Visualization of locally specific MNH care performance

Indonesia is still struggling with high maternal and neonatal mortality despite the the stable economic growth in the last fifteen years. These rates are the highest among regional peer countries. Beside constraints in supply and demand side to access quality MNH care mostly at rural and remote areas, the frontline facility managers and district officials experience issues with multiple data entry process in the recording and reporting systems. The National Health Insurance information system have no direct connection with the system used by health facilities to report clinical data. They are silo vertical information system with no bridge to coordinate and have interoperable with one information system to another. The central MoH has developed several digital reporting systems such as MNH e-cohort, Information System for Maternal and Neonatal deaths, outpatient clinic reporting system and operation system to help the mother and other patients' referral from first to secondary facilities. These systems, however, are not interconnected, and therefore, the data collected in these two system are difficult to use. The frontline health workers and facility managers are hardly use the information collected from these system to measure their program performance and to identify obstacles in the fields that need to be addressed. 

The Government of Indonesia has put a lot of efforts to interconnect and interoperate these scattered information systems into "One Health Data", and applying digital transformation of recording and reporting. This aims to reduce work burden and time among frontline workers for working on this system. On MNH program, it is observed from district level, that there is significant improvement when e-cohort was introduced. This system covers reports on all clinical signs and symptoms, and services provided by facilities ranging from ante natal care up to post natal care. This system has a dashboard to visualize the level of performance by village, that aims to help MNH program managers at facility to take intervention when they see issues. This cohort, however, does not connect with the population database to show the program achievements in given areas. Therefore, "hotspots" of low coverage are not available despite the data may have been in the system but left unchecked. Additionally, this e-cohort have yet to link with a referral systems that store data for high-risk pregnant women, mothers and neonates in emergency state that urgently in needs to be referred to higher level facilities. This information if put in a dashboard then it would help local officials to monitor if these mothers and babies receives appropriate care at the higher level facilities. 

The pandemic has opened a new way for digital transformation, making the central MoH creating "peduli lindungi" and later "Indonesia Health Service" applications that links population database with COVID19 laboratories and healthcare facilities. This creates a healthy environment for further inter-operate service recording systems such as MNH e-cohort had its access to these two applications. With data visualization software, we would like to show primary care performance data into a geo-spatial visualization e.g. for MNH service coverage, immunization coverage and other priority services. This locally specific monitoring date could help the village leaders and district officials to see a dashboard depicting services given to the population, high-risk pregnant women, and how the primary care able to provide the right services according to the risks these groups have.

We offer a solution to transform manual cohort recording into a digital or electronic recording using DHIS2 platform (as basic platform for Satu Data Kesehatan). This is done through collecting cohort data on pregnant women from manual imputation into electronic imputation using mobile application or desktop done by community health workers who assist pregnant women, village midwives, midwives at primary clinics or primary care. The cohort data will range from the first semester until postpartum period . 

The electronic cohort data on MNH care performance could show more detail information if visualized graphically and using geospatial visualization. Data integration is done by using unique identity number. Thus, population database would make a comparation with the service coverage in certain areas, then show villages with under-service coverage. Not only then the facility manager are able to intervene, these integrated database could also be used for further analyses for MNH program planning, while maintaining the data security.  

The data and information exchange among different systems could also serve district health officials to monitor the state of mothers and newborns at risks, and what actions to be taken to ensure that they receive the appropriate care. With this system in place, it will help decision makers to anticipate emergency state that may occur and to ensure these mothers and newborns are safely treated at the given facilities. 

This solution will serve health managers directly as to indirectly serve women and newborns to access quality service in emergency settings. 

The Digital Transform Maternal Cohort on Primary Care Geo-Spatial Interoperability will contain complete data of all pregnant women from the first trimester until the postpartum period. eCohort will provide visualize these data on the dashboard as maps, graphs and warnings of high risk conditions if any. The geospatial mapping points out high-risk pregnant women, mothers newborns and families domicile, and where the frontline workers need to anticipate the emergency state that potentially occurs, the location of midwives, medical doctors and  specialists who could provide care when needed, and the route for transportation to higher level facilities. 

Yayasan Project HOPE (YPH) has the team to provide expertise, facilitation, and support for district authorities to have the health workers receive capacity building, the health managers to exercise better coordination method to mobilize not only health sectors under the district leadership, but also cross-sectoral contribution, and community development to improve maternal and child health program and bringing down the maternal and infant mortality rates as some of district's development indicators. And this is speaking from the experience providing technical assistant to 7 districts.   

In 2019-2021 for example, YPH provided supports to Banyumas district in central Java region with a new information system - a simple application to monitor all mothers and newborns at risks, with their health conditions, and care given to them. The application is called as Satria Gemati. This system provides a dashboard, and this was one of the communication tools for the government leader (Mayor) with the geospatial page on location of pregnant women: the distribution across villages, residents of where high-risk pregnant women lives, location of frontline healthcare workers and primary and secondary care facilities where these women need to visit if they experience emergency situation. With this warning system, this Head of District could directly contact the village head, the doctors, midwife, ambulance drive and even the specialist to inform emergency situation of any mother, and continue to monitor how the health workers provide required services as to ensure that those mothers and babies are safely taken care. YPH received 306 warning alert during 2 years of this Satria Gemati application, and of those, 292 alerts got the right response, and delivered their babies safely with their newborns received the right care at the facilities.  

This MNH information system use was supported by frontline healthcare workers by actively inputting the correct and reliable information about pregnant women, newborns and their conditions. Community Health workers and head of village also provide information on new pregnant mothers and newborns to the healthcare workers and also help to prepare transportation and other means to help those mothers and families. These system are integrating eCohort, Local Area monitoring system and the population database.

