Research
Monitoring continuity of maternal and child health services, Indonesia
Siti Helmyati,a Dhian P Dipo,b Insan Rekso Adiwibowo,c Maria Wigati,a Erri Larene Safika,d
Muhammad Hafizh Hariawan,d Monita Destiwi,c Yoga Prajanta,c Mirza HST Penggalih,a Toto Sudargo,a
Dewi MD Herawati,e Tiara Marthias,f Masrul Masrulg & Laksono Trisnantorof
Objective To implement an online system to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on maternal and
child health and nutrition essential health services in Indonesia.
Methods We developed an electronic monitoring and evaluation system to assist district health offices in making rapid assessments of
the impact of COVID-19 on maternal and child health and nutrition programmes in their area and in developing policy and programme
responses. This implementation research was conducted from September to December 2020 in 304 districts. The strategies consisted of
technical assistance for district offices by 21 partner universities and development of an online dashboard for rapid situation analyses and
reporting. We collected qualitative data on feasibility and adherence to the intervention, as well as quantitative data from routine health
databases to analyse the impact of COVID-19 on maternal and child health and nutrition indicators.
Findings In the majority of districts key maternal and child health and nutrition services were moderately or severely affected by the
pandemic, particularly child growth monitoring and antenatal care services. Adherence to the protocol of the intervention varied across
districts but the system is a feasible approach to be scaled up to other regions and health programmes. High uptake by the health ministry,
district office and university partners provided the platform with collaborative efforts for health-systems strengthening.
Conclusion The electronic monitoring and evaluation system could be implemented and completed with several modifications to
accommodate district offices and universities. There is a potential to scale up the intervention with better implementation planning and
training.
Introduction
Indonesia, a lower-middle-income country with a population
of more than 260 million people, has a high burden of infant
and maternal mortality and child undernutrition. In 2018, the
prevalence of stunting was 30.8% (27 023 of 87 737 children
aged 0–59 months),1 significantly higher than in other countries with comparable economic development status.2,3 The
prevalence also varies widely across provinces, ranging from
17.7% in the capital city Jakarta to 42.6% in the less-developed
province of East Nusa Tenggara.1 In 2019, Indonesia’s infant
mortality (20.2 per 1000 live births) and maternal mortality
(177 per 100 000 live births) were among the highest in the
South-East Asia Region.4–6 The United Nations Children’s Fund
in Indonesia has reported that lack of awareness, unequal capacity and distribution of health resources, insufficient budget
allocation, and lack of vertical and intersectoral coordination
were the most prominent factors related to those problems.7
Indonesia’s national strategy for stunting reduction has
been in place since 2015.8–10 However, the coronavirus disease
2019 (COVID-19) pandemic has halted many public health
programmes, particularly those delivered by community
health centres and integrated health posts.11–13 By 2020, the
Indonesian health system was at its capacity, with the government diverting resources towards COVID-19 mitigation.14–16
Budget reallocation to the pandemic has jeopardized the
country’s capacity to maintain essential health services, with
a notable impact on pre-existing problems,7 including programmes focused on the health of mothers and children’s nutrition.11 Providing timely data on the impact of the pandemic
on routine programmes is necessary to rapidly map strategies
to recover from the disruption caused by the pandemic. Managerial problems that might be faced by district health offices
can provide evidence of the need for capacity improvement
from external resources.
We describe our experience in developing and implementing an online system to help maintain maternal and
child health and nutrition programmes in Indonesia during
the COVID-19 pandemic. The initiative was a collaboration
between the Ministry of Health of Indonesia and Gadjah Mada
University in Special Region of Yogyakarta, with 20 other
partner universities across Indonesia.
Methods
Study setting
This implementation research was done in provinces and
islands throughout Indonesia. In 2020, the national government designated 120 districts as priority areas for reducing
maternal and neonatal mortality and 260 districts as priority
areas for improving nutrition, specifically child stunting. These
a
Department of Nutrition and Health, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia.
