The Maternal and Child Health Handbook (MCH handbook)*1, which records the health of a mother and child from pregnancy to delivery and the growth of the child, was created in Japan in 1948, soon after World War II, and has been used in about 50 countries around the world. In Indonesia, one of the first countries to receive JICA assistance in 1993, the enthusiasm and efforts of the Indonesian people moved the country to introduce the handbook to all provinces through a ministerial decree in 2004. Now, many countries are trying to learn from Indonesia’s experience.
Ms. Kirana Pritasari from the Indonesian Ministry of Health and Ms. Keiko Ozaki, JICA International Cooperation Specialist, who have contributed to the dissemination and development of the MCH handbook in Indonesia, spoke about their 30 years of cooperation, challenges they have faced, and prospects for further dissemination.
Creating a Maternal and Child Health Handbook by Indonesia for Indonesia
-What was the situation regarding childbirth and maternal and child health care in Indonesia in 1993, when JICA’s cooperation began?
Pritasari The MCH handbook was first introduced in Indonesia in the city of Salatiga, Central Java, through the efforts of Dr. Andriansha Arifin, who was in charge of the maternal and child health program in the province at the time. Dr. Arifin, together with JICA experts, began to introduce the MCH handbook to her home country.
In 1993, when Indonesia was beginning to deploy approximately 54,000 midwives in villages across the country, the coverage rate was still not 100%. Although the immunization rate was about 70%, the maternal mortality rate was about 390 per 100,000 live births and the infant mortality rate was about 57 per 1,000 live births, five to ten times higher than in neighboring countries such as Singapore and Thailand.
With the support of JICA, we decided to create a pilot version of the Maternal and Child Health Handbook by consolidating the various cards that had been used in Indonesia up until then related to maternal and child health and growth and development. In 1997, a standard version of the Indonesian MCH handbook was developed.
Ms. Kirana Pritasari, former Director General of Public Health of the Indonesian Ministry of Health, and Ms. Keiko Ozaki, JICA International Cooperation Specialist
Ozaki: Many people may imagine that the Indonesian version of the MCH handbook is simply a translation of the Japanese version into Indonesian. In reality, however, it was never a translation of the Japanese version. Rather, it did not work that way. What those involved at the time did was first consolidate existing tools. Until then, Indonesia had been using several cards for the same mother and child, such as vaccination cards, maternal and child health cards, and child development cards. JICA experts at the time spent a great deal of enthusiasm and time to support the creation of the mother-child handbook so that all users and health care workers, regardless of whether they were in urban, rural, or island areas, would have a sense of ownership of the handbook.
Pritasari: Each state’s MCH handbook is designed to incorporate the wisdom and characteristics of the local community. For example, the handbooks include information on nutritional guidance using locally available ingredients, Islamic prayers in deeply religious states, and in some cases, photos of local scenery and parents on the cover so that the handbook can be easily recognized at a glance.
Various mother-child handbooks produced in various provinces in Indonesia
-In 2004, the Minister of Health issued a decree recommending the use of the Maternal and Child Health Handbook. Please tell us about the difficulties you faced up to that time and the efforts you made after the Minister’s decree.
Pritasari: In Indonesia, decentralization was underway from 1998 to 2000, and health policies were reviewed. Therefore, it was necessary to make provincial and district health administrators aware that the attempt to disseminate the MCH handbook was not only the job of the central government, but also that of local governments. In addition, since the information contained in the MCH handbook covers multiple programs, we had to convince program officers within the MOH to use the unified “MCH handbook” as a common tool.
In addition, there was a financial problem. Until the ministerial decree was issued, the Ministry of Health was responsible for printing the MCH handbooks with the support of JICA. However, if the handbooks were to be distributed in all provinces in accordance with the ministerial decree, a huge number of copies would need to be printed. Since it would be difficult to cover all of this centrally, it was necessary to persuade states and provinces to take responsibility.
Ms. Pritasari and Mr. Ozaki have worked together for more than 20 years to improve maternal and child health care in Indonesia (Photo right: JICA/Kenshiro Imamura)
After the Ministerial Decree, the challenge was how to monitor the use of the MCH handbook. This was because Indonesia is a vast country with as many as 33 provinces and more than 500 districts and municipalities. *2 Therefore, we asked the National Statistics Office to help us collect information on how many mothers received and used the MCH handbook in their national survey on maternal care and vaccinations, which they conduct every five years.
As a result of continued monitoring, it was found that the number of safe births assisted by medical personnel has increased: from 71% at the time of the Ministerial Decree in 2004, to 75% in 2010, then to 80%, and finally to 95% in 2022. It can be said that awareness-raising and health guidance through the Maternal and Child Health Handbook have contributed greatly to this improvement.
Mothers visiting for a checkup with their mother-child handbook (Photo: JICA/Kenshiro Imamura)
Ozaki: JICA similarly found various challenges, one of which was coordination among multiple programs related to maternal and child health. This required some kind of political decision, so the decision by ministerial decree to integrate them into a common format called the “Maternal and Child Health Handbook” was a very big step forward. Nevertheless, it was important that the MCH handbook be properly positioned within the overall health system in order for it to be used sustainably by women who became pregnant this year, the following year, and so on.