Yayasan Project HOPE continues to support 7 new districts with Saving Lives At Birth programs, and plan to expand this Satria Gemati to these 4 districts.

Because the approach Yayasan Project HOPE (YPH) used was effective, and fully supported by the higher level authorities (provincial and national levels). Therefore, if this system could help more districts to improve their care performance, then YPH will be in service to help district reducing maternal and neonatal deaths. 

YPH currently implements MNH Intervention in 7 districts (Grobogan, Sampang, Indramayu, Sumedang, Bantul, Klaten, Bandung), with different focus on Saving Lives at Birth, Saving Lives at Newborn at Risk, and Mental Health Psychosocial Support. Each district will have different challenge, but we deploy a Field Officer under supervision of Project Coordinators and Program Managers to overcome the challenge and provide technical support and assistance on regular basis. 

Successfully piloting "Satria Gemati" digital solution to help monitor the mothers and newborn at risks in Banyumas district, we would like to expand to 7 other district, to help frontline healthcare workers and primary care facility managers with an integrated information system that could help them provide a dashboard to visualize the location of mothers and those at risks or potentially come into emergency state, monitor the given services and take immediate action to ensure that they are delivered babies safely. This will also help to visualize the service coverage and create a real time actions to address service gaps in village that need more attentions as they can be directly show the service given to the real time population database.

Use existing technology and advancing it to show visualization of care performance. 

Dashboard will show information and alert system for taking necessary actions to provide urgent care to those mothers and newborns, and to take immediate action and coordinate with all players to make sure these mothers and newborns get the right care at the right facilities and receive the fast response from the healthcare workers.  

For developing the dashboard, we need collaboration and coordination with multiple players at district up to village levels, facilitate commitments to work together among different players to input the righ data and information so that they are valid and reliable information to help action plan development as well as to make an urgent action when needed.  

Engagement of community cadres, midwives, village communication forum and other apparatus are important to maintain data and information about pregnant women and babies in their respective area, and reporting them into MNH e-Kohort so that these data can be visualized in the dashboard in District Command Center. While, at village level, the head of village must also find the way that these families have the financial protection from either national Insurance as well as from the Free Delivery financial scheme from central MoH. Arranging transportation and blood donor could also be part of the planned action.  

Dashboard at the Command Center within the office of the Head of District will visualize the locations of pregnant women and newborns at risks, who will be the first responders when the emergency stage occurs, what the financial protection status, the arranged transportation and blood donors when needed. Integration among different MNH information system, and interoperability with Indonesia Health Care application, population database and National Insurance database are very important to make the system running well to save mothers and babies.

We will evaluate the pilot of "Satria Gemati" in Banyumas district, and to see the sustainability after one year operation. We will also test these system to interoperate with different district digital landscape of the 7 districts where we operate the MNH program. 

In the year two, we expect to implement these interoperable digital application with the Central MoH interoperability platform for Indonesia Health Care application.

In year three, we expect to have interoperability with MoH managed Indonesia Health Care Application, MNH e-Cohort and the Satria Gemati application and we will also create an digital environment for interoperability with National Health Insurance database.

In the nest five year, we would like to expand nationally these system.

Impact: contribute to acceleration of the reduction of preventable maternal and neonatal deaths 

Outcome: MNH Dashboard established and interoperate with different systems for enabling a evidence based planning and real time actions for emergency cases 

Output:  

#at least 7,000 health care workers / administrator from 7 districts trained on used of eCOHORT and SISRUTE (Satria Gemati)

# at least 14,000 CHWs and Village Midwives from 7 districts trained on used of eCOHORT and SISRUTE (Satria Gemati)

By having an interoperability among different MNH system, we can visualize all pregnant mothers and newborns, and will be having the complete and reliable information inputted into the system, for better local specific MNH care performance measurement and evidence based planning to the right risk groups, so the preventable causes of maternal and neonatal can be rapidly identify and those at risks will receive the right care at given time. 

Data collection using mobile phone, or MS-Excel by CHWs and village midwives 

eCOHORT, SISRUTE, MNH Information System using prototype Borland Delphi and MYSQL 

Dashboard using DHIS2 

The Community Health workers and frontline health providers, and they will get incentive from the primary care capitation from the National health insurance

The Yayasan Project HOPE is a growing foundation with a mission to empower healthcare workers facing the world's largest health crisis to build resilient communities and a healthier and more just world with respectful and caring staff who embrace diversity and empower everyone to learn and provide the best technical support.

We have been working closely with the central MoH division on Maternal and Neonatal Health and the center for Data and Information, We have also been having a close relationship and collaboration with district authorities in 7 districts where we run the Saving Lives at Births, Saving Newborns At Risks and Maternal Mental Health and Psychosocial support programs. We provided technical assistance and support while during program implementation we facilitate the self reliance of the district in which they are allocating fund for operating and maintaining the system as they will be the primary beneficiaries of MNH care improvements. For expanding the system to other districts, we will facilitate the co-funding with the primary care facilities to use their capitation payment they receive from the National Health Insurance agency. 

As mentioned above, we will focus on the development of the system/application and the installation of the system within the Command Center at the office of Head of districts. For further operation and financial sustainability, we will ask the district to fund them as they will benefit from the improved MNH care performance and could prevent unnecessary maternal and neonatal deaths. 

We will also motivate the primary care facilities to contribute to the systems through their capitation money that they receive from National health insurance. 

For further provision of technical support to the system, we will closely work with central MoH as they have the priority on digital transformation goals. Local private philanthropies will also be sought.  

The Banyumas district provided fund for further operation and sustainability of the Satria gemati, MNH operation system.

The Head of District in Sumedang offer technical support from their digital division in the district government to install the system in the district.