................................................... 31

FIGURE 5: COMPETENCY IN THE ANTENATAL CARE .................................................................................. 32

FIGURE 6: ANC SKILL BY INDICATORS ............................................................................................................... 33

FIGURE7: COMPETENCY IN USING PARTOGRAPH ...................................................................................... 34

FIGURE 8: THE COMPETENCY IN NEWBORN RESUSCITATION .............................................................. 35

FIGURE 9: RESUSCITATION SKILLS PER INDICATOR ..................................................................................... 36

FIGURE 10: RESULTS OF OBSERVATION ON THE MANAGEMENT OF PRIVATE MIDWIFE

PRACTICE ................................................................................................................................................... 37

FIGURE 11: THE RESULT OF OBSERVATION ON FACILITIES AND SUPPLIES OF PRIVATE

MIDWIFE PRACTICE ............................................................................................................................... 38

USAID JALIN RAPID ASSESSMENT OF BIDAN DELIMA PROGRAM | 1

EXECUTIVE SUMMARY

BACKGROUND

The Bidan Delima program was established in 2003 with USAID support as a franchise model of

Ikatan Bidan Indonesia (Indonesian Midwives Association – IBI). The aim was to enhance the

performance of private midwives and ensure their adherence to standards for safe pregnancy and

delivery practices. Private midwives who have practiced for three years, have a practice license, and

are motivated to improve their facilities, skills, and knowledge can apply to join the program. Once

certified, they are supervised and mentored by facilitators who are also private midwives and who

conduct the supportive role on a voluntary basis. By 2019 the membership had grown to include

over 19,000 private midwives, or about 40 percent of all private midwives in the country, and over

2,000 facilitators.

Recent analyses in Indonesia have shown that the performance of private midwives is often sub-

optimal, and maternal and newborn health outcomes are not on a par with neighboring countries in

the region. In addition, the rapid expansion of the national health insurance program has created

challenges for private midwives in terms of accessing the financing mechanisms, resulting in

substantial decreases in caseloads for some midwives. In the longer term, this is likely to further

exacerbate deficiencies in the quality of care available for pregnant women and newborns, thus

detracting from the government’s desire to accelerate reductions in preventable mortality and

morbidity.

Global evidence shows that a strong and well-supported midwifery workforce is a critical element in

achieving such goals and is cost-effective.1Therefore, as one of its core programmatic areas, the

USAID Jalin project is supporting the Ministry of Health (MOH) and IBI to strengthen the

performance of private midwives. It is envisaged that enhancing the Bidan Delima program will be an

important part of this process and, thus, a rapid review was commissioned to identify key challenges

and ways to improve the future relevance and effectiveness of the Bidan Delima model.

METHODOLOGY

The review had three main objectives, namely: assessment of the quality of care provided by the

Bidan Delima program; examination of the program relevance and value; and identification of the

future strategic direction regarding the business model. The review was conducted between

December 2019 and January 2020 and the methods used included:

1. A review of relevant reports, case studies, and policy and planning documents;

2. Observation of clinical practice using standard assessment tools in selected Bidan Delima and

non-Bidan Delima sites across eight districts in four provinces – three USAID Jalin-supported

(East Java, West Java and North Sumatra) and one not supported by any donor partner (Central

Kalimantan) – altogether 23 Bidan Delima and 23 non-Bidan Delima midwives were assessed;

3. Group discussions (18) and in-depth interviews (43) with key informants at national and sub-

national levels.

1 The Lancet Midwifery series 2014: https://www.thelancet.com/series/midwifery

https://www.thelancet.com/series/midwifery


FINDINGS

The document review confirmed that private midwives are an important part of the maternal and

newborn health workforce in Indonesia. However, since the launch of the Jaminan Kesehatan

Nasional (National Health Insurance – JKN) program, many private midwives have faced challenges

accessing the funding opportunities arising from this as they cannot register easily as providers.

Although the Bidan Delima program is assumed to ensure a higher quality of midwifery practice and

it has been suggested that having certification could provide benefit for JKN registration, the

program has not been formally reviewed since 2011. Nevertheless, the MOH is keen to test new

contracting mechanisms to improve the inclusion of private midwives in JKN and stimulate enhanced

quality of care.

The clinical assessment conducted on a small sample of private midwives provides a snapshot of

better facility readiness and the quality of care among Bidan Delima midwives. Facility readiness was

measured in terms of management (infrastructure, recording and reporting systems, written

procedures and guidelines) and availability and condition of facilities and supplies. The competency of

midwives was measured in terms of skills in family planning (FP) counseling, antenatal care (ANC),

using partographs and resuscitation of a newborn baby.

Overall, the Bidan Delima facilities and midwives had higher scores compared to non-Bidan Delima,

for example:

BIDAN DELIMA NON-BIDAN DELIMA

Facility management 77% 45%

Facilities and supplies

availability/condition 93% 84%

FP counselling skills 77% 46%

ANC skills 72% 54%

Use of partograph 61% 39%

Newborn resuscitation 44% 31%

The Bidan Delima program is still generally perceived by most stakeholders as being relevant and of

value to the health system. It is associated with quality midwifery services by health officials and

midwives, and the tools developed for the program, as well as its staff, have been widely used and

appreciated by other partners. Nevertheless, many problems with registration, supervision, and

maintaining motivation were identified as challenges going forward. There was also little awareness

about the program among some of the key stakeholders and the clients interviewed showing an

urgent need for greater promotion of the brand.

Since the rapid expansion of the national health insurance scheme, many private midwives, including

Bidan Delima midwives, have experienced a significant drop in their caseloads. As one key

motivation for joining the Bidan Delima program is to have an increased caseload, this has serious

implications for the sustainability and validity of the business model. In addition, the rapid assessment

revealed that many midwives just find the processes and costs associated with joining Bidan Delima

too onerous.


RECOMMENDATIONS

These fall under five areas:

1. Strengthening the quality assurance mechanism of the Bidan Delima program: including reviewing

the Bidan Delima instruments and guidelines and revising the tools and validation process;

specifically addressing critical gaps in midwifery competencies that affect the quality of care;

finding creative ways to recruit and incentivize facilitators; enhancing routine monitoring and

feedback mechanisms for midwives; and including reward mechanisms for quality midwifery

services rendered.

2. Strengthening Bidan Delima management: including a formal review of the overall management

by IBI and MOH; a review of the financial management and sustainability of the program; and

improvement of the entire Bidan Delima information management system to enable better

monitoring of the management and technical performance of the program at district, provincial

and national levels.

3. Enhancing collaboration with stakeholders to support the Bidan Delima program: MOH and

Provincial and District Health Offices should work with IBI at all levels to develop stronger

partnerships with key stakeholders at national and sub-national levels, such as General

Practitioners, OB/GYN consultants and the professional associations, as well as other private

sector players including pharmacies, banks and local companies.

4. Strengthening collaboration with JKN: including reviewing the processes for certification of

private midwives and ensuring that IBI is fully engaged in the Strategic Health Purchasing

discussion and working groups where midwives are concerned.

5. Promoting the brand of Bidan Delima: MOH and IBI should work together to agree on the

future direction of the program and how best to revitalize the brand. This will include enhancing

the added value of services provided by Bidan Delima midwives and promoting this value widely

through multiple channels to increase awareness and stimulate higher demand by clients and in

the population in general.

If these recommendations are implemented, the Bidan Delima program can become a driving force

for strengthening the midwifery profession in Indonesia. Placing midwives at the center of the health

system with an approach that values their contribution and complements their services with higher

level support when needed, is likely to help achieve the desired improvements in health outcomes

for mothers and newborns.


1. INTRODUCTION

USAID Jalin conducted a rapid assessment of the Bidan Delima program in coordination with the

Indonesian Midwives Association (IBI). The assessment findings will inform development of an

enhanced program that is responsive to the changing environment brought about by the scale up of

the national health insurance program, the national focus on improving the quality of maternal and

newborn health (MNH) services to reduce maternal and newborn mortality, and the prevention of

stunting throughout the country.

1.1. BACKGROUND

1.1.1. NATIONAL FOCUS ON REDUCING MATERNAL MORTALITY IN RPJMN 2020-2024

The President of Indonesia, Joko Widodo has signed the Presidential Regulation, Perpres 18/2020

regarding the National Medium-term Development plan (RPJMN) 2020-2024. RPJMN is the main

planning reference for the next five years. Maternal mortality ratio (MMR) and stunting reduction

were among the list of 41 Major Projects which are considered as Strategic Priority Projects in this

plan, called “Acceleration of reduction of MMR and stunting”. The MMR goal set for 2024 is a

reduction to183 per 100,000 livebirths. The baseline data used was the 2015 Intercensal survey

MMR estimate of 305 per 100,000 livebirths.

1.1.2. PRIVATE MIDWIVES’CONTRIBUTIONS IN MNH CAREAND BIDAN DELIMA PROGRAM

Private midwives are important contributors in the provision of MNH care in Indonesia. The 2018

Basic Health Survey2shows that private midwives provide 42.5 percent of antenatal care (ANC) and

conduct up to 34.5 percent of deliveries in Indonesia. Private midwives also provided 52 percent of

family planning (FP) services in 2019.3 Evidence, however, suggests that the quality of maternal and

newborn care provided by private midwives is highly variable. To address quality assurance issues

related to private midwives, Ikatan Bidan Indonesia (Indonesian Midwives Association – IBI), with

USAID support, initiated the Bidan Delima program in 2003. The program educates and incentivizes

private midwives to meet and maintain adherence to the standards for safe pregnancy and delivery

practices.4 Bidan Delima is designed for private midwives who have practiced for three years, have a

practice license, and are motivated to improve their facilities, skills, and knowledge.5

Initially started in six provinces (East, Central, West Java, Banten, North Sumatra and South

Sulawesi), the Bidan Delima program has expanded to 23 provinces covering 281 districts in

Indonesia by March 2020.6

1.1.3. USAID JALIN SUPPORT TO INDONESIAN MIDWIVES

USAID Jalin in partnership with IBI, works to strengthen the systems for building and sustaining the

competencies and quality of care provided by midwives, with a special focus on private midwives.

USAID Jalin aims to strengthen the Bidan Delima program to enable private midwives to better

deliver maternal and newborn services along the continuum of care and to adeptly identify, manage

and refer emergency maternal and newborn complications when required. USAID Jalin and IBI need

to understand the status, strengths, weaknesses, opportunities, and challenges pertaining to the

2 2018 Basic Health Survey (Riset Kesehatan Dasar/Riskesdas), MOH Republic of Indonesia, 2019 3 2019 Welfare Statistics, BPS (the Central Bureau of Statistics), 2019 4 Maharani Cynthia et al, The Implementation of a Franchise Model in Regulating Performance of Private Midwife in

Indonesia, A Case Study, 2011 5 Developmental Evaluation for USAID Jalin Bidan Delima technical brief, November 2019 6http://www.bidan-delima.org/isianggota.php, access date 9 March, 2020

http://www.bidan-delima.org/isianggota.php


Bidan Delima program implementation in order to

develop the most appropriate and effective Bidan Delima

enhancement strategies.

The latest available review of the Bidan Delima program

is dated July 2011.7Since then, the landscape of the

Indonesia health system has changed substantially,

particularly by the implementation of the Jaminan

Kesehatan Nasional (National Health Insurance – JKN)

program launched in January 2014. Therefore, an

updated review was required to gain a better

understanding of the value of Bidan Delima certification

in the context of JKN, the opportunities to evolve the

model, and the challenges to be addressed.

1.2. OBJECTIVES OF THE ASSESSMENT

The main purpose of the assessment was to provide USAID Jalin and IBI with up-to-date information

regarding the Bidan Delima program’s effectiveness, relevance, and value. Results of the assessment

will inform the development of strategic directions for the Bidan Delima program enhancement and

the refinement of its business model.

The specific study questions are described below.

A. Program effectiveness in assuring quality of service:

A.1. To what extent does the Bidan Delima program increase the quality of care provided by

private midwives?

i. How does facility readiness and competencies and clinical practices of Bidan Delima

compare to non-Bidan Delima midwives?

ii. Do midwives who go through the Bidan Delima certification process improve after

becoming qualified as a Bidan Delima as measured by scores on quality assessments?

A.2. What gaps exist in the model in assuring quality?

B. Program relevance and value:

B.1. How have private midwife practices changed since implementation of JKN and what are

the implications for the Bidan Delima program?

B.2. How do private midwives currently perceive the value of Bidan Delima? (e.g. why do

midwives join or not? Renew or not renew?) What would make it of more value?

B.3. What is the perspective of MOH, Badan Penyelenggara Jaminan Sosial (Social Insurance

Administration Organization - BPJS), IBI and other stakeholders on the value of the Bidan

Delima program and the potential for enhancing the program to support MOH goals for

reduced maternal and newborn mortality?

B.4. What do pregnant women know and think about Bidan Delima and private midwives in

general?

7 Maharani Cynthia et al, The Implementation of a Franchise Model in Regulating Performance of Private Midwife in

Indonesia, A Case Study, 2011

The USAID Jalin Project is a five-year initiative

implemented by DAI Global, LLC and its

consortium of partners – IntraHealth, Vital

Strategies, and Market Share Associates – that

supports the Ministry of Health (MOH) and other

stakeholders towards achieving the following

results:

1. Improved MNH quality of care in public and

private, and primary and secondary facilities,

at scale; and

2. Improved efficiency and effectiveness of the

emergency referral system at community and

facility levels, at scale.


C. Bidan Delima Business Model:

C.1. How has the Bidan Delima model evolved since the program was last documented in

2011?

C.2. What Bidan Delima program modifications are needed to ensure its future viability? This

will include identification and prioritization of new elements of the program, financing

mechanisms, staffing, information systems, and governance and leadership. Specifically, the

assessment will address:

i. What program enhancements would be feasible and add value to the program? e.g.

digital health tools (assessment of usefulness of each suggested tool, the midwife’s

competency in using digital tools and enabling factors to support scale up), referral

mechanisms, certification for JKN participation, marketing, formation of provider

network for contracting with primary health care providers or directly with BPJS.

ii. What financing mechanisms are in place or could be developed to cover the cost of

program operations (e.g. staffing, information systems) and enhanced member benefits

(e.g. digital tools, increased mentoring, JKN certification)?

iii. What more is required from current information systems to capture the volume and

quality of services provided by private midwives and elements of the program that can

give information for continuous improvement?

iv. What modifications are recommended to strengthen the peer mentoring and support

mechanisms given that facilitators are fewer in number than needed to fully support

Bidan Delima midwives?

v. Are there modifications needed to the governance leadership and structure of the

program?


2. METHODOLOGY

2.1. DATA COLLECTION

Data and information for this assessment were collected through the following activities:

a. Desk review

b. Clinical observation: Assessment of midwives’ clinical skills was carried out through a direct

observation when the respondent handled clients. However, if this is not possible, then the

observation of clinical skills is carried out through roleplay in which one member of the research

team will act as a client.

c. Qualitative assessments, i.e. focus group discussions (FGD)and in-depth interviews.

USAID Jalin assigned a team consisting of one Lead Researcher, one Field Assessment Lead, and

eight Field Assessors to carry out the rapid assessment. The team had a mix of medical/midwifery

and advanced public health expertise. The Lead Researcher was in charge of desk review and in-

depth interviews with national level stakeholders. The Field Assessment Lead and Field Assessors

were responsible for FGDs and in-depth interviews with provincial and district level stakeholders, as

well as the clinical observation. All Field Assessors were provided with a one-day orientation on the

methodology and assessment tools before collecting data from the field.