Directorate of Public Health Nutrition, Ministry of Health, Jakarta, Indonesia.
c
Center for Health Policy and Management, Universitas Gadjah Mada, Yogyakarta, Indonesia.
d
Center for Health and Human Nutrition, Universitas Gadjah Mada, Yogyakarta, Indonesia.
e
Department of Public Health, Padjadjaran University, Bandung, Indonesia.
f
Department of Health Policy and Management, Universitas Gadjah Mada, Yogyakarta, Indonesia.
g
Department of Nutrition, Andalas University, Padang, Indonesia.
Correspondence to Siti Helmyati (email: siti.helmyati@gmail.com).
(Submitted: 18 July 2021 – Revised version received: 27 November 2021 – Accepted: 2 December 2021 – Published online: 29 December 2021 )
b
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Siti Helmyati et al.
focus areas may receive greater budget
allocation from the national level for
programme innovations and implementations. Since 76 districts are focus areas
for both maternal and neonatal mortality and for stunting, we included a total
of 304 districts in the study.
Intervention
We developed an electronic monitoring
and evaluation system (called eMonev)
to assist district health offices in making rapid assessments of the impact of
COVID-19 on maternal and child health
and nutrition indicators in their area and
in developing policy and programme
responses. The health ministry appointed Gadjah Mada University as the
lead academic partner to supervise and
implement the system. The intervention
consisted of technical assistance for district offices by partner universities and
development of an online dashboard
for analysis and reporting. Both strategies were designed to provide remote
assistance to improve the managerial
capabilities of the staff of district offices,
including situation and policy analysis
using routine data, and to map the
impact of the pandemic and possible
mitigation strategies.
Technical assistance and mentoring
to district offices was delivered by the
health ministry and 21 partner universities, including the lead university.
The universities were selected based on
previous collaboration with the health
ministry in providing expert assistance
in data analysis on other projects, and
each university was assigned to assist
staff in 14–16 district offices closest to
them. The lead university recruited all
304 district health offices to the study
and held several meetings with partner
universities to discuss the activities.
We designed the online dashboard
to display maps and charts summarizing
the data collected. We also developed
a website where participants could
open the training resources, access
online meetings, view other materials
and upload documents written by the
district health offices. The development
of the dashboard and website started
with gathering information and inputs
from the health ministry and assessing
which indicators to include. The selected
indicators were routine data collected by
district offices and stored in the health
ministry database. Information about
the impact of the pandemic, and strategies and challenges to deal with it, was
gathered from the district offices and
quality checked by the lead university
before being transferred to the online
dashboard. All activities were documented in open-access websites.17–20
Each district office was expected
to produce three documents from an
analysis of the national routine data
in their area: (i) a situation or impact
analysis of the pandemic on the selected
indicators; (ii) a policy analysis; and
(iii) a policy brief with recommendations for post-pandemic recovery. Staff
at the lead university collated the reports
and categorized the severity of impact of
the pandemic (severe, moderate, mild,
cannot be determined, or no data available) according to the number of indicators adversely affected. All documents
and the results of the analysis collected
by district offices were then displayed
online in the dashboard.
Implementation
Recruitment of universities and district
offices to the study began in September
2020. The intervention phase was from
October to December 2020. Fig. 1 shows
the steps in the implementation of the
intervention from planning, recruitment
and training, through data collection
and analysis, to feedback to participants
and dissemination to the health ministry
and other stakeholders. Throughout the
study we communicated with participants and collected data through online
activities such as videoconferencing,
email and text messages.
To facilitate implementation of the
intervention we designed staff development programmes for representatives
of universities, to build their capacity
as consultants, and for representatives
of district offices, to improve their ability to analyse situations and policies.