Therefore, we provided various support to the Indonesian Ministry of Health to ensure that the MCH handbook will continue to be used even after JICA’s cooperation period ends. For example, we created model activities to promote the use of the MCH handbook, such as motherhood classes, incorporated the MCH handbook into the curriculum of schools for training health workers, and encouraged local governments and private facilities to make use of the handbook.
Motherhood classes utilizing the Maternal and Child Health Handbook with the cooperation of JICA
From Indonesia to the rest of the world
- In recent years, the Indonesian Ministry of Health, together with JICA, has been actively conducting international training programs.
Pritasari Indonesia had already rolled out the maternal and child health handbook in all provinces, and I had participated in JICA’s international training program in Japan, and through my interactions with health officers from other countries that I met there, I realized that our experience could be useful to them.
Therefore, starting in 2007, the Indonesian Ministry of Health took the initiative to conduct international training together with JICA experts. This was a very good experience for the Indonesian officers in charge. Not only did they share the process of introducing the MCH handbook in Indonesia, but they also gained insight into how to strengthen their own health system.
International training programs provide an opportunity to share experiences and knowledge with each other
Indonesia has hosted 15 international training programs to date, inviting 17 countries and regions. Participating countries include not only Southeast Asian countries, but also Palestine, Afghanistan, Tajikistan, Uganda, Cameroon, Morocco, Madagascar, Kenya, and a wide range of other countries. The training covers a wide range of topics, such as how to use the MCH handbook after disasters such as earthquakes and the positioning of the MCH handbook in the context of the establishment of the national health insurance system, etc. Some countries are decentralized, such as Indonesia, while others are centralized, so learning from each other allows participants to gain a different perspective. Indonesia is also a country that has a strong commitment to the policy of maternal and child health care in Japan. Indonesia has not followed all of Japan’s maternal and child health care policies. Similarly, other countries cannot simply adopt Indonesia’s experience.
Ozaki: It is a real pleasure for me to see people across continents, including Asia and Africa, learning from and interacting with each other. The Indonesian participants also said that they welcome questions from people from other countries. They say they welcome questions from people from other countries, because it is through such questions that they can realize the significance of their own efforts and what they are lacking.
In response to this international training trend, in 2018, the World Health Organization (WHO) developed Guidelines for Household Records Related to Maternal and Child Health. These guidelines stress the importance of health records, including maternal and child health records, and Ms. Pritasari served as a member of the WHO’s guideline development group. Programs related to maternal and child health around the world have been fragmented into multiple programs, including maternal health, newborn health, childbirth, immunization, and nutrition. However, the international community should be more united in its efforts, and the guidelines compiled by WHO are meaningful for this purpose, and will help countries that wish to effectively utilize the MCH handbook within their own health systems.
Ms. Pritasari and Mr. Ozaki speaking at an international training session Official side event on home health records for mothers and children at the WHO Annual Meeting
30 Years of Cooperation: Achievements and New Goals
- How do you both evaluate the results of the 30 years of cooperation and what expectations do you have for future development?
In order to measure the degree of dissemination and effectiveness of the Pritasari MCH handbook, we collaborated with a university in Indonesia to compare regions that actively promoted its use with those that did not. The rate of child immunization and the use of a series of services related to maternal and child health care also improved. In the future, it is necessary to make efforts to ensure that information reaches each new generation of pregnant women and health workers.
Ozaki: I believe that the MCH handbook has further potential for Indonesia. Currently, JICA is experimenting with activities to utilize the MCH handbook more effectively for a better health system. For example, we are currently developing a 6-month health checkup as a form of care that supports infant development while utilizing the MCH handbook. Furthermore, we are also developing supplementary support in addition to the MCH handbook for mothers and families with babies born prematurely or with low birth weight. We look forward to Indonesia continuing to use the MCH handbook as a platform for its health system and addressing various issues that change with the times.
Pritasari Fragmentation by technology is another challenge. Indonesia has a very high rate of cell phone use, and all information is now digitalized and efficiently available through cell phones. One of the important roles of the MCH handbook is to facilitate communication between mothers and health care providers, but relying solely on digital technology reduces the opportunities for communication. Dialogue is still needed to ensure that mothers properly understand the information they receive.
Ozaki: That’s exactly right. Digital is an opportunity for us, but we find it difficult to switch everything from paper to digital. How can we best combine digital and paper, how can we be efficient and effective, how can we be interactive and sustainable? These challenges are common not only to Japan and Indonesia, but to all countries that wish to learn from each other. I am grateful to be working with Indonesia toward this goal.
Indonesia has already shown leadership in other countries and regions such as Afghanistan and Palestine. I sincerely hope that JICA will continue to be a good partner of Indonesia as we work together in a friendly manner with each other, even as the generations change.
- 1 The predecessor “Maternal and Child Health Handbook” was extended to childhood and became the “Maternal and Child Health Handbook” in 1948. The current official name is “Maternal and Child Health Handbook.
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