Clinical observation and qualitative assessments were conducted from December 12 – 22, 2019 in

four provinces that include three of USAID Jalin’s target provinces (North Sumatra, West Java, and

East Java) and one non-USAID Jalin province (Central Kalimantan). Central Kalimantan was selected

based on IBI’s recommendation to represent areas where IBI expanded the Bidan Delima program

without USAID funding support. In each province, two districts were purposively selected to

represent the following variations:

- Urban vs. rural districts.

- Districts with high and low number of Bidan Delima midwives and different ratios between

facilitator and Bidan Delima midwives.

The selected districts for the field assessment are as in Table 1.

Table 1: Bidan Delima Program Rapid Assessment Areas

Province Notes Districts

North Sumatra

USAID Jalin supported areas

1. Deli Serdang

2. Asahan

West Java 1. Depok City

2. Sukabumi

East Java 1. Sidoarjo City

2. Pasuruan District

Central Kalimantan Non-USAID Jalin supported area 1. Kotawaringin Barat

2. Kotawaraingin Timur


Details on each of the data/information collection activities are as follows:

2.2. DOCUMENT REVIEW AND SECONDARY DATA ANALYSIS

The reviewed documents include past Bidan Delima program evaluations, case studies, latest surveys

related to MNH services, and relevant policy and planning documents. The review highlights the

scale and scope of private midwifery practices in Indonesia and documents changes in the

environment since JKN implementation to estimate its impact on private midwives and provide an

updated profile of the Bidan Delima program. The secondary data reviewed includes updated data

on membership, renewals, monitoring data and other data available in IBI’s Bidan Delima routine

data sources.

The document reviewed are as follow:

1. Bidan Delima Evaluation Report. Sustaining Technical Achievements in Reproductive Health

(STARH) project 2006.

2. Bidan Delima, Expanding Quality Midwifery Services in Indonesia. Concept Paper for Donors,

2007.

3. Evaluation of Health Service Program (HSP) in Indonesia. Taking Stock and Looking Forward.

USAID, 2008.

4. Bidan Delima Accreditation: The implementation of a franchise model in Regulating Performance

of Private Midwives in Indonesia, A Case Study. Centre for Health Care Innovation, Mercy

Corps, 2011.

5. Revealing the Missing Link: Private Sector Supply-Side Readiness for Primary Maternal Health

Services in Indonesia, World Bank.

6. UNFPA Midwifery Consulting report, September 2014.

7. IBI internal information, presentations and data base on Bidan Delima.

8. Updated Midwifery law – Law No 4, 2019 on Midwifery.

9. Technical Guideline Mentoring and Supervision of Private Midwifery Practice, 2018.

10. Bidan Delima program description by Developmental Evaluation (DE) internal document for

USAID Jalin.

11. 2018 Basic Health Survey Report, MOH, 2019.

12. RPJMN /Perpres No. 18.

13. Strategic Health Purchasing for Maternal Health, Summary for Decision Makers (Draft,),

Strategic Health Purchasing team (MOH, USAID, World Bank Group and BPJS), 2019.

14. Bidan Delima Technical Guidelines, 4th edition, October 2014.

2.3. CLINICAL OBSERVATION

The clinical observation aimed to compare the quality of care of Bidan Delima and non-Bidan Delima

midwives, particularly on the following aspects:

1. Clinical readiness, which includes clinical management, condition and completeness of the facility

and supplies.

2. Midwife’s competence

Clinical competencies assessed were selected from the list of mandatory skills-set in the

validation instrument for Bidan Delima candidates. The selected skills for observation are ANC,

Family Planning counseling, neonatal resuscitation, and use of partograph. Considering the ease

of its implementation, the skill to deliver baby was not selected as an object in the clinical skills


assessment because it requires the use of specific dummy-model which is quite expensive, not

easily obtained or moved.

Mixed quantitative and qualitative methods were used to assess the quality of care of Bidan Delima

and non-Bidan Delima practices. Forty-six private midwife practices were purposively sampled; 23

practices are owned by Bidan Delima certified midwives and the other 23 by non-Bidan Delima

certified midwives. The selection of Bidan Delima and non-Bidan Delima midwives was based on

several criteria; years of experience as Bidan Delima, years of experience in midwifery practice,

location, number of clients, education background, training information, midwife age and access to

private midwife practice. The summary of clinical observation by clinic and district was analyzed by

using MS Excel software.

In addition, exit interviews were conducted with the clients of the sampled midwives to explore

their perception regarding the quality of midwives’ services. The exit interviews involved 18

pregnant and 17 post-partum women.

2.4. FOCUS GROUP DISCUSSIONS AND IN-DEPTH INTERVIEWS

FGDs and in-depth interviews with key informants (KIIs) were conducted at the national and district

levels. Key questions were developed to guide the FGDs and interviews.

In total, 18 FGD sessions were conducted during the assessment. There were 17 FGD sessions

conducted in the eight districts of study from December 12-22, 2019. They include seven FGD

sessions with the Bidan Delima midwives, eight with non-Bidan Delima midwives, and two with Bidan

Delima Facilitators. Each session involved 8-12 participants. One FGD session was conducted in

Jakarta on January 16, 2020. The last FGD session involved the management board of IBI at central

level, the chairperson of IBI of the assessed provinces and districts. It aimed to validate the findings

of the assessment and facilitate further discussion about the strategy in strengthening the Bidan

Delima program and other relevant issues.

In-depth interviews were carried out from December 10, 2019 – January 16, 2020 with 43 key

stakeholders at national and sub-national levels, representing government agencies, Bidan Delima

management, development partners, non-government organizations, and professional organizations.

Organizations and roles of the43 key informants are listed in Table 2.

Table 2: List of Key Informants for In-depth Interviews

National Level Sub-National Level

• Directorate of Family Health, MOH

• Directorate of Health Services, MOH

• Center for Health Insurance and Financing (P2JK),

MOH

• IBI

• Bidan Delima Management

• POGI (Indonesian Obstetrics and Gynecology

Association)

• MNH Partners: UNFPA, Jhpiego, HP+

• Chairperson of IBI district chapter (8 persons)

• Head of Family Health section in DHO (8

persons)

• Provincial and district managers of Bidan Delima

(12 persons)

• Facilitators of Bidan Delima in six select districts

(6 persons)


The recording and transcripts of FGDs and in-depth interviews were analyzed using NVivo software

version 12.

2.5. LIMITATIONS

This assessment intended to understand the strengths and weaknesses of the current Bidan Delima

program. A purposeful sampling strategy was used to gain insights from people from different

perspectives (e.g. rural and urban, size of facilities and years of experience), cultures (different

Indonesian provinces and islands) and situations (Bidan Delima and non-Bidan Delima). The

assessment however does not allow for conclusions to be drawn about the actual frequency of

findings across the country, as it does not define the size of the denominator and did not assess a

significant sample size to allow for statistical significance.

Additionally, the selection of the key informants for interviewing has an influence on the kind of

findings gained including their interpretation. Though the assessment team contacted BPJS for an

interview they were not able to schedule an appointment during the assessment period. The absence

of information from BPJS must be considered in the interpretation of the findings, conclusions, and

recommendations from this assessment, specifically on the Bidan Delima business and financing

related issues.


3. ASSESSMENT FINDINGS

3.1. FINDINGS FROM DESK REVIEW AND QUALITATIVE ASSESSMENTS

3.1.1. BIDAN DELIMA INCEPTION AND EXPANSION

The Bidan Delima program was initiated by IBI in 2003 in collaboration with the USAID Project in

Family Planning and Reproductive Health following the advice from government partners to

implement a quality improvement program through the private sector rather than the public sector

to enhance program implementation.8 It followed the successful implementation of the government’s

Family Planning program to expand the FP services into the private sector through the introduction

of the Blue Circle program.9 The name and logo of “Bidan Delima” (Pomegranate Midwife) were

selected after extensive consultation with IBI management and members, and based on IBI’s logo.

The program consists of two complementary parts: one, to increase the supply of high-quality

service providers by promoting standards and offering training as needed to meet those standards;

and two, to create a brand identity among clients and among providers so that clients seek services

from a “Bidan Delima” midwife, thereby increasing her caseload (and income).10

The conception and early expansion of the Bidan Delima certification program was supported by

two consecutive USAID flagship health projects, i.e. STARH and HSP [1]. IBI also collaborated with

private companies (such as Johnson&Johnson and Exxon) to expand the Bidan Delima program.

Initially the program was implemented in six provinces (DKI Jakarta, West Java, Central Java, East

Java, North Sumatra, and South Sulawesi). By 2009, the Bidan Delima program had expanded to 203

districts and 15 provinces[2]. By March 2020, the program has reached 281 districts in 23

provinces[3].

Replicability is recognized as one of the Bidan Delima program’s strengths. The USAID-HSP

evaluation report noted that the Bidan Delima program had positioned the idea of midwives as

entrepreneurs who have pride in their services and live up to a standard of care[1]. However, the

report also pointed out that Bidan Delima midwives perceived limited value added by the program

because the rise in caseloads was not so much affected by the brand of Bidan Delima but by the

improvement of their practices. A more recent review on the Bidan Delima program [2]highlighted

further that the unmet expectation of accreditation versus increased caseload is likely to demotivate

midwives to pursue or renew their Bidan Delima certification. This situation poses a risk to the

sustainability of the program.

One district manager explained the indicators she uses to judge Bidan Delima’s improvement:

• The increasing number of Bidan Delima midwives; there were only 60 Bidan Delima in Sukabumi

district before 2014 and now there are 245 BD midwives.

• The number of Bidan Delima facilitators.

• The number of branches (sub-district) with Bidan Delima; there were initially only six branches

with Bidan Delima initially and now there are ten branches due to a new policy to establish each

hospital as a branch.

• A better structured management board.

• More intensive meetings.

8 USAID-STARH. Bidan Delima Evaluation Report 9 Barron T. Indonesia Family Planning aims for sustainability. Family Plan World. 2002 Nov-Dec; 1(2):22-3, 30 10 USAID-STARH. Bidan Delima Evaluation Report


Midwifery Law

The Law No 4 Year 2019 is the statute on midwifery approved by Joko Widodo, President of

Indonesia on 13 March 2019. The law regulates midwifery education, registration and practice

licenses, including midwives who are Indonesian citizens who have graduated abroad, foreign

midwives, midwifery practices, rights and obligations, midwifery professional organizations,

empowerment of midwifes, and coaching and supervision.

The midwifery profession has been strengthened by the enactment of the new law. Two issues relate

to private practice: 1) Midwives should obtain a professional bachelor’s degree to be recognized as a

professional midwife, and hence eligible for a license, and 2) Midwifery private practice is defined as a

health service facility in this law. To be fully implemented, some implementing regulation(s) would

need to be put in place. Interviews with key informants suggested it will take two years to have the

implementing regulation in place, not only to develop but also to review and adapt the existing

regulation, such as the MOH Decree, PMK 28/2017, with the new law. This decree will still be valid

until 2026, when the transition to the new professional degree requirement becomes official as a

requirement for licensing. The educational system would need adaptation to establish schools to

provide a bachelor’s degree education for new midwifery students, and for development of the

adaptation process for existing midwives with a D3 certificate. Pengembangan dan Pemberdayaan

Sumber Daya Manusia (The Center for Health Human Resource Development – PPSDM) is expected

to be the lead on this six-year transition for midwifery professional education.

During data collection in the districts, most of the heads of IBI and/or the Unit Pelaksana Bidan

Delima (Bidan Delima Executive Unit– UPBD) were very aware of the change in the midwifery

education requirement in the law and have a plan to accelerate the process of improving the private

midwife education level. IBI Pasuruan plans to work with Politehnik Kesehatan (Health Polytechnic –

Poltekkes) Malang to establish a new professional midwifery education program.

The enactment of the new law is assumed to bring some changes, such as:

• Private midwives will be more internet literate, and be more active in WhatsApp groups

• Senior midwives –who are D3 graduates–will be reluctant to pursue the professional degree, so

they might stop practicing

• Private midwife practices will tend to refer patients to Puskesmas

• Midwives are not allowed to use public facilities for their private practice. For example, Bidan

Delima will not be able to open private practice in Polindes after office hours. Consequently, the

number of Bidan Delima midwives will decrease, because many dual practice midwives will stop

their private practices

• Four-hand delivery will be enforced, but fortunately most midwives already practice it

• The law gives clarity about a midwife’s authority

• It also provides legal protection to midwives and the patients, “It will make us feel peaceful, we

have legal protection… you know, we are frequently suspected to conduct malpractice and so on. That’s

why we put our best effort to have this law.”- (Bidan Delima, Sidoarjo)

3.1.2. CHARACTERISTIC OF THE RAPID ASSESSMENT AREAS

Maternal and Neonatal Mortality Figures

The demographic data of assessed districts was collected during the assessment from several

sources such as; District Health Office (DHO), reputable websites and data published by Badan Pusat

Statistik (Central Agency of Statistics – BPS). Some of the districts that were assessed showed a


major contribution to the number of maternal and newborn deaths at the provincial level. Table 3

summarizes relevant demographic data of the assessed districts.

Table 3: Demographic Data of Bidan Delima Program Rapid Assessment Areas

Province/District Population Number of Maternal

Deaths

Number of Neonatal

Deaths

North Sumatra

Deli Serdang 2,234,320 13 NA

Asahan 1,605,307 15 112

East Java

Sidoarjo 2,262,440 17 157 (2018)

Pasuruan 1,779,405 19 121

West Java

Sukabumi 2,523,992 41 218

Depok 2,254,513 32 78

Central Kalimantan

Kotawaringin Barat 290,000 7 28

Kotawaringin Timur 460,000 16 97

Geographic Conditions

Geography is one of the big challenges in these districts. For example, Sukabumi district is quite large

and many locations are difficult to reach—including the three referral hospitals. Travel constraints

discouraged midwives to join the certification process. Equally, Kotawaringin Timur is a hard to

reach area.

MNH Service System

As in all of the districts in Indonesia, the DHO takes a lead in efforts to reduce maternal and

newborn mortalityin USAID Jalin’s rapid assessment areas. The DHO in all districts or municipalities

authorizes the sub-district Puskesmas to supervise and coordinate the health facilities in their area as

networks. The network that includes Puskemas Pembantu, Puskesmas Keliling, Poliklinik Desa, Bidan

Desa is called Jaringan or network Puskesmas, while Jejaring Puskesmas consists of the Jaringan, with

hospitals, private clinics and private midwife practices. In addition, these networks are required to

report data to the DHO on a monthly basis which feeds into district health reports.

A number of activities have been conducted by the DHO to improve the quality of midwives. Some

DHO officials acknowledged that their training plan is supposed to include all health facilities in the

area that are in Jejaring Puskesmas in the program but because of limited resources, the midwives

who work in Puskesmas and its Jaringan are prioritized for participation. In addition, the DHO is also

responsible for conducting regular supervision and monitoring activities but the implementation

varies in terms of the frequency and mechanism.

“In the supervision visit, they checked the rooms in my private practice, and the reports about babies

and pregnant mothers. The doctor and coordinator midwife usually do the supervision visit from the

Puskesmas, IBI does not come along. IBI only supervises for SIPB renewal. Before IBI visit, I usually

asked the Puskesmas to check [my private practice].” - (non-Bidan Delima, Pasuruan)


In Kotawaringin Barat, midwives reported that the Puskesmas supervision just started in the last

three years. One of the non-Bidan Delima midwives acknowledged the visits from Puskesmas and

Badan Kependudukan dan Keluarga Berencana Nasional (National Population Family Planning Board -

BKKBN) for supervision purposes. Sidoarjo’s non-Bidan Delima midwives confirmed that in their

Jejaring Puskesmas meetings were conducted every two months to strengthen the Jejaring as well as

to refresh their knowledge. In addition, quarterly visits to private midwife practices were conducted

by Puskesmas to assess compliance with the quality standards. Similar activities were also reported

in Depok, Sukabumi and Pasuruan.