Training was delivered in online sessions
by experts in the field of qualitative
and quantitative data management and
health management and policy. The sessions comprised an introduction to the
electronic monitoring and evaluation
system; training in collection and analysis of quantitative and qualitative data;
and an introduction to the dashboard
(more details are in Fig. 1 and the data
repository).21 We used a blended learning approach, synchronously via videoconferencing applications and through
recording material and literature on the
programme website. Information on the
website could be accessed by participants throughout the study.
Bull World Health Organ 2022;100:144–154A| doi: http://dx.doi.org/10.2471/BLT.21.286636
Data analysis
To evaluate the implementation of
the intervention we assessed the following outcomes: (i) feasibility of the
intervention delivery; (ii) fidelity to the
intervention protocols; (iii) availability
of data for analysis; (iv) availability of
documents describing the impact of the
pandemic on key indicators; (v) staff
development programmes received
by universities and district offices;
and (vi) availability of the electronic
monitoring and evaluation programme’s
websites (Table 1 available at: https://
www .who .int/ publications/ journals/
bulletin/).
We assessed these outcomes quantitatively by analysis of routine data on
maternal and child health (based on
eight indicators) and nutrition (based
on six indicators) to create a descriptive
summary of the extent to which each
service was affected by the pandemic.
We analysed the data and generated
maps and charts using Excel (Microsoft Corp., Redmond, United States of
America, USA), R (R Foundation for
Statistical Computing, Vienna, Austria)
and shinyapps (R Studio, Boston, USA)
software. While data validity is a concern in the routine systems for collection
of data on nutrition and maternal and
child health, we aimed to use the best
available data and to provide an opportunity to improve its quality via the
intervention. We complemented these
data with qualitative data obtained from
our observations throughout the study,
from discussions between universities
and district offices and from questionnaires to all participants in universities
and district offices. Questionnaires covered the participants’ views about implementation of the intervention, government policies related to COVID-19 and
budget allocations for maternal and
child health and nutrition programmes.
Results
Programme analysis
More details of the participating universities and district offices are shown
in the data repository.21 Three of the
21 universities (14%) were absent from
several development meetings and did
not reach all their assigned districts to
assist them in completing the required
documents. Of the 304 district health
offices, 80 offices (26%) did not attend
all the trainings and were unable to com145
Research
Siti Helmyati et al.
Monitoring maternal and child health programmes, Indonesia
plete all the required documents. Only
158 offices (52%) were able to validate
the quantitative data and provide all the
necessary qualitative information.
Adherence to standard operating
procedures by participants, based on our
observations, is shown by the shadings
in Fig. 1. We needed to modify most
of the activities in the intervention to
meet the short timeline of the study,
and to meet the challenge of bringing
the electronic monitoring to scale in
304 districts nationwide. Our use of a
blended learning system was efficient
for the large number of participants and
enabled participants to learn and open
the materials even after the training.
The electronic monitoring and
evaluation system was effective in
assisting district offices to use routine data for situation analysis and
decision-making in their area (Table 1).
Technical assistance by universities was
an important component in helping
district offices conduct these activities.
Now that the national routine data are
digital-based and relatively easy to use,
the system has sustainability. However,
challenges such as poor internet access
and the small number of staff focused
on maternal and child health and nutrition in the district offices and universities need to be considered (Box 1). The
lead university has filed a report about
these challenges to the health ministry
for further action.
Table 2 presents the follow-up analyses of the challenges of the pandemic
reported by participants and the innovations that took place to mitigate the
impact of the pandemic. We note with
interest how community health workers
(CHWs) coped well with the restrictions
imposed by the pandemic. However,
the situation varied across provinces.