Data reporting to the district is a requirement for private providers but private midwives expressed

some challenges in complying with requirements. Private midwives in some districts prepare their

service reports manually by filling out hardcopy forms and sending them to the Puskesmas. Private

midwife practices can use the online application Si Cantik in Sidoarjo and Sistem Informasi Bidan

Mandiri (Mandiri Midwife Information System-- SiBiMa) in Depok to report their services. Use of the

Si Cantik application is a prerequisite to renew the Surat Izin Praktek Bidan (Midwife Practice License

–SIPB). Midwives who never report service data through the application will not be granted a new

SIPB. Some senior midwives who were not familiar with computers and technology sought help from

other people.

Other difficulties raised by midwives in using a digital application for reporting included: lack of

familiarity with the application, poor internet connection, no internet quota, and size of application

on cellular phone screen.

“It’s important and faster if we use email or technology like that, but I am not capable at operating

a computer, so I asked other people to do that”. - (DHO Sidoarjo)

Private Midwives

Private midwives work as government health workers during regular office hours and work as

independent practitioners in the remaining time. Generally, midwives in Indonesia run a dual-

practice, which means the midwives run private practices and also work in Puskesmas, hospitals,

other clinics or training institutes. For midwives in dual-practice, providing maternal and newborn

services in their private practice during working hours (0800-1400) is unacceptable. All services

during working hours should be conducted in Puskesmas and only in their private practice after

office hours. The resource persons interviewed in the assessment estimated 50 percent of midwives

run dual-practice but not all districts provided information about this. In West Kotawaringin, only 20

percent of private midwives purely work as a private midwife compared to 52 percent in Sukabumi

and 67 percent in Depok (see Table 4).

Table 4: Private Midwife Data in Assessed Districts, per December 2019

Province/

District

Number of

Midwives

Pure Private

Midwife

Practices

Number

of Private

Midwives

Number of

Bidan

Delima11

Number of

Facilitators

Ratio

Facilitator

and Bidan

Delima

North Sumatra

Deli Serdang 1,400 NA12 506 240 47% 24 1:10

Asahan 1,200 NA 600 22 4% 2 1:11

11 Based on UPBIDAN DELIMA district report 12 NA = Not available


Province/

District

Number of

Midwives

Pure Private

Midwife

Practices

Number

of Private

Midwives

Number of

Bidan

Delima11

Number of

Facilitators

Ratio

Facilitator

and Bidan

Delima

East Java

Sidoarjo 1,400 NA 506 379 74% 24 1:15

Pasuruan 1,189 NA 456 354 77% 36 1:10

West Java

Sukabumi 1,246 216 416 245 75% 16 1:15

Depok 1,004 275 410 304 74% 27 1:11

Central Kalimantan

West Kotawaringin 530 85 415 3 6% 1 -

East Kotawaringin 500 NA 35 2 4% 1 -

Source: District routine monitoring data

Overall, the DHO is responsible for efforts to improve the quality of MNH services in the districts

while efforts to improve quality for all private midwife practices are the responsibility of IBI through

the Bidan Delima program.

“We had no control over the quality of private practice midwives after they got their licenses ...

Bidan Delima program is the only way for us to be able to monitor the quality of their services.” -

(IBI Depok)

3.1.3. BIDAN DELIMA MEMBERSHIP

In the national scope, the number of Bidan Delima members appears to be continuously increasing

from 1,407 midwives (including 748 Facilitators ) in 2005 [3] to 18,206 midwives (including 1.786

Facilitators) in March 2020 [4].

Bidan Delima certification becomes a compulsory program for midwives who run private practices in

areas where increasing the number of Bidan Delima members is considered essential, like Depok and

Pasuruan. All IBI members who are not members of Bidan Delima but working in a clinic or hospitals

or in other sectors are termed Bidan Delima candidates. In Pasuruan, every midwife who wants to

have a midwife practice license (SIPB) must be a member of Bidan Delima, and follow through the

qualification process, regardless of her interests. IBI in East Java province is aiming to have 100

percent of private midwives in the Bidan Delima program by 2023.

However, Bidan Delima membership data indicate that the number of active Bidan Delima13is either

stagnant or declining in some districts in recent years. As seen in Figure 1 the number of active Bidan

Delima midwives is declining in Pasuruan, Sidoarjo and Depok, while in Deli Serdang it is stagnant2

Asahan district has not had any Bidan Delima midwives since 2011. According to the interviewed

district UPBD managers, the major reasons for declining number of active Bidan Delima members

are:

- Some Bidan Delima midwives are retired (due to old age or sickness)

- Some Bidan Delima midwives relocated out of the district (either for personal or

professional purposes)

13 Active members of Bidan Delima are midwives whose Bidan Delima certificate is still valid.


- Some midwives decided not to renew their Bidan Delima membership due to decreasing

number of patients since the implementation of the JKN program. The decreasing number of

patients means less income, so they found it hard to pay the Bidan Delima fee, in addition to

the IBI membership fee.

Figure 1: Number of Bidan Delima Midwives in the Rapid Assessment Areas from 2011 – 2019

3.1.4. BIDAN DELIMA CERTIFICATION PROCESS AND COSTS

A case study of Bidan Delima that was published in 2011 [2]explained the Bidan Delima certification

process and costs as follows:

It starts when a private midwife practitioner proposes her candidacy to be a Bidan Delima midwife

and takes a pre-qualification test. Next the candidate is given self-learning modules on the Bidan

Delima program. Then the facilitators validate the candidate’s aptitude and understanding of the

Bidan Delima standards. Bidan Delima certification is given to those who pass the aptitude test and

the facilitators continue their mentoring process until the new Bidan Delima midwife is ready to work

on her own. Those who pass the test pay the first membership fees of IDR 350,000 (USD 40) and

in return are certified and authorized to post the Bidan Delima logo on their name boards. To keep

their membership, Bidan Delima midwives pay as much as IDR 250,000 (USD 28) annually. The

certificate is good for up to five years, at which point they need to renew the certificate.

The information given by respondents in USAID Jalin’s rapid assessment confirms that the same

steps are still applied in the process of becoming a Bidan Delima midwife today. Figure 2 summarizes

the Bidan Delima certification process as explained by USAID Jalin’s rapid assessment respondents.

208

150

231 237

136

162

269 250

66

244

344

171176

307

398

375

12

117 117 118

31

0 0 00

50

100

150

200

250

300

350

400

450

2011 2014 2017 2019

Sukabumi Depok Sidoarjo Pasuruan Deli Serdang Asahan


Figure 2: Bidan Delima Certification Process as Explained by the Bidan Delima Midwives

The Bidan Delima certification process and costs are described in more detail by the respondents of

USAID Jalin’s rapid assessment as follows:

1. Workshop

The workshop is conducted after more or less 40 private midwives have registered to join Bidan

Delima, to provide detailed information about Bidan Delima. During the workshop, the

UPBD/IBI shares guidance on self-assessment including the assessment tool with Bidan Delima

candidates.

2. Pre-Qualification

The pre-qualification process already shows the midwife the standard that must be fulfilled as

Bidan Delima. After registering as a Bidan Delima candidate, the private midwife must complete

the pre-qualification tools and fulfill 75 percent of criteria standards. The standards used by the

Bidan Delima program are in accordance with the standards that must be met to obtain a SIPB

as stated in the law, the Ministry of Health decree or Permenkes number 28, 2017.

3. Validation process

The Bidan Delima candidate is also equipped with self-assessment tools which include the health

facility readiness standard regarding the readiness of the facility to provide services and also

measure midwife competency. Before the validation process, the candidate uses the self-

assessment tool to measure the readiness for becoming a certified Bidan Delima midwife and the

facilitator provides mentoring during this process.

The completeness of facility and infrastructure is the most difficult part to fulfill according to

midwives. It takes quite a lot of time and money to renovate the facilities to follow the

recommended floor plan and provide the complete set of instruments. Collaboration with other

health services for waste disposal management was also mentioned as somewhat troublesome

for Bidan Delima midwives in Depok, because of the high cost: 1,500,000-2,500,000 IDR per

month. During the report review process, the Central Level IBI caretaker provided information

that the waste management fees are not determined by the local government but involve a third

party, thus varies across the regions.

For the clinical competency assessment, a Bidan Delima candidate must perform different clinical

skills on patients in front of the Bidan Delima validator.

Improving

clinic facility

Registration

Pre-

Qualification

Self-

Assessment

Validation

Certified

Bidan Delima

Passing grade

100%

Workshop


“Bidan Delima facilitator/validator came and asked about the barriers, how many [indicators] from

the checklist is met, and after the [indicators in the] checklist were met, I had clinical competency

assessment with the facilitator, a comprehensive one, from pregnancy examination, delivery,

perinatal check-up, all were tested using a checklist. My validator was Ibu K.” - (Bidan Delima)

Usually they need to arrange with approximately five other Bidan Delima candidates that are

located in the same or nearby areas to save on the validation visit budget and time. Non-Bidan

Delima midwives perceived this step to be costly, because of the sense of obligation to provide

refreshments for the validators. The validation process may require several repeat visits

depending on the assessment result, because the required score is 100 percent, or all indicators

met.

4. Inauguration

The respondents informed that inauguration ceremony and Bidan Delima kit cost approximately

1,650,000 IDR per midwife and has to be paid prior to the inauguration. For some midwives,

particularly the non-Bidan Delima respondents the cost was too high for them to afford.

During the report finalization, the Central Level IBI caretaker clarified the standard fees that due

to the midwives during the process of becoming a Bidan Delima and the following years, as

follows:

• Fee to attend the Bidan Delima registration workshop costs at the district/city level IDR

75,000 per person. The participating midwife will receive a workshop kit: pre-qualification

forms and self-assessment books, meals and accommodation.

• The first-year fee as Bidan Delima is IDR 600,000 to cover the following items:

- IDR 550,000 for the production and delivery of Bidan Delima starter kit that consists

of certificate, pin, signage, printed material of 10 steps in Family Planning service

(posters, leaflets, stickers), Bidan Delima manual books, bag with Bidan Delima logo,

audio-visual for e-learning, and apron.

- IDR 50,000 for mentoring service by UPBD at district/city level.

• Annual fee to be paid from the second year of IDR 250,000. This fund is allocated to

financed operational and activities of UPBD with the following details:

- IDR 150,000 for district/city level UPBD,

- IDR 50,000 for provincial level UPBD,

- IDR 50,000 for central level UPBD.

The central level IBI caretaker emphasizes that additional fees beyond the standard as mentioned

above is the discretion of district/city/province level UPBD. The additional fees are usually to cover

the costs of inauguration ceremony, which include accommodation, meals, fee for guest speakers,

and uniform for the Bidan Delima midwives.

The entire process from workshop to the inauguration takes from a month up to a year, as reported

by our respondents across the study areas. However, the amount of time needed to prepare for the

certification (including clinic renovation and waste management improvements to meet the Bidan

Delima standards) may be substantially longer than for the certification process itself.


“Before I launched my private practice, I have prepared everything, from infrastructure to

instruments. I checked the requirements and looked for examples online. Then I registered, and it

took only a year for me to process to become Bidan Delima. But the preparation itself took five to

ten years, during which I worked as a midwife in a private practice.” - (Bidan Delima, Depok)

3.1.5. PRIVATE MIDWIVES IN THE JKN ERA

The Indonesia national health insurance program, JKN, started on January 1, 2014.The financing

component in the JKN program is administered by BPJS, a special agency sanctioned by the Law no.

24/2011 and reporting directly to the President.

The regulations currently imposed by BPJS have resulted in two main challenges for private

midwives’ empanelment to JKN:

1. BPJS does not recognize private midwife practices as facilities. Thus, private midwives cannot

directly provide MNH services to JKN participants but must go through contractual

agreements with Puskesmas or private clinics that have partnered with BPJS. According to

the President of IBI, the problem lays in the absence of clear regulations regarding the

distribution of tariffs between the midwives and the contractor facilities as anecdotal reports

suggest that some contractor facilities take up to 40 percent of the tariff that paid for the

midwives' services.14This has resulted in low participation of private midwives – including

Bidan Delima midwives – in the JKN. IBI data indicates roughly only 58 percent of private

midwives and 45 percent of Bidan Delima midwives were empaneled to JKN in 2016.15 It is

necessary to note, that the proportion of respondents in this assessment who have engaged

with BPJS’ providers is higher in the Bidan Delima group than in the non-Bidan Delima

group (71% or 12 of 17 Bidan Delima respondents vs 53% or 9 out of 17 non-Bidan Delima

group).

2. The tariff of services set by BPJS is too low to adequately cover the operational costs of

private midwives. Unlike public facilities, private practices generally do not have other

sources of funds to cover the operational costs other than service fees paid by the clients.

In 2017, a policy paper was developed based on a review of private providers by analyzing data on

the “missing link” of primary maternal health service provision. It was seen as a critical issue since 54

percent of all deliveries in Indonesia currently occur in the private sector, compared to 22 percent

in the public sector. Key findings from the analysis elucidate the potential value of the private

sector in expanding access to MNH services covered by the strategic and financial purchasing

umbrella of JKN, the effectiveness of these private MNH services, and patient satisfaction.16

The review found that there was low coverage of private MNH providers under JKN because

of low reimbursement rates and non-fulfilment of eligibility criteria. It was found also that the

private MNH providers were relatively weak concerning their supply of emergency obstetric

drugs and the actual use of diagnostic tests (measured by patient exit interviews) .

Based on these reviews the policy paper presented some policy implications around the theme:

14 Kompas, Bidan Enggan Ikut Jejaring JKN, June 26, 2014. 15 Nurjasmi, Emi., Pandangan Profesi Bidan Serta Rekomendasi Perbaikan Kebijakan Belanja Strategis Kesehatan, presentation,

2016. 16 Yap, Wei A., et al. Revealing the missing link: private sector supply-side readiness for primary maternal health services in

Indonesia - maternal health report (English). Washington, D.C.: World Bank Group, 2017


‘Spend more, right and better. MNH is a key human development investment

opportunity; investments should be made conditional on BPJS advancing its capabilities

from passive claims administration to active strategic purchasing’.

In addition, improving private midwives’ empanelment to JKN, coupled with accelerating and

sustaining improvements in the quality of care by private midwives, could also substantially

contribute to national goals of reducing maternal and infant mortality and also address stunting.17

Strategic Health Purchasing Summary Report

In 2017-2019, a strategic health purchasing (SHP) piece of work was initiated by Pusat

Pembiayaan dan Jaminan Kesehatan (Center for Financing and Health Insurance – PPJK) at the MOH.

This office convened a multi-stakeholder SHP Technical Working Group (TWG)18 for maternal

health, which has completed a draft policy brief for decision makers.19

The policy brief confirms that 2017 IDHS shows good program coverage rates of at least four ANC

visits (77 percent), births delivered with a skilled health worker (91 percent), and births in a health

facility (74 percent). But this does not correspond to low maternal mortality. The policy makers

should focus their attention on improving the quality of services, including adherence to

standards, and continuity of care from the time of pregnancy until the postpartum period.

One of the recommendations of this draft policy brief is to improve quality of services by testing

new types of Badan Pengelola Jaminan Sosial Kesehatan (Health Social Insurance Administration

Organization– BPJS-K) contracting arrangements for midwives, such as networks of midwives (e.g.

Bidan Delima), provider associations (i.e. IBI), and/or maternity clinics (i.e. rumah bersalin). The

contracting unit would be responsible for accreditation and management of payments to individual

midwives.

3.1.6. BIDAN DELIMA PROGRAM MANAGEMENT

Following one of the recommendations from the USAID-HSP evaluation [1] i.e. “to form a dedicated

committee comprised of program staff, board representatives, and donors to guide management and

expansion of the program” IBI established a dedicated unit to manage the Bidan Delima program

namely the UPBD. The UPBD is located at national, provincial, and district levels. All personnel in

the UPBD work on a voluntary basis (except national UPBD). At the central level the managers are

appointed and report directly to the IBI President.

The management team at central level is chaired by a General Manager who oversees the Quality

Assurance Manager, Bidan Delima System Development Manager, Human Resources Manager,

Finance and Accounting Manager, Administration and Logistics Manager. However, the current

situation is that the General Manager is unable to work full time as she is also appointed to be a

Surveyor, and instead of having a full team of five managers, there are only three managers with one

of the vacant positions being the Quality Assurance Manager.

“We at the central management have weaknesses. It should be that each manager thinks about

each of their activities, but we are short of managers so we all just do it together scatter...” -

(National UPBD)

17 Several specific and sensitive intervention to prevent stunting are in the midwives` standard of procedures for quality

care. (Ref: ‘National strategy for acceleration of stunting prevention’) 18 Members of the Core TWG included MOH (PPJK, YANKES, NTP), BPJS-K, and development partners 19 Strategic Health Purchasing for Maternal Health, Summary for Decision Makers (draft)


The district or municipality UPBD management consists of a manager, secretary, financial manager,

recruitment department and quality assurance department. The quality assurance department

supervises facilitators and has responsibility for quality improvement of the Bidan Delima service.

This management team is the key player to ensure the Bidan Delima program is progressive at the

district level, while the provincial UPBD assumes the function to facilitate the coordination between

national level and district level UPBD.

The UPBD selection is made simultaneously with the IBI board of management selection, every five

years. The steps are: 1) IBI board meeting to identify candidates that suit the requirements, 2) the IBI

board at the district level chooses from the candidates,3) the list of selected candidates is proposed

to IBI National board, 4) IBI National board inaugurates the selected UPBD personnel. One of the

requirements for UPBD manager is not holding any position in the IBI board. UPBD and IBI need to

have close coordination and according to the West Java UPBD manager, this is one of the key

factors for a successful Bidan Delima program.

“The leadership factor at Province and District is very influential. The system is not yet developed

well, so that its success depends on the leadership...” - (National UPBD)

During the assessment, Bidan Delima midwives from half of the areas assessed were unhappy with

the way the UPBD manages the program. Terms used to express their unhappiness were: ineffective,

overly busy with other roles, unsupportive to Bidan Delima midwives and not prioritizing Bidan

Delima.

Based on those weaknesses, the suggestions made to UPBD by Bidan Delima midwives were:

• Must be smart

• Try to get financial support

• Focus on their assignments as UPBD

• Support and prioritize Bidan Delima midwives in various activities

• Choose senior, retired or pure private midwives with no other job or focus

Choosing retired or senior midwives to manage Bidan Delima is a compelling suggestion. Depok,

whose UPBD are senior midwives, received positive feedback from Bidan Delima midwife groups for

spending more time monitoring and mentoring, particularly in Bidan Delima practices. Depok’s

UPBD is the only UPBD where the midwives commented,

“Oh my... it’s almost monitoring time again? They just visited me for monitoring not long ago!” -

(Bidan Delima)

3.1.7. BIDAN DELIMA QUALITY ASSURANCE SYSTEM

According to the 2014 Bidan Delima Program Technical Guideline for District Chapter IBI [5] the

monitoring of Bidan Delima midwives’ quality of services is conducted by a monitoring team at the

district UPBD that consists of:

• Supervisor of the recruitment and mentoring at the district UPBD;

• Facilitators;

• Clinical trainer (if available).

Findings from USAID Jalin’s rapid assessment indicate thatthe regular quality monitoring activities

was in practice conducted by the facilitators only.


The prerequisites to become a Bidan Delima facilitator are described in the Bidan Delima technical

guidelines, i.e. have been active as a Bidan Delima midwife and have commitment to mentor

candidates for Bidan Delima. The FGD participants confirmed the prerequisites as: 1) operating

private practice, 2) willing to spend time to undertake facilitator’s tasks, and 3) committed to self-

improvement.

Being a facilitator means becoming a role model for Bidan Delima, therefore, the prerequisites are

indispensable. The main tasks of the facilitator are: 1) to assist Bidan Delima candidates during the

selection process, 2) to validate the self-assessment results, and 3) to monitor and mentor Bidan

Delima midwives in maintaining and improving the quality of care.

According to managers of UPBD and facilitators who were interviewed in the assessment, in general,

Bidan Delima members become facilitators due to the appointment by UPBD managers instead of

self-nomination. The selected facilitators must participate in facilitators’ training that is conducted at

provincial level, and then the IBI National board releases an official letter to announce their position

as facilitator.The training costs 2,500,000 IDR and is supposedly paid by the district UPBD. But since

2017 the facilitator training has not been conducted as frequently as expected.

UPBD at district and provincial levels and IBI estimated the ideal ratio between facilitators and Bidan

Delima midwives is 1:10. However, as presented in Table 4 the ratio in Sukabumi, Sidoarjo and

Asahan is less than ideal. In Sukabumi, one facilitator supervises 27-28 Bidan Delima midwives, and

on top of that, all facilitators reside in central business areas so Bidan Delima midwives on the

outskirts of Sukabumi are rarely visited.

In Depok, although the proportion is close to ideal, like in Sukabumi uneven distribution is another

problem to resolve. They are distributed across 11 sub-districts or ranting, but not in proportion to

the Bidan Delima midwives. For instance, Tapos sub-district in Depok with 44 Bidan Delima

midwives has only two facilitators, while Cilodong sub-district with 26 Bidan Delima midwives has

four facilitators. This affects the burden of each facilitator in mentoring Bidan Delima midwives.

Facilitators reported that they receive rewards in the form of a facilitator training certificate,

improved knowledge and Bidan Delima membership fee waiver, but they still have to pay extra

expenses incurred when visiting Bidan Delima’s practices to assume their roles, since the

transportation and consumption allowance from UPBD is very small.

UPBD in Kotawaringin Timur, whose members were just three midwives, could not financially

support facilitator’s activities, so “… we really expect to get financial support to cover the operation of

Bidan Delima, so we can improve this program.”


The evaluation of USAID-HSP [1] has also highlighted the heavy reliance on volunteerism as a

weakness in Bidan Delima program operations that potentially hampers further expansions and

sustainability of the program. The evaluator recommended development of a new system in which

paid staff augment facilitators in performing validation and supervisory visits. The 2011 review of the

Bidan Delima program conducted by Mercy Corps [2]reiterated the need to find an effective

incentives scheme for volunteers amongst UPBD and field facilitators to stimulate active monitoring

and reporting.

3.1.8. BIDAN DELIMA PROGRAM FINANCING

Bidan Delima members pay a mandatory annual membership fee of IDR 250,000. The amount is

similar across areas, but payment methods are different across sub-districts. The annual fee can be

paid at once or as monthly installments. The payment period is also varied across the districts. Some

collect the money in the middle of the year, some at the end of the year. In addition to the

mandatory fee, sub-districts may request additional fees for their operations/programs.

The collected annual fee is shared with all levels of UPBD with the following composition:

• IDR50,000 per Bidan Delima midwife for central level UPBD;

• IDR50,000 per Bidan Delima midwife for provincial level UPBD;

• IDR150,000 per Bidan Delima midwife for district/city level UPBD.

The district UPBD is authorized to manage their funds. Some district UPBD manage their finances

completely separated from IBI, while some others, although they have a treasurer or financial

manager, maintain a joint bank account with IBI in the district, or simply save all UPBD income to

IBI’s account.

Not all Bidan Delima midwives pay the membership fee, but UPBD cannot insist on the collection of

unpaid feeds or punish members who have not paid. There is no clear information regarding the

compliance of Bidan Delima midwives to pay the annual fee but the IBI National board mentioned

that only 50 percent pay it regularly. It has been difficult for the UPBD to take action on this as they

could not show the advantage of joining Bidan Delima.

The challenges faced by Facilitators to promote Bidan Delima

“We had an interesting experience when trying to develop Bidan Delima in Sukamara district. Bidan Delima is a brand

of excellent quality of care, in order to eliminate the MMR and NMR. So…. I tried to introduce it to a neighborhood

district, hoping they can develop Bidan Delima program. Because the road was still on construction, and also the

private midwife’s practices opening hour, I left home at 5 a.m., and later I arrived home at 9 p.m. In the introduction

process, the private midwives were very enthusiastic, three of them were eager to join Bidan Delima, so we continued

the process with verification, validation, and so on. But two weeks before the inauguration, those three midwives stated

that they cancelled the application. At that time, the provincial UPBD was the one who provided data and guidance

through WhatsApp.

The reason why they cancelled their membership is a big question for me. It is an unforgettable memory! My sacrifice

did not yield a good result”

(Facilitator – Kotawaringin Barat)


UPBD Asahan explained that their members have never paid membership fees. The reason is not yet

clear but possibly it is because they do not currently have facilitators in the district. While in Deli

Serdang, the UPBD manager decided not to collect membership fees in 2019, because there was no

supervision and mentoring from provincial and national UPBD.

3.2. STAKEHOLDERS’ PERSPECTIVE ON BIDAN DELIMA PROGRAM

3.2.1. MINISTRY OF HEALTH AND NATIONAL LEVEL STAKEHOLDERS’ PERSPECTIVE

The MOH respondents recognize the Bidan Delima program as the mechanism to improve quality of

private midwives by IBI as a professional association. They also recognize that Bidan Delima

standards of service quality are in compliance with the most updated MOH regulation on the

Licensing and Operations of Midwife Practices i.e. PMK no. 28/2017, thus aligned with the other

MNH tools produced and utilized by the MOH including the MCH Handbook20and SiMatneo (i.e.

MOH’s digital application for maternal-neonatal health indicators tracking).

“Bidan Delima is a form of member management and supervision (pembinaan) by IBI to members.

It has helped DHO to extend supervision to private midwives. Items in the facilitative supervision

tools used by DHO have similar items with Bidan Delima’s tools.” - (MOH Family Health

Directorate)

Bidan Delima program’s quality assurance mechanism also gains recognition from international

development agencies. UNFPA, for example, has adopted Bidan Delima’s coaching/mentoring

approach to expand the skills and quality improvement supports to midwives in the public and

private sector, beyond the Bidan Delima members. The UNFPA project that was implemented in

West Java, Bekasi, DKI Jakarta, Lampung, Surabaya, and Makassar, recruited the existing Bidan

Delima facilitators as coaches because they were more ready and familiar with the quality

improvement tool including the MOH’s facilitative supervision tool.

3.2.2. DISTRICT HEALTH OFFICIALS’ PERSPECTIVE

The majority of resource persons from DHO highlighted the strength of Bidan Delima’s concept in

improving quality of care,

“Bidan Delima’s concept is excellent, but it has to be implemented.” - (DHO Sidoarjo)

As a program that focuses on quality improvement of private midwife practices, Bidan Delima is

valuable for the government. Private midwife practices contribute to increasing coverage of antenatal

visits, kunjungan 1-4 (K1-K4) and complement the MNH services of Puskesmas. They often are

located closer to where the pregnant women live, particularly in remote areas like Kotawaringin.

“If private midwife practices are to be accredited, the answer is Bidan Delima.” - (Family Health

section DHO, Pasuruan)

Bidan Delima is under the radar of some policy makers at district level. They have not fully

understood the program, although they know that Bidan Delima is run by IBI. They consider

improving Bidan Delima to be an internal IBI issue.

20 MCH Handbook (Buku KIA) contains health records of pregnant and post-partum women and children 0-5 years old as

well as relevant health care advises. The MOH distributes the book to all pregnant women and mother with children under

5 years old through health facilities, including midwife practices.


“We in the DHO haven’t read the detailed guidelines of Bidan Delima,”, the head of Family Health section

in Kotawaringin Timur stated. She was not able to tell the difference between Bidan Delima and non-

Bidan Delima midwives. The Head of Family Health section of DHO Deli Serdang also seemed to

lack understanding of Bidan Delima. She said, “as I have explained, I don’t know and am not familiar with

Bidan Delima… I only know at first that Bidan Delima encouraged SOP compliance, human resources and

facilities.”

The lack of DHO's understanding of Bidan Delima has caused a lack of support for the program

itself.

“There’s no appreciation and endorsement from other stakeholders, particularly the DHO.” - (UPBD

manager)

3.2.3. CLIENTS’ PERSPECTIVE

During clinical observation, the assessor also conducted interviews with pregnant women in Bidan

Delima and non-Bidan Delima practices. The characteristics of the interviewee can be seen in Table

5. Among the interviewees, some already had experience in receiving assistance for childbirth at the

same practice with the same midwife.

The interviews show that no clients knew about the meaning of Bidan Delima. The preferences of

clients in choosing the midwife practice for ANC are: 1) midwife is well known in community; 2)

friendliness of the midwife; 3) the private midwife practice was nearby her house and low cost.

Generally, information regarding the private midwife practice is received from colleagues, family,

midwives, parents, relatives, Posyandu (health post) and friends. Only a few clients knew about the

practice from an advertisement, social media (Facebook)or BPJS clinic.

Table 5: The Characteristics of Pregnant Women who were Interviewed

Item Bidan Delima Practice (N=9) Non-Bidan Delima Practice (N=9)

Age (range) 22 – 37 years 19 – 32 years

Pregnant

Child number 1 (n=2) Child number 1 (n=4)



Education

Elementary (SD) (n= 2) Elementary (SD) (n= 1)

Senior High School (SMA) (n= 6) Junior High School (SMP) (n= 5)

University (n= 1)

Senior High School (SMA) (n= 1)

University (n= 8)

Number of visits 2 - 10 times 1 - 8 times

All the clients of Bidan Delima practices confirmed that they already received ANC and FP

counseling and five out of nine were educated about initial breastfeeding. Most of the clients in non-

Bidan Delima practices confirmed that they already received ANC services but only two out of nine

were educated about initial breastfeeding and three out nine were educated about FP.

Interviews were also conducted with postpartum mothers with characteristics as shown in Table 6.


Table 6:The Characteristics of Postpartum Mothers who were Interviewed

Item Bidan Delima Practice (N=9) Non-Bidan Delima Practice (N=8)

Age (range) 18-38 22-37

Number of Children




Child number 4 (n=1)



Education

Elementary (SD) n = 2 Elementary (SD) n = 1

Junior High School (SMP) n = 2 Junior High School (SMP) n = 5

Senior High School (SMA)n = 4 Senior High School (SMA) n = 1

University n = 1 University n = 1

The length of stay after delivery 5 – 48 hours 8 – 24 hours

The baby's weight 2.5 – 4 kgs 2.7 – 4.2 kgs

The same answer was given by most of the interviewees regarding the reasons for choosing the

clinic for the delivery process. One client in a Bidan Delima clinic mentioned that she heard about

Bidan Delima from her employer (factory) who suggested the employees should deliver the baby in

the Bidan Delima practice, but she did not know about the clinic.

None of the clients in the private midwife practices mentioned difficulties during pregnancy and

delivery, nor about complications during labor or after wards. But based on one Bidan Delima

midwife’s explanation, there was one mother who experienced obstructed delivery or shoulder

dystocia during the labor process.

Most of the clients in the private midwife practices explained that after delivery, the midwife took

action to check the temperature, check the pad or ask about bleeding. Two out of nine mothers in

Bidan Delima practices and one out of eight mothers in non-Bidan Delima practices mentioned that

the midwife did not encourage them to start early breastfeeding.

All pregnant and postpartum mothers were satisfied with the services and there was no specific

suggestion regarding the quality of services. Only one Bidan Delima client suggested to reduce the

waiting time by adding more midwives and to have ultrasound available and one non-Bidan Delima

client suggested to open the practice earlier in the morning.

On the other hand, many midwives who were key informants in the assessment are convinced that

Bidan Delima has gained popularity in their areas, and even beyond, although increasing patient flow

to at least the pre-BPJS level is one contemporary challenge to resolve.

“Patients are more satisfied with Bidan Delima’s service,” is a common presumption across Bidan Delima

and non-Bidan Delima groups. The non-Bidan Delima group also presumed that people see Bidan

Delima as more experienced, and compliant to standards.

The Bidan Delima groups are presumed to be seen as more innovative and different from the

average midwife. This presumption possibly comes from the variety of services they provide for

pregnant women and their significant other services, such as pregnancy yoga and baby spa.

But some midwives also admitted that people are no longer familiar with Bidan Delima. Patients

often thought Delima is the midwife’s name, so they called the midwife “Ibu Delima”. Sometimes,


after seeing the Bidan Delima signboard, they asked their private midwife what Bidan Delima is, and

the differences between Bidan Delima and other midwives, regardless of whether or not she is a

Bidan Delima midwife.

Lack of promotion was thought to be the reason why not many clients know Bidan Delima. The

majority of Bidan Delima midwives affirmed that signboards are the only means to promote Bidan

Delima nowadays. Previously there used to be TV advertisements, and a series of promotions, such

as karaoke contests at district level.

3.2.4. MIDWIVES’ PERSPECTIVE

Bidan Delima midwives have a positive view of themselves and felt entitled to charge higher service

fees because of their superior service compared to other midwives. Generally, non-Bidan Delima

midwives also recognized the quality level of Bidan Delima’s administration, facilities and equipment.

Table 7 show the list of midwives’ perceptions about Bidan Delima.

Table 7: The Thoughts and Opinions of Private Midwives about Bidan Delima

Positive Challenges

• Highly trustworthy, a good brand of quality

midwife

• Higher self-confidence

• Higher number of patients

• More experienced

• Have support group to discuss experiences and

problems

• Broad and updated knowledge

• Better quality, i.e. facilities, waste management,

complete IEC materials, recording, higher

compliance to standard, administration

• Higher membership fee (annual fee, Bidan

Delima kit package)

• Costly, funds needed for private practice

renovation

• More reporting obligations

• Extra expenditure to become Bidan Delima

3.3. MIDWIVES’ PERCEPTIONS ABOUT JOINING THE BIDAN DELIMA PROGRAM

3.3.1. COMMON MOTIVATIONAL FACTORS FOR BECOMING A BIDAN DELIMA MIDWIFE

• Advancing knowledge through trainings, seminars, groups of learners

• Providing excellent services including prioritizing patients’ satisfaction, meeting the standard

operating procedure (SOP), and being well-known and trusted by patients and the community in

the area

• Increasing income from higher patient flow and confidence to charge higher fees for services

• Surpassing other private midwives, through innovative services, and better networking – this is

actually an indirect benefit from joining Bidan Delima.

• Facilitating the licensing (SIPB) process

“When you need to renew your SIPB, you’ll see that the requirements... you have to have this and

that instruments” “We, the Bidan Delimas, already have complete instruments as required.”- (Bidan

Delima, Pasuruan)

• Expanding their network, thus facilitating the referral process due to acquaintances with

OB/GYN and referral facilities.


But, on other hand, several non-Bidan Delima midwives across groups thought that Bidan Delima is

no longer associated with quality improvement. Even some Bidan Delima acknowledged there are

non-Bidan Delima midwives who have better competencies than the Bidan Delima ones.

“Maybe people want to know what Bidan Delima is, and we say Bidan Delima is quality of service.

But the thing is… there’s no difference between Bidan Delima and other private midwife practices.”

- (Bidan Delima, Asahan)

They particularly mentioned that the private midwife practice’s floor plan met the regulation of

Ministry of Health. However, they were implicitly apprehensive about the amount of money and

effort spent to achieve that quality level, through Bidan Delima.

In Pasuruan, specifically, Bidan Delima seemed to feel more secure facing legal cases or lawsuits if

they had followed the SOPs. Legal cases, such as suspected malpractice, were not mentioned in any

other Bidan Delima groups. When the assessment was underway, there was a recent maternal

mortality case that involved Bidan Delima in Sukabumi. The Bidan Delima group did not mention it,

but the non-Bidan Delima group and other resource persons discussed it. In Sidoarjo, four maternal

mortality cases last year were referred from Bidan Delima.

“Please show us the added value, whatever that is, because until now we haven’t been able to see

the added value of Bidan Delima.” - (Non-Bidan Delima, Sukabumi)

Monitoring and evaluation, according to a Family Health section head in Sidoarjo, is essential to

ensure quality and to see the differences between Bidan Delima and non-Bidan Delima, because,

“… sometimes it’s difficult to tell. Some have been certified as Bidan Delima but still cheat... our

friends in IBI often complained about that.” - (DHO Sidoarjo)

3.3.2. COMMON DEMOTIVATING FACTORS FOR BECOMING A BIDAN DELIMA MIDWIFE

There are some reasons why private midwives may still be hesitant to join Bidan Delima;

• Inability to fulfill the requirements

“From 33 midwives, only one wanted to join Bidan Delima. The rest actually wanted to but thought

that the requirements were too hard to fulfill.” - (Facilitator, Kotawaringin Barat)

• Burden of midwife administration work

Some noted that being a Bidan Delima midwife means having extra administration work to add

to their already heavy workload such as: patient’s registration, cohort, recording and reporting

obligations from the Puskesmas/DHO, to BPJS supporting documents, and so on.

• Higher annual fees

In addition to the Bidan Delima annual fee of 250,000 IDR per year and 600,000 IDR for the

Bidan Delima kit package, they also had to pay an annual fee as an IBI member of 300,000 IDR

per year.

• Negative thoughts about the Bidan Delima program

Non-Bidan Delima midwives were wary that the UPBD or facilitator would scrutinize their

financial reports.


“They scrutinize the financial report... Other midwives will know [our internal issues], it’s like we’re

being watched closely... Why do you do it that way?” - (Non-Bidan Delima)

Lack of complete and clear information is the reason for this situation. One non-Bidan Delima

midwife showed her limited knowledge regarding this program during focus group discussion.

“I don’t know, I’ve never been offered to be Bidan Delima or informed about what Bidan Delima is.

I just saw it on the signboard, but then forgot to ask in the meeting. The Bidan Delimas are all

seniors, they rarely meet us, either.” - (Non-Bidan Delima)

However, the UPBD stated that they still promote Bidan Delima among IBI members to acquire

more Bidan Delima midwives, through IBI sub-district meetings. During the meetings they commonly

discussed issues with mixed participants, including IBI members and Bidan Delima, and expected to

attract non-Bidan Delima IBI members to join Bidan Delima.

“IBI routinely built the competency of private midwives, and then did some interventions and pushed

those who have filled the prequalification form [to become a Bidan Delima].” - (UPBD, Kotawaringin

Timur)

3.4. FINDINGS OF CLINICAL OBSERVATION

In total, 46 private midwives were sampled for the clinical observation, including 23 Bidan Delima

midwives and 23 non-Bidan Delima midwives. The characteristics of the sampled midwives are

summarized in Table 8.

Table 8: Characteristics of Private Midwives Sampled for the Clinical Observation

Characteristic Bidan Delima

(N=23)

Non-Bidan Delima

(N=23)

Age

26 - 37 years 3 12

38 - 49 years 15 7

>50 years 5 4

Have a valid license

Yes 23 21

No 0 0

Number of cases in last 3 month

ANC

0 - 8/month 2 9

9 - 23/month 5 10

>= 24/month 16 4

Family planning

0 - 60/month 8 9

61 - 110/month 7 10

>111/month 8 4

Delivery

0 - 4/month 8 16

5 - 9/month 7 5

> 10/month 8 2


Characteristic Bidan Delima

(N=23)

Non-Bidan Delima

(N=23)

Training activities within the last 3 years

Normal Delivery Care (APN) 1 5

Contraceptive Technology Update (CTU) 8 7

Midwifery Update (MU) 13 14

3.4.1. AGE DISTRIBUTION

As seen in Table 8, Bidan Delima midwives were more likely to be within the age range of 38 – 49

years than those in the non-Bidan Delima group. Most (12 out 23) of the non-Bidan Delima group

were within the age range of 26 – 37 years.

In Depok, Deli Serdang, Kotawaringin Barat and Timur, the majority of Bidan Delima midwives were

senior midwives. The seniors provide examples for the juniors in many aspects. A senior midwife is

expected to join Bidan Delima, to be a role model of a quality midwife for junior midwives,

expanding their network, thus facilitating the referral process due to acquaintances with OB/GYN

specialists and referral facilities.

3.4.2. OWNERSHIP OF VALID LICENSE

The private midwife license, SIPB, provides authorization to carry out midwifery practices based on

the DHO recommendation.

All Bidan Delima midwives had a valid license, whereas two non-Bidan Delima midwives did not have

a license. The first was a newly practicing midwife in Sidoardjo and she had already started providing

ANC and FP services and other general treatment in the last two months. Previously, this midwife

provided services at another Bidan Delima practice. The second midwife, who had no license opened

a private practice in Deli Serdang. However, her license is in the process of renewal, so she has not

provided any services at her practice in the last three months.

In addition to issues regarding the unavailability of valid licenses, other findings relate to the types of

services that midwives are allowed to provide. Based on Law 4, 2019 on midwifery; the tasks of

midwife practice are to provide maternal health services, child health services and women's

reproductive health services and family planning. But in practice, some private midwives still provide

general treatment services.

3.4.3. MIDWIFE COMPETENCY

a. Counseling Skills in Family Planning

FP counseling skills were observed based on direct interaction with clients or simulation activities.

Only two out of 46 observations were direct counseling practice with FP clients, the rest were

based on simulation. Figure 3 shows an overview of the Bidan Delima and non-Bidan Delima

competency in conducting FP counseling.


Figure 3: Competency in Family Planning Counseling

In general, the competency of Bidan Delima midwives in counseling is better than non-Bidan Delima

midwives, as shown by the average score of counseling skills of Bidan Delima midwives of 77

percent, compared to that of non-Bidan Delima midwives of 46 percent. Three Bidan Delima

midwives scored 100 percent on this skill while four Bidan Delima midwives scored under 50

percent.

Figure 4 shows that all private midwives met the criteria of treating the client with respect. This

figure also shows that Bidan Delima midwives are better at some counseling indicators, i.e. ask open

questions, encourage clients to ask questions, use visual aids, use medical records and ensure client's

confidentiality. But non-Bidan Delima midwives are better in other counseling indicators, i.e. treat

client personally, discuss about the next visit and ask about the client’s concerns. There is a notable

gap for five out of 23 Bidan Delima and 10 out of 23 non-Bidan Delima midwives who have no

dedicated counseling room. These midwives provided counseling in an open space or carried out

counseling in the ANC room or in a room with only a fabric divider.

Figure 4: Family Planning Counseling Skills by Indicators

It should also be noted that generally midwives did not explain all FP methods but directly made the

decision to explain one method or continued with the type of contraception desired by the client.

85%

69%78%

67%

82% 78% 82% 78%

100%

40%

69%

52%

37% 37%48%

37%48%

0%

20%

40%

60%

80%

100%

120%

Deli Serdang Asahan Depok Sukabumi Sidoarjo Pasuruan Kotawaringin

BaratKotawaringin

TimurParameter

Bidan Delima Non Bidan Delima

23

2019

1817

16

14 1413

2323

1312

16

19

14

16

7

18

0

5

10

15

20

25

Treat client

with respect

Encourage

client to raise

the question

Ask with open

question

Ensure client

confidentiallity

Discuss about

the next visit

Use medical

record

Ask clien't

concern

Use visual aids Treat client

personally

Parameter

Bidan Delima Non-Bidan Delima

Encourage

client to raise

questions

Ask open

questions Ask about

client’s

concerns


b. Antenatal Care Skill

One strategy for decreasing MMR is high quality ANC. ANC aims to monitor and maintain the

health and safety of the mother and the baby, detect all complications of pregnancy and take the

necessary actions, respond to complaints, prepare for birth and promote a healthy lifestyle. Access

to ANC by pregnant women has increased to 77 percent according to IDHS 2017, with most of it

provided by midwives. The national survey (Riskesdas) results of 2013 to 2018 show that midwives

continue to be the main providers of ANC, although the number decreased from 87.7 percent to

84.8 percent. Key causes of MMR in order of incidence are: 1) postpartum and antepartum

hemorrhage, and 2) eclampsia and preeclampsia.21 The risks for those conditions may be

exacerbated by underlying tuberculosis, heart and liver problems, or diabetes. Potential risk for

eclampsia and preeclampsia can be identified early inpregnancy by 18-20 weeks by ultrasonography

of the uterine artery. In support of the RPJMN’s plan for MMR reduction acceleration, the MOH is

working on defining the standard for ANC as six visits, including a visit to a doctor to screen for

high-risk pregnancy and potential risk for delivery. Pregnant women with normal pregnancy could

continue ANC with a midwife. The high-risk women would be referred to a health facility 22.

The ANC skills were observed by the assessor based on the midwife’s practice with clients or

simulation. Only one out of 46 observations were based on direct practice with a pregnant woman,

the rest on simulation.

Figure 5: Competency in the Antenatal Care

Figure 5 provides an overview of private midwife competency in ANC. Generally, the competency of

Bidan Delima midwives is better than non-Bidan Delima midwives, based on the average score for

Bidan Delima midwives of 72 percent while the average non-Bidan Delima score is 54 percent. Even

21 Yap, Wei A., et al. Revealing the missing link: private sector supply-side readiness for primary maternal health services in

Indonesia - maternal health report (English). Washington, D.C.: World Bank Group, 2017 22 Interview with key informants, MOH and POGI

85%82%

64%

73%

67% 68% 67% 68%

100%

47%

78%

59%

45% 45%

55%

45%

55%

0%

20%

40%

60%

80%

100%

120%


Barat

Kotawaringin

Timur

Parameter



so, the average scores for ANC competencies of Bidan Delima midwives in most districts are less

than 75 percent, except for two districts: Deli Serdang (85 percent) and Asahan (82 percent).

Seven out of 23 Bidan Delima midwives achieved a score under 60 percent, and the score of one

Bidan Delima midwife in Sukabumi was 47 percent. Aspects that showed poor performance include:

hand wash before and after, ask about the baby’s movement, record examination result in medical

record, provide tetanus vaccine, discuss about birth preparation and complication, discuss about FP

contraceptive, and complete the status of pregnant mother.

Figure 6 shows that all private midwives practiced measuring blood pressure during ANC

observation. Bidan Delima midwives also performed other measures, i.e. explaining to the mother

about the result, providing healthy behavior information and checking the fetal heart rate. It is

notable that the gaps in ANC skills for Bidan Delima and non-Bidan Delima midwives were similar

despite scoring differences. The least met indicators were hand washing before and after

examination and discuss with mother about birth preparedness and possibility for complication.

Figure 6: ANC Skill by Indicators23

c. Skill in using Partograph

The private midwives’ competency in using a partograph was observed by asking the midwife to fill

the partograph based on a case study and answer questions related to the case study. This is also

23The indicator of ensuring the baby’s position (more than 36 weeks) was not applied for this case study, since the

mother’s pregnancy was still 27 weeks (see Annex 1, the tools assessment).

8

6

8

7

14

13

13

15

22

20

14

14

20

13

21

23

23

7

8

10

11

11

17

18

18

20

20

21

21

22

23

23

23

0 5 10 15 20 25

Hand wash after examination

Hand wash before examination

Discuss birth preparation

Ask about baby's movement (>= 26 weeks)

Discuss about contraceptive for Family Planning

Provide and explain about mother and child health (KIA) book

Provide tetanus vaccination

Encourage mother to raise questions

Ask about mother's concerns

Explain to mother about the examination

Complete mother's status

Record examination result in medical record and KIA book

Checking fetal heart rate (> 16 weeks' gestation)

Educate mother about healthy behavior

Explain to mother about the result of examination

Measure blood pressure

Parameter



one of the midwife competency areas that needs to be improved. In general, the midwives’

competency in using a partograph was very low as shown in Figure 7.

Figure7: Competency in Using Partograph

Figure 7 shows that overall, there is a difference between Bidan Delima and non-Bidan Delima

midwives’ skills in using a partograph. However, non-Bidan Delima midwives in some districts have

the same average competency as Bidan Delima midwives or even better. The average score of Bidan

Delima competency in using a partograph is 61 percent and 39 percent for non-Bidan Delima

midwives. Altogether 14 out of 23 Bidan Delima midwives and eight out of 23 non-Bidan Delima

midwives filled the partograph and answered the questions correctly or achieved a score of 100

percent.

Many private practice midwives were unable to complete partographs and were unable to provide

precise answers to the questions. The biggest mistakes during observation were: errors in describing

labor contractions, information not provided about amniotic rupture, fluid or food intake and output

were not measured, fetal heart rate was not recorded, blood pressure and pulse filling were

incomplete, and did not fill the signs of head descent.

Beside assessing the competency and knowledge of midwife in filling the partograph, assessors also

reviewed five copies of partographs. These copies were the records of the last five deliveries in

private midwife practices.

Table 9: Results of Partograph Document Review

No Result

Bidan

Delima

(N=23)

Non-Bidan

Delima

(N=23)

1 Partographs were available, all information was filled correctly, used

routinely to monitor the progress of labor

3 0

2 Partographs were available, all information was filled correctly but

not used routinely to monitor the progress of labor or was completed

after delivery

9 7

3 Partographs were available, not all information was filled

correctly, not used routinely to monitor the progress of labor or

completed after delivery

8 8

33% 33% 33%

67% 67% 67% 67% 67%

100%

0%

33%

67%

33%

0%

67%

0%

67%

0%

20%

40%

60%

80%

100%

120%


barat

Kotawaringin

timur

Parameter



No Result

Bidan

Delima

(N=23)

Non-Bidan

Delima

(N=23)

4 There were no copies of the last partographs in private midwife

practice, it was sent to BPJS

3 4

5 There were no delivery services in private midwife practice 0 4

Table 9 shows the result of the partograph document review by the assessors. Only three out of 23

Bidan Delima midwives filled the partograph correctly and used it routinely to monitor the progress

of labor in practice. Nine out of 23 Bidan Delima midwives used the partograph for each delivery

and filled it correctly but it was not used to monitor the progress of labor or was completed after

delivery.

d. Newborn Resuscitation Skills

Newborn resuscitation skills were observed by the assessor based on simulation with a baby doll

and ambu bag. The assessor did not just observe but also asked questions regarding SOPs for

resuscitation skills. The assessment results show that midwives' skills in this aspect need to be

improved as can be seen in Figure 8.

Figure 8 shows the average score of Bidan Delima midwives is 44 percent while that of non-Bidan

Delima midwives is 31 percent. There is not a big difference in the Bidan Delima and non-Bidan

Delima scores, and in some districts, the average score of non-Bidan Delima midwives was higher

than that of Bidan Delima midwives. Only Bidan Delima midwives in Deli Serdang showed a good

performance in this skill. It should also be noted that none of the private midwives in Depok and

non-Bidan Delima midwives in Deli Serdang could demonstrate their competency in this skill.

Figure 8: The Competency in Newborn Resuscitation

The most fulfilled indicator for resuscitation skill area was installing the ambu bag properly (see

Figure 9). Notably, some private midwife practices do not have an ambu bag or lack the proper size

ambu bag.

Based on the observation results of the role play, there were many midwives in Sidoarjo and

Pasuruan who did not take the correct steps in handling asphyxia in newborns including: in assessing

when the baby should be resuscitated and when newborn care can be given and when the baby

should be referred to the hospital, and if the baby must be referred, the midwife also did not

97%

60%

0%

33%23%

40%

23%

40%

75%

0%

67%

0%

40%30% 30% 30% 30%

0%

20%

40%

60%

80%

100%

120%


Barat

Kotawaringin

Timur

Cut of point



remember what needs to be prepared and what should be monitored during the referral process

until the baby arrives at the referral hospital.

Figure 9: Resuscitation Skills per Indicator

During the assessment, private midwives provided reasons for the lack of competency in

resuscitation skills. They noted that there were no cases so far or they were very rare and some had

never undertaken resuscitation so they did not feel confident to carry out the newborn resuscitation

practice. Some private midwives also mentioned that they just referred the patient to the primary

health facility.

3.5. DOCUMENT AND RECORD REVIEW

3.5.1. THE SERVICE LOAD OF PRIVATE MIDWIVES

Based on Table 8, it was shown that, in the last three months, Bidan Delima midwives provided a

higher number of services compared with non-Bidan Delima midwives. In the sampled group, 11 out

of 46 are single practitioners and the remaining work with more than one midwife or occasionally

there may be a “midwife assistant”. The number of midwives who work in one Bidan Delima

practice is generally more than two midwives, but there are even private practices with nine

midwives.

Bidan Delima clinics were more likely to have five or more deliveries per month compared to non-

Bidan Delima where 16 of 23 practices had four or less deliveries per month. There are several

private midwife practices with a high number of normal deliveries per month. A Bidan Delima

practice in Sukabumi district had the highest number of deliveries per month (40) and a non-Bidan

Delima practice in Depok had 14 normal deliveries per month.

On the other hand, there was a practice with no normal deliveries in the last three months, but the

midwife still provided ANC services (65 per month). This private practice just referred the client to

2

2

9

9

8

3

12

6

15

23

5

5

7

8

8

8

10

12

14

0 5 10 15 20 25

assess the newborn baby and stop ventilation

assess and then refer the baby

Assess the baby

Cut the umbilical cord quickly

Counseling to refer baby with mother and family

Continue resuscitation, monitor danger signs, monitor

umbilical cord

Prepare a referral letter.

Ventilate Positive Pressure 20x in 30 seconds (pressure

20cm water). Value every 30 seconds.

Install the ambu bag

Parameter


Prepare a referral letter

Assess and then refer the baby

Assess the newborn baby and stop ventilation


the health facility for childbirth. Single practitioner private midwives conducted on average one or

two deliveries in the last three months and a maximum of four deliveries.

3.5.2. TRAINING ACTIVITIES

Information about the training activities of private midwives was collected during the assessment.

The assessors asked about the type of the training that was followed by the midwife within the last

three years. There is no regulation regarding the type of training that must be attended by Bidan

Delima midwives. IBI just encourages all midwives to be trained for improving their knowledge and

skills as Bidan Delima, and midwives must be trained in Asuhan Persalinan Normal (Normal Delivery

Care – APN) and Contraceptive Technology Update (CTU). The participation in clinical training is

one of the factors to consider in the pre-qualification process for joining Bidan Delima.24

Table 8 shows that there was no difference in the level of participation of Bidan Delima and non-

Bidan Delima midwives in training activities. All Bidan Delima midwives in the six districts in three

provinces (West Java, East Java and North Sumatra) had already been trained in APN and CTU, but

most of them were trained before 2015 and have had no refresher training after that. In Central

Kalimantan, none of the Bidan Delima midwives were trained in APN. However, most of them were

already trained in Midwifery Update (MU). This was also the case for non-Bidan Delima midwives.

APN is a competency-based training, the trainee must be competent in the model and dealing with

clients. MU is not a competency-based training, the trainee is updated on all knowledge related to

maternal, neonatal and family planning. The trainee just needs to be familiar with the model. IBI has

conducted MU training since 2017.

3.6. THE READINESS OF PRIVATE MIDWIVES TO PROVIDE SERVICES

The assessors evaluated the readiness of private midwife practices for providing services by

observing the management and the availability, completeness and condition of facilities and supplies.

During the assessment, the assessor did not just observe but also reviewed documents and asked

some questions of the private midwife to complete the observation tools.

Figure 10: Results of Observation on the Management of Private Midwife Practice25

24 Panduan Pra Kualifikasi Bidan Delima 25 The percentage 0% implies that all management or facilities or supplies had none of the service readiness indicators

(unweighted) met; while the score of 100 % implies that all facilities met all the service readiness.

73%80% 77%

63% 63% 67%

80%

67%

100%

13% 10%

23% 23%

37% 37%

60%

43%

0%

20%

40%

60%

80%

100%

120%


Barat

Kotawaringin

Timur

Parameter



The standard quality benchmark is 100 percent as for the Bidan Delima program. The result of the

observations is shown in Figure 10. The management indicators measure the readiness of practices

in providing quality services and cover: cleanliness, client registration, written procedures and

guidelines including emergency preparedness, regular recording and reporting including financial

aspects.

Overall, Bidan Delima practices show better management compared with non-Bidan Delima

practices. The average score of fulfilled criteria indicators in management of Bidan Delima practices

is 77 percent while for non-Bidan Delima practices it is 45 percent. Nevertheless, four out of 23

Bidan Delima practices have an average score for management of under 50 percent.

Seven out of 23 non-Bidan Delima practices have a management score less than 30 percent and

three out of those seven practices did not meet any management indicators (0 percent). However, it

is notable that the non-Bidan Delima practice in Sidoarjo demonstrated good management. The

private midwife just opened her practice in the last two months but has already achieved 80 percent

of the management indicators. This midwife is undertaking the process to become a Bidan Delima

midwife.

The least met criteria for management indicators in Bidan Delima practices are: the availability of a

regular cleanliness schedule, financial balance book, documentation or filling complete forms.

Figure 11: The Result of Observation on Facilities and Supplies of Private Midwife Practice26

Figure 11 shows the availability of facilities and supplies in private midwife practices. This observation

covered: physical facilities, i.e. counseling room, basic amenities, pelvic inspection equipment,

delivery set, newborn care including resuscitation equipment, infection prevention and supplies

including medicines for emergency preparedness.

Overall, the scores of all private midwife practices regarding availability of facilities and supplies are

good. The average facility and supplies score of Bidan Delima practices is 93 percent, while that of

non-Bidan Delima practices is 84 percent.

26 The percentage 0% implies that all management or facilities or supplies had none of the service readiness indicators

(unweighted) met; while the score of 100% implies that all facilities met all the service readiness.

99% 99% 99% 99% 96%91% 89% 85%

100%

86% 87% 88% 92% 88%84% 82%

78%

0%

20%

40%

60%

80%

100%

120%


Barat

Kotawaringin

Timur

Parameter



Table 10: Availability of Equipment and Supplies in Private Midwife Practices

No Item Bidan Delima (N=23) Non-Bidan Delima (N=23)

1 Basic amenities 95% 88%

2 Delivery set 96% 92%

3 Suturing set 96% 89%

4 Newborn care equipment 95% 85%

5 Supplies 95% 93%

6 Infection prevention 89% 70%

Table 10 shows the readiness of facilities and availability of supplies in private midwife practices. It

shows that Bidan Delima midwives maintain supplies and equipment for infection prevention at

higher levels than non-Bidan Delima practices which need to improve their readiness especially in

this sub-category

Emergency preparedness

Availability of oxytocin. Oxytocin or Syntocinon is provided in the practices to address

postpartum hemorrhage, the most common cause of maternal mortality. All private midwifepractices

provided it except two out of 23 non-Bidan Delima practices.

Availability of emergency medicine–Magnesium sulphate (MgSO4). Based on the assessment, all

private midwife practices provided MgSO4, except two out of 23 non-Bidan Delima practices.

However, the MgSO4 at one Bidan Delima practice and one non-Bidan practice had expired.

Most of the private midwife practices stored oxytocin and MgSO4 in the refrigerator, but some are

stored with food or skincare. During the assessment, there was also a practice that stored drugs in

an emergency bag which was hung on the wall of the labor room.

Although it is not an assessment indicator, it should be noted that there were two Bidan Delima

practices and four non-Bidan Delima practices that provided formula milk for 0 – 6 months old

babies.

3.7. HEALTH INSURANCE REIMBURSEMENTS FOR BIDAN DELIMA SERVICES

3.7.1. BIDAN DELIMA MIDWIVES AND JKN EMPANELMENT

The implementation of JKN/BPJS requires private midwives to adjust and inevitably brings

controversies. To some extent midwives see JKN/BPJS as indispensable and helpful, but on the other

hand, they experience a variety of adverse effects on their practices, both private and public.

Private midwives’ decisions regarding JKN empanelment fall into five categories:

1. Interested to join or continue with JKN

2. Unhappy but still persist as an empaneled provider of JKN

3. Undecided or hesitate to join JKN

4. Refuse to join JKN

5. Withdrew from JKN network


The involvement of private sector providers is encouraged to broaden care availability under JKN

but private midwives are required to collaborate in a network with Puskesmas, private clinics,

independent and individual GPs and private clinics with two or more GPs in group practice27, thus

become empaneled private Maternal Health (MH) providers. Their connection to BPJS is mediated

by the primary health care providers’ network. The private midwife is allowed to empanel with

maximum two primary health care providers.

“They [JKN] want us to provide excellent service but they are careless about the money needed to

improve the quality. It’s more about money.”- (Non-Bidan Delima)

Being empaneled MH providers with an indirect connection to JKN brings various problems to

private midwife practices. Discussing further about how JKN affects their clinics day-to-day

operation, midwives across areas and groups said their experiences led them to perceive that lack of

information, which actually stemmed from their position as a partner or “mitra” of the primary

healthcare provider network of JKN, is considered as a big barrier for them to operate under JKN.

MOH - Health Services has provided a strong statement about the meaning of working in a Jejaring

or network in Fasilitas Kesehatan Tingkat Pertama (Primary Health Care Facility – FKTP) and the need

for this to be strengthened. It should not be for administrative purposes only, but also technical. It

should be clear where the responsibility lies. Patients’ safety while being treated in FKTP or its

network of services should be under the responsibility of the doctor/GP of the FKTP. The

performance monitoring of an active FKTP is the cumulative measure of performances by the FKTP

and sub-clinic(s) in its network.

Reasons for Not Engaging with JKN

The situation regarding private midwives and JKN was also raised during the clinical observation.

The assessor interviewed private midwives about this when asking about the referral mechanism.

Ten out of 23 Bidan Delima and 13 out of 23 non-Bidan Delima clinics were not empaneled as MH

providers for JKN. Six out of all assessed private midwives had experience with JKN but had already

withdrawn from the primary health care network for empaneling with JKN. The reasons these

private midwives were not engaged with JKN are shown in Table 11.

Table 11: Reasons for not Empaneling as MNH Provider for JKN28

Reasons Given for Not Empaneling with JKN Number of Private Midwife Practices

JKN requirements not met 7

Experience with delayed claim disbursement 6

Puskesmas quota for JKN network was exceeded 1

Payment too low 2

Not interested 3

Did not receive claim reimbursement 3

Patient numbers too low 2

Complicated process for claim 1

Have no license 1

27 MOH Degree 71/2013 28 One clinic could have more than one reason for not empaneling with JKN


JKN Requirements for Service Providers

Midwives are recognized by MOH PPJK as health providers for delivery assistance, for which JKN

provides support for midwifery services within the context of the FKTP. As they could not have a

direct contract with BPJS, they could register through the FKTP. Another option would be through

Jampersal, which is available for mothers who are not covered under BPJS but would like Jampersal

instead (refer to later subsection on Jampersal).

The difficulty to fulfill the JKN requirement was one of the main reasons for not engaging in JKN. But

it is also notable that six out of seven private midwives who gave this reason also showed the lowest

scores or less than 10 percent in management, facility and supplies indicators during the clinical

observation.

The primary health care provider needs to collect copies of ID card, family card, tax file number,

bank account, and most importantly private midwife practicing license/ permit and registration

certificate and carry out verification before preparing a Memorandum of Understanding (MoU) and

the private midwife only needs to sign it as a proof of agreement.

According to the midwives, there are no JKN regulations and how-to manual on hand that they can

refer to, as guidance in service provision for JKN holders. Besides, private practices or Puskesmas, as

their JKN parent network, do not effectively act as a mediator between the private midwives and

JKN. The important information is either not written in the MoU, or a number of midwives admitted

they had not scrutinized the MoU in order to sign it. Thus, the willingness and ability of clinics to

communicate with the private midwives, as well as to mediate communication between the midwives

and BPJS determine the smoothness of BPJS procedure implementation.

Limited JKN socialization to public audiences regarding its terms and conditions makes it challenging

for private midwives to provide maternity services under BPJS, particularly in areas where most

patients come from lower socio-economic classes.

Patients may be manipulative to ensure BPJS covers services received from health providers, both

public and private. “We wrote the diagnosis based on the conditions of our patient, ma’am. Sometimes they

dramatized it, like rolling over [acting like they’re in pain],”one midwife said. In other cases, a pregnant

woman would wait until they reach 8-9 cm dilation before going to a midwife for delivery because

BPJS is not applicable if the dilation has not reached 5 cm This was seen as a way to get BPJS

coverage, and raised concerns among midwives about dealing with potential problems during

delivery, like hypertensive disorders, when the patient comes late.

3.7.2. BARRIER FOR JKN EMPANELMENT: FEE FOR SERVICE

As can be seen in Table 11, “payment too low” is also one of the reasons given by midwives for not

engaging with JKN. This issue was also raised by midwives in the assessment. The JKN fee-for-

service is considered inappropriate or unsuitable for the level of effort, in addition to equipment and

medical supplies that need to be provided by midwives. The amount of the service fee was reported

to be similar across areas, 700,000 IDR for assisting childbirth, and 50,000 IDR for each of the four

ANC visits and four postnatal care (PNC) visits. Pregnant women are recommended to get services

from one MH provider to assure the providers’ familiarity with the patient’s pregnancy condition and

readiness to assist the delivery. However, the fee-for-service applied by JKN is very small or almost

one third of the normal fee for vaginal delivery at private midwife practices in many areas, which is

approximately 1,500,000 - 2,000,000 IDR.


Currently, some Puskesmas are already authorized to receive income directly or are included in

BPJS capitation and also manage the process directly without going through local government,

namely Badan Layanan Umum Daerah (Regional Public Service Agency – BLUD). Midwives assumed

that the BLUD Puskesmas needed to gain more money since the district government does not

provide financial assistance anymore. Hence, midwives reported that the fee for service received

from BLUD Puskesmas was approximately 187,000 IDR (60 percent fee-for-service, 40 percent is for

administration work, etc.).

Non-BLUD Puskesmas usually transfer 700,000 IDR fee-for-service to the empaneled private

midwives (fee-for-service is 60 percent of the claim). However, in private practices, midwives feel

obligated to give back some funds to the Puskesmas from the service claims; depending on the

agreement with midwives in the Puskesmas, this is approximately 100,000 IDR per delivery.

For most dual-practice midwives, even if they are allowed to assist deliveries in their private

practice, they choose not to. Whether the delivery is conducted at the Puskesmas or private

practice, they receive the same amount of fee-for-service because that is the only portion of JKN

fee-for-service for which they are eligible. When they assist deliveries in their private practice,

expenditure on supplies is not covered by JKN.

“I used to have 20 deliveries (in private practice) in a month, but now, after the Puskesmas nearby

opens 24 hours, I only help maximum five deliveries a month....” – (Bidan Delima)

Regarding ANC and PNC fees, JKN provides a higher amount than the actual expenditure for ANC,

although the number of ANC visits is limited to four. Midwives need to inform patients and obtain

their agreement to pay personally if they come for ANC more than four times.

“50,000 from BPJS is enough to give them Gentiamin, Folic acid and other vitamins for pregnant

women. We usually charged them 35 or 40 thousand rupiah. However, because they only cover

four ANC visits and forbid us from charging higher fees, we have to talk with the patient that after

four visits, they have to pay by themselves and not to complain about it.” - (Non-Bidan Delima FGD,

Kotawaringin Barat)

Some midwives in other areas disagreed with this statement. They said they never claimed any

ANC/PNC services performed because the fee-for-service is too low. Just like the delivery service,

they thought that the fee for ANC/PNC was unsuitable given the cost midwives paid.

3.7.3. JKN REIMBURSEMENT MECHANISM BY BPJS-K

Reimbursement or claim processing was one issue that midwives across areas, groups and BPJS-K

empaneled status complained about. BPJS-K uses a fee-for-service, a retrospective or reimbursement

method, in which payment is made by BPJS-K after the health service is provided. The empaneled

midwives submit a fee-for-service claim with all documents required and wait until the decision

about the payment is made and the money is transferred. Some private midwives had negative

experiences regarding the reimbursement mechanism:

1. Delayed reimbursement

The waiting time can be very long, from two months up to two years, according to midwives.


2. Rejected claims

Claims can be rejected for different reasons, predominantly lack of documentation, and ineligible

services. Since it is a retrospective claim, and the midwife was sure that the claim met the

requirement of BPJS coverage, the patient would have already been discharged from the clinic

without paying. In that situation, midwives sadly said they could not, “chase the patient to pay

the claim rejected by BPJS”. Hence, it is a financial loss for them.

Another issue is related to patients’ BPJS membership. Many patients became aware of BPJS and

the benefits it provides just before their delivery date, so they registered with BPJS directly.

Midwives could not claim fees because the service was provided prior to the patient’s

membership approval.

On the other hand, some patients who were already aware of the benefits, registered, received

the service (usually delivery) and immediately stopped paying the compulsory monthly payment

after they were released from the private midwife practice. In this case, the midwife’s claim

would also be rejected because the claim was received after the membership cancelation,

although the service was performed when the patient still paid the monthly fee.

3. Unclear methods for submitting claims

Midwives also reported two methods to submit claims to BPJS: digital (for secondary and

tertiary health service providers, or hospitals) and manual. In Asahan, midwives were

disappointed because of the ever-changing methods BPJS use to submit claims and required

documents. In Kotawaringin Barat, midwives who worked in the hospital were not informed that

they had to submit claims through both methods, digital and hard copy, so the claims that were

submitted through the online system expired because the hard copy document had not been

received by BPJS.

Although these incidents happened in the hospital, not in the midwife’s private practice, the

negative experiences affected their inclination toward BPJS as a midwife who also runs a private

midwife practice.

3.7.4. JKN AND THE REFERRAL MECHANISM

Midwives felt strongly that JKN facilitates referral cases. With JKN coverage, the patient’s family

does not have to worry about the cost for emergency service. What they need to do is to ensure

that the midwife sends the patient to a secondary or tertiary health care provider in the JKN

network.

However, some also thought that in non-emergency cases BPJS seems to put the burden on the

midwives’ shoulders to send patients to other primary health care providers before sending the

patient to the hospital. This obligation is considered time-consuming and unnecessary.

A different situation occurs in private midwife practices which are empaneled with MH providers for

JKN. These private midwives have no clear referral mechanism. The midwife will refer the client to

the primary health care facility or to the hospital after going through several stages:

1. Discuss with patients regarding the selection of referral facilities.

BPJS patients will be referred to health facilities that receive JKN and non-JKN patients, and will

be referred to the client’s preferred clinic;


2. The midwife will directly contact the selected health facility by phone, and then the client will be

referred if confirmation is received;

3. Four Bidan Delima and non-Bidan Delima midwives in Depok and Sukabumi explained that they

contacted the SijariEMAS Call Center before making a referral but two other midwives stated

that the mechanism through SijariEMAS was too long, so they immediately coordinated with the

Sistem Penanggulangan Garurat Darurat Terpadu(Integrated Emergency Management System –

SPGDT) through a WhatsApp group which also involved the referral hospital.

3.7.5. COPING WITH CURRENT CIRCUMSTANCES

In general, private midwives stated that income from their private practices was sufficient to cover

the operation of the practice with some profit to cover their necessities, although as noted, the flow

of patients has been decreasing due to BPJS and other regulations that restricted them from assisting

deliveries.

The day-to-day operation expenses are usually paid monthly, and comprise logistics and medicine,

utilities, waste management fee, and assistant’s salary if applicable. Without an assistant, to comply

with the four-hand or six-hand delivery, midwives need to collaborate with one or two other

midwives to help with the delivery. This means they have to include the collaborator’s fee in their

expenditure, usually by sharing the delivery fee, as explained in the BPJS fee-for-service section. The

same mechanism applies to the normal delivery fee (non-JKN) as well.

Although the fee for delivery was found to be similar in some areas (between 1,500,000-2,000,000

IDR per delivery), midwives stated there was variation in fees across areas, even in the same district.

Non-JKN service fees were determined based on: 1) agreement with midwives in the area (sub-

district). In Beji and Cimanggis, Depok, midwives agreed on the lowest fee below which they were

not allowed to charge patients, 2) other midwives’ fees for comparison. Midwives said that they had

calculated the expenditures carefully although in determining the amount they followed the norms

among midwives. Some explained that they could adjust the fee based on the patients’ profile,

particularly when the patient seemed to come from a lower socio-economic class.

Midwives believed that excellent service enabled them to charge higher fees, so that many of them

provided extra services, “For example, [the patient is charged] 2 million IDR for delivery, but that includes

baby massage when the baby is one month old. So that’s the innovation”. Nevertheless, they were also

aware that choices patients made are mainly based on the fees.

“Sometimes, although we give them good service, they’re still shocked knowing the fee they have to

pay. We have patient with hemorrhage who needs intravenous fluid…when we charge 2 million,

they are like… blank… why is it that expensive?”- (Bidan Delima)

Many midwives, Bidan Delima and non-Bidan Delima, planned to open a side business to cope with

the circumstances they faced. In Kotawaringin Timur and Barat, Asahan, and Depok, they aspired to

conduct trainings for pregnant women and their partners on massage, hypnobirthing, and classes for

prenatal yoga and pregnancy exercise. Some other midwives thought about opening a baby shop or

even a non-maternity related shop, such as an ice cream shop. In Depok, a formula producer offered

a business partnership to midwives. To open a prenatal yoga class, the yoga institute would provide

the equipment and trainer, but the midwife was required to gather at least 20 class members. Water

birth, the novel maternity business, has caused controversies, particularly in Depok. IBI has issued a


letter to restrict water birth practice, as it was not included in the SOP. Yet, some midwives in

Depok were identified as water birth endorsers and practitioners.

Expanding business by opening a private midwife clinic is challenging in Sukabumi because midwives

are only allowed to commit to two practices in one district. A midwife who tried to open a branch

in a nearby district failed because of that restriction.

3.7.6. JAMPERSAL

The other health financing scheme covering MNH services is the Jaminan Persalinan (Childbirth

Assurance – Jampersal) program. Jampersal provided a comprehensive MNH services package

before JKN, regardless of socio-economic status. This program was discontinued after the

implementation of JKN in 2014, but then re-introduced in 2016 with modification to the benefit and

coverage. Jampersal II only covers services for uninsured-poor women29.

“There is still some delivery financed through Jampersal. For mothers who are not member of JKN

and would like to be covered by Jampersal...”- (MOH)

Midwives in Central Kalimantan (Kotawaringin Timur and Kotawaringin Barat) explained about the

use of Jampersal instead of JKN. Jampersal covers delivery services for people who have a certificate

indicating poverty, although they do not havea local ID card. Some midwives mentioned that a

certificate of domicile and a referral form are required to access Jampersal assistance. The DHO of

Kotawaringin Barat permitted primary healthcare providers to shift fee-for-service claims that were

overdue in BPJS to Jampersal.

The idea is considered controversial because Jampersal is actually meant to cover people who

cannot afford JKN. In Central Kalimantan, blue-collar workers of companies (usually mining and

logging) that neither can afford nor access JKN are the targets of Jampersal. Unfortunately, as

described by midwives, to be eligible for Jampersal, the workers still need to bribe officials to get the

domicile certificate as a substitute for the ID card, with help from the midwife who empathizes with

their situation.

Midwives liked Jampersal more than JKN because the claims were always paid within three months

without hassle, the process is clearer and the fee-for-service is on a par with JKN.

3.7.7. STRATEGIC HEALTH PURCHASING

Strategic purchasing means active, evidence-based engagement in defining the service mix and

volume, and selecting the provider mix in order to maximize societal objectives. Improving the

strategic purchasing of health services is central to improving health system performance and making

progress towards universal health coverage.

A strategic purchasing program approach is being develop by a multi-stakeholder TWG that involves

MOH (PPJK, Family Health Directorate, Planning Bureau etc.), BPJS, development partners, and

other stakeholders: IBI, POGI, Ministry of Home Affairs, Ministry of Finance.

“This is quality purchasing service. The service will be paid if it is a quality service....” -(MOH)

29 Yap, Wei A., et al. Revealing the missing link : private sector supply-side readiness for primary maternal health services in

Indonesia - maternal health report (English). Washington, D.C.: World Bank Group, 2017


Led by PPJK-MOH, this TWG is working on approaches on how to have an effective purchasing

system. According to a national key informant, private midwives would need to be in a network with

the Puskesmas. The purpose of strategic health purchasing is to ensure a good payment mechanism

and contract system. The TWG is also working on how to integrate resources from other program

sources. There will be a need for strong accountability in order to bundle services into an integrated

system. A policy brief has been produced after about one year of mapping and discussing the

problems, with recommendations on suggested changes to be made. The recommended changes will

be piloted first.

IBI sees strategic purchasing as a way to guarantee the quality of service. The requirement that

private midwives must be in a network creates many challenges; if the reimbursement rate cannot

meet the operational needs of midwives, then the midwife’s motivation decreases. The networking

of private midwives with primary clinics is currently more on the administrative side. To include

technical aspects in the networking with FKTP, IBI wants to have an in-depth discussion first. This

idea is still under development and being discussed in the TWG. In the end, strategic purchasing

might still require the private midwife to be in a network, but without the problems experienced

currently.


4. CONCLUSIONS

The rapid assessment of the Bidan Delima program is summarized based on the three key objectives

of the assessment:

4.1. THE EFFECTIVENESS OF THE BIDAN DELIMA PROGRAM IN ASSURING QUALITY

The analysis of effectiveness of the program focuses on the facility readiness and midwife

competency in a small sample of facilities in selected districts. The findings are not intended to be

conclusive, but rather to flag some critical issues about the Bidan Delima program. The facility

readiness was measured in terms of management (infrastructure, recording and reporting system,

written procedures and guidelines) and availability and condition of facilities and supplies. The

competency of midwives was measured in terms of skills in FP counseling, ANC, resuscitation of a

newborn baby and using partographs.

Based on the results of the assessment, it can be concluded that the Bidan Delima program has

contributed to enabling private midwives to provide quality maternal and neonatal services in many

areas. Overall, Bidan Delima practices had higher scores in terms of facility readiness and midwife

competency compared to non-Bidan Delima practices. The characteristics and quality care of Bidan

Delima midwives are summarized in Table 12.

Table 12: The Characteristics and Quality of Care of Sample Midwives


Characteristics

• All assessed Bidan Delima midwives have a valid

license

• A high number of cases in the last 3 months.

There are 8 midwives with more than 10

deliveries per months

• No difference in the training activities of Bidan

Delima and non-Bidan Delima midwives

• Two non-Bidan Delima were found to have no

license

• A small number of cases in the last 3 months. There

are 16 midwives with less than 4 deliveries per

months.

Facility readiness

• The average score of Bidan Delima practices in

management is 77%

• Three out of 23 Bidan Delima fulfilled 100% of

management indicators but 4 out of 23 had an

average score less than 50%

• The average score of Bidan Delima practices in

facility and supplies availability is 93%

• One Bidan Delima practice had expired MGSO4

• The average score of non-Bidan Delima practices is

45%

• Eleven out of 23 non-Bidan Delima practices scored

less than 50%

• The average score of non-Bidan Delima practices in

facility and supplies availability is 84%

• Two out of 23 non-Bidan Delima lacked availability

of oxytocin

• One non-Bidan Delima practice had expired MgSO4

Midwife competency

• The average score of Bidan Delima midwives for

FP counseling is 77%

• The average score of Bidan Delima midwives in

ANC skills is 72%


resuscitation skills is 44%


• The average score of non-Bidan Delima midwives

for FP counseling is 46%

• The average score of non-Bidan Delima midwives in

ANC skills is 54%


resuscitation skills is 31%




using partograph is 61% using partograph is 39%

Quality gap

• Overall, the quality of care provided by Bidan Delima midwives is better than that of non-Bidan Delima

midwives, even though some still need to improve their competency, especially regarding resuscitation of

newborn babies and skills in using partographs

• There is a lack of facilitators to undertake validation of Bidan Delima candidates and monitoring of the

existing Bidan Delima midwives

• Regular monitoring and supervision are currently insufficient to attain and maintain the quality of services. A

feedback mechanism of post-supervision and monitoring activities would be helpful to show the midwife the

specific quality gaps that need to be improved.

4.2. PROGRAM RELEVANCE AND VALUE

Midwives cover a great proportion of essential MNH services (e.g. ANC, safe delivery services, etc.)

that can support reduction of MMR and NMR and are often the first point of contact for pregnant

women.

The Bidan Delima program is still relevant as a program which focuses on promoting quality private

midwifery practice. The relevance of this program was concluded based on the current status of

Bidan Delima, the added value of the program and the positive impression of stakeholders regarding

the program.

4.2.1. PROGRESS OF BIDAN DELIMA PROGRAM

About 50 percent of private midwives run dual-practices as providers in Puskesmas, hospitals or

other clinics while also running private practices. The number of certified Bidan Delima midwives

was increasing until 2011, especially in the three provinces (West Java, East Java, North Sumatra)

which had received donor support until then. The progress was steady and increased again after the

program was revitalized in 2014. This progress was shown in several districts such as; Sukabumi,

Depok, Sidoarjo and Pasuruan. However, the certification mechanism has not been improved. There

is no "stick and carrot" for Bidan Delima midwives who are no longer active. Based on analysis of

routine data, there is a notable reduction in the number of active midwives or the certification is out

of date. Some midwives reported that they had withdrawn from Bidan Delima because of three

reasons: the midwives decided to retire because of old age or sickness, the decreasing number of

patients due to BPJS/JKN, or other obligations that obliged the midwives to move out of the district.

4.2.2. THE ADDED VALUE OF BIDAN DELIMA

Some added value of Bidan Delima includes; highly trustworthy with a good brand of quality

midwifery services in terms of the facility readiness and high competency of the midwife, high level of

self-confidence, high number of patients, more experience, access to a support group to discuss

experiences and problems, broad and updated knowledge and the validation process can be used to

facilitate the license or SIPB process. These advantages motivate private midwives to join Bidan

Delima.

Nonetheless, there are factors that discourage some private midwives from joining Bidan Delima

such as: lack of confidence to fulfill the standard requirements, burden of administration work,

higher annual fee and “negative thoughts” related to data confidentiality. These were, to some

extent, caused by unclear and incomplete information about the program.


4.2.3. THE PERSPECTIVE OF STAKEHOLDERS REGARDING BIDAN DELIMA PROGRAM

The Bidan Delima program as a quality midwifery program was recognized by the district, especially

the DHO. But, lack of information, including information about the challenges faced by the program,

resulted in a lack of support from the DHO to strengthen the program. Despite the identification of

areas for improvement, stakeholders appreciated that the Bidan Delima program is closely aligned

with DHO quality improvement efforts in that it uses the same tools, complies to the same

standards and supports licensing efforts. UNFPA appreciated that Bidan Delima facilitators had

developed competencies to provide supervision and use quality improvement tools.

4.2.4. THE CLIENTS’ PERSPECTIVE ON BIDAN DELIMA SERVICES

None of the clients interviewed recognized Bidan Delima as a sign of a quality midwife. All clients

were satisfied with Bidan Delima and non-Bidan Delima services. Lack of knowledge of clients

regarding the standard of services results in low demand from clients for quality services. The main

preferences of clients in choosing the health facility are: the midwife is well known among the

community, friendliness of the midwife, and access to the facility. Increasing the awareness of the

clients about quality services will encourage the health facility to provide quality services.

4.3. BIDAN DELIMA AS A STRATEGIC DIRECTION FOR A BUSINESS MODEL IN THE

FUTURE

The document review revealed the need to revisit the Bidan Delima program outputs defined in the

initial design and assess whether the intended outputs reflect the social and business impacts

envisioned by the certification process, which can be considered as a Social Franchise model. The

program performance indicators appear to aim solely towards compliance with the standards of care

and not necessarily increasing caseloads. A Social Franchise model in health programs is adopted

mainly to improve access to quality health services for the public (as the provision of quality health

services is argued to be the right for everyone). The adoption of Social Franchise models, such as

with the Bidan Delima model, has business implications since the Bidan Delima midwives have the

potential to increase their income by increasing their caseloads after being certified as Bidan Delima

midwives.30

The Bidan Delima assessment found that the program succeeded in encouraging private practice

midwives to achieve quality midwifery standards, improving the readiness of facility and midwife

competency, and it built their self-confidence to provide better services. This assessment also found

that there is a difference between Bidan Delima and non-Bidan Delima caseloads for FP, ANC and

delivery services in the previous three months. But there is no evidence to show an increase in

caseloads after joining Bidan Delima. It is notable that there is a general perception that Bidan

Delima practices have higher caseloads compared to non-Bidan Delima practices.

The assessment found that the caseload in private midwives’ practices is strongly influenced by the

JKN system. To some extent private midwives see JKN as indispensable and helpful, but on the

other hand, they experience a variety of adverse effects on their practices. Half of all assessed

private midwives are either not empaneled or have withdrawn empanelment with MH providers for

many reasons, e.g. difficulties to fulfill the requirements, experienced delayed claim reimbursement,

payments too low, complicated claim process. Other private midwives are also not happy with JKN

30 Maharani, et al. 2014. Bidan Delima Accreditation: The Implementation of a Franchise Model in Regulating Performance

of Private Midwives in Indonesia – A case study.


but still empaneled with MH providers. Some dual-practice midwives assisted deliveries at the

Puskesmas because the costs for supplies were not covered by BPJS resulting in a decreasing number

of deliveries by private midwives.

The current business model which relies on volunteer facilitators is challenging to sustain and has

not produced adequate supervision or support for Bidan Delima midwives or enabled verification of

compliance once the clinic is certified.

Overall, many gaps were found during the assessment but there were also many opportunities and

strengths that could be developed from the Bidan Delima midwifery program. There is a high level of

interest among private midwives to join Bidan Delima, although there are also private midwives that

are still not interested in joining. This all supports IBI’s ongoing commitment to keep promoting

quality MNH services through the Bidan Delima program.


5. RECOMMENDATIONS

5.1. STRENGTHEN THE QUALITY ASSURANCE MECHANISM OF THE BIDAN DELIMA

PROGRAM

The quality assurance mechanism in the Bidan Delima program needs to be improved in terms of the

certification processes and maintaining the quality of certified Bidan Delima midwives. Specific action

points for consideration include:

• IBI should review the Bidan Delima instruments and guidelines (management and technical) and

revise the tools and validation process so that they are more appropriate for Bidan Delima

candidates.

• IBI should explore ways, in collaboration with other partners, such as MOH, UNFPA, USAID

Jalin, and professional associations, to specifically address gaps in midwifery competencies that

affect the quality of care, including newborn resuscitation, management of obstructed labor and

other complications.

• IBI must find ways to overcome the current barriers to recruiting facilitators and incentivizing

them, for example, increasing their access to further training, provision of annual awards,

creating better opportunities for promotion, providing stronger support for them so they will

be able to conduct regular supervision and mentoring to certified Bidan Delima midwives. This

will require support and collaboration from partners, such as, MOH, DHO, professional

associations, civil society organizations, and the private sector.

• The certified Bidan Delima midwives need to receive constructive and written feedback, which

will guide them to find appropriate and effective solutions to solve the challenges they face in

providing quality services. For example, peer group mechanisms could be established to help

them share experiences and learn from each other. IBI also needs to support them to have

greater access to information and updates on clinical practice. The routine mentoring by

facilitators needs to be strengthened to ensure Bidan Delima midwives perform with high

quality of care.

• An incentive mechanism should be developed to encourage the certified Bidan Delima midwives

to maintain quality services. Reward mechanisms should be incorporated into the program, such

as, opportunities to attend trainings and workshops, or being promoted as champions.

5.2. STRENGTHEN BIDAN DELIMA MANAGEMENT

The management of the Bidan Delima program needs a formal revision with committed leadership,

strengthening of the organizational systems, a proper staffing structure and reporting structures at

national, provincial and district levels. This should be undertaken jointly by IBI and MOH, with other

partners involved as appropriate.

There is also a need to review the financial management and sustainability of the program, including

reviewing the fee structure, financial transparency about program revenues and costs, other sources

of funding required to support the program, and other income generating activities that could be

developed.

A strengthened information management system should be established so that IBI can track data on

certified midwives including quality indicators, status of certification, training, fee payment and many

other indicators to effectively run a certification program. IBI, with the Bidan Delima management

team, needs to define what are the measurable output indicators of the program and select the key


indicators for a program and management dashboard. The existing Bidan Delima monitoring

guidelines can be used. There are many local digital applications being used in various districts which

would need to be reviewed and integrated as much as possible.

These modalities could be used to refine the management supervision mechanism to be

implemented regularly every six months to monitor the management and technical performance of

the Bidan Delima program at district and provincial levels.

5.3. ENHANCE COLLABORATION WITH STAKEHOLDERS TO SUPPORT THE BIDAN

DELIMA PROGRAM

This program could be potentially highly strategic as a key part of a strong health system that values

and promotes midwifery as a quality profession in Indonesia. MOH and PHO/DHO along with key

stakeholders at national and sub-national levels need to be involved and support IBI in this process.

This will include collaborations with GPs, OB/GYN consultants and the professional associations,

and requires ongoing strengthening of the referral system so that midwives are not operating in a

vacuum but are critical players for improved MNH outcomes. MOH and IBI should lead this process

with support from other key actors in the health sector. This collaboration will provide potential

opportunities for the Bidan Delima program to be linked with other quality improvement efforts

within government and with other potential partners, for example, pharmacies, banks, and local

companies.

5.4. STRENGTHEN COLLABORATION WITH BPJS/JKN AND INVOLVEMENT IN

STRATEGIC HEALTH PURCHASING DISCUSSIONS

The MOH and its partners in health financing should review the processes for certification of private

midwives in BPJS so that midwives can become stronger and more active partners in the provision of

MNH services. The current blockages that are preventing midwives from joining should be reviewed

and efforts made to simplify the processes and ensure easier participation by midwives.

The current discussions around SHP relate to plans to pilot a new mechanism of contracting private

midwives with revised and improved payment conditions. This would provide an opportunity for IBI

to position the Bidan Delima certification to be accepted among the criteria for registration in BPJS-

K (new BPJS-K post SHP pilot). Therefore, IBI should be fully engaged in the SHP discussion and

working groups, and the MOH should fully support this involvement.

5.5. PROMOTING THE BRAND OF BIDAN DELIMA

Once the quality of care aspect is well established and a sustainable business model is developed, an

effective communication strategy will be developed which includes brand promotion. There is a need

to enhance the added value of services provided by Bidan Delima midwives and to promote this

value widely through multiple channels to increase awareness and stimulate higher demand.

Some ways of doing this could include:

• More opportunities for continuous professional development

• E-learning platforms

• Technical support and toolkits to help midwives participate in JKN


• Consumer facing services that could be branded such as helplines, mother baby classes, mobile

applications

• Marketing and advertising

• Business management classes for midwives

• Links to financing programs and group purchasing equipment lease programs

The demand by the community or client for quality services is likely to be increased through such

measures if accompanied by continuous awareness-raising about the patient’s right to receive good

quality services and improved information dissemination about what constitutes these services.

Increasing clients’ awareness and demand will be one effective way to encourage private midwives to

provide quality services. The Bidan Delima program can play an important role in this by creating a

new and refreshed image of a quality midwife and dispelling any negative associations with the brand.


REFERENCES

[1] D. A. C. e. al., "Evaluation of the Health Services Program (HSP) in Indonesia: Taking Stock and

Looking Forward," USAID, Washington, 2008.

[2] A. C. e. a. Maharani, "Bidan Delima Accreditation: The Implementation of a Franchise Model in

Regulating Performance of Private Midwives in Indonesia A Case Study," Mercy Corps, Jakarta,

2011.

[3] N. Emi, Pandangan Profesi Bidan Serta Rekomendasi Perbaikan Kebijakan Terkait Belanja Strategis JKN,

Jakarta: PP IBI, 2016.

[4] "Informasi Anggota Bidan Delima," [Online]. Available: http://www.bidan-

delima.org/isianggota.php. [Accessed 09 March 2020].

[5] Unit Pelaksana Bidan Delima Pusat, "Bab XII: Monitoring Kualitas Pelayanan Bidan Delima," in

Petunjuk Teknis Program Bidan Delima Tingkat Cabang, Jakarta, PP IBI, 2014, pp. 66-70.

[6] Unit Pelaksana Bidan Delima, Petunjuk Teknis Program Bidan Delima, 4th Edition, Jakarta: Ikatan

Bidan Indonesia, October 2014.

USAID JalinWorld Trade Center 5, 16th floorJl. Jend. Sudirman Kav. 29 Jakarta Selatan 12920 Indonesia

rapid assessment of bidan delima program

Documents