Several provinces would have benefited
from collaboration with other ministries
or agencies involved in development
planning, particularly in addressing preexisting health-system challenges. These
problems include security problems (in
Fig. 1. Steps in implementation of the intervention to maintain maternal and child health and nutrition programmes during the
COVID-19 pandemic, Indonesia, September–December 2020
Recruitment
The lead university recruited 20 universities and 304
district health offices to participate in the electronic
monitoring and evaluation system activity
Dashboard development
The lead university designed the online
dashboard to display the information
collected and to be ready to be
synchronized with the national health
information system
Capacity-building
The health ministry and lead university carried out
online training for staff in partner universities
(100-minute sessions to groups of staff from 4–5
universities) on how to be consultants to the district
health offices. The partner universities then carried
out online training for staff of the district health
offices (100-minute sessions to groups of 60 staff) to
improve their capacity to analyse and assess the
impact of the pandemic
Progress report and monitoring for partner
universities
The lead university held an online meeting with
partner universities once a week for 1 hour. The lead
university was also available for informal contact by
mobile phone chat application. Discussions often
centred on universities’ constraints in implementing
assistance to district health offices
Progress report and monitoring for
district health offices
Partner universities held an online
meeting with district health offices once
a week for 2–3 hours. Discussions often
centred on issues with implementation
of the intervention by district
health offices
Data collection and analysis
District health offices compiled routine data on the
maternal and child health and nutrition indicators
(as defined in the intervention protocol) from the
national data system that was displayed in the
dashboard. If local data were available, the health
office staff compared both data sets and used the
most up to date. Supervision was by
partner universities
Analysis of impact of COVID-19 pandemic
District health offices carried out an analysis of
maternal and child health and nutrition indicators in
their area, based on routine data collected. Weekly
meetings were held so that district health offices
could consult with their partner university about the
results. District health offices compiled the results into
a document on the impact of the COVID-19 pandemic
in their area
Collection of report documents
Partner universities reviewed the
analysis documents and sent them to
the lead university. The lead university
checked the completeness of the data,
compiled the data into one file and
created a summary of information from
each document
Data entry into COVID-19 dashboard
The lead university as dashboard developer and
manager uploaded the documents from district
health offices and made a compilation and summary
of information from each document in the dashboard
Dissemination of results
The results of the intervention were disseminated by
the lead university to all those involved in efforts to
help maternal and child health and nutrition
programmes recover from the COVID-19 pandemic at
the national and regional levels (the health ministry,
participants from universities and health offices,
Indonesian family planning agency and
the general public)
Evaluation of results of the analysis
and reports
A meeting was held between the lead
university and the health ministry to
evaluate the activities and results
of the intervention
Data verification
District health offices were able to verify or change
the data displayed on the dashboard by contacting
their partner university
COVID-19: coronavirus disease 2019.
Note: Dark blue shading indicates that the step in the intervention protocol was implemented as intended; light blue shading indicates that the step was
implemented with modifications.
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Monitoring maternal and child health programmes, Indonesia
Siti Helmyati et al.
Papua Province), lack of appropriate
anthropometric measuring tools and
lack of trained staff. Furthermore, many
district offices reported poor internet
access and infrastructure.
Impact analysis
Fig. 2 maps the impact of the COVID-19
pandemic on key maternal and child
health and nutrition indicators across
districts of Indonesia as of 22 January 2021. Based on the analyses of
nutrition-related programmes in 260
priority districts, 23 districts (9%) were
severely affected by the pandemic, 101
districts (39%) moderately affected, 61
districts (23%) mildly affected and 75
districts (29%) could not be assessed
due to lack of data. Fig. 2 shows the
impact of the pandemic on maternal
and neonatal mortality indicators in 120
priority districts:15 districts (13%) were
severely affected, 59 districts (49%) were
moderately affected, and 46 districts
(38%) were mildly affected.
We also assessed the impact of the
COVID-19 pandemic on four of the six
nutrition indicators (Fig. 3) and eight
maternal and child health indicators
(Fig. 4) as of 22 January 2021. Growth
monitoring (nutrition indicators) and
maternal services coverage (at least four
visits; maternal and child health indicators) were the most affected (89 and 91
districts affected, respectively), while
vitamin A supplementation (nutrition
indicators) and family planning services
(maternal and child health indicators)
were the least affected (80 and 25 districts, respectively).
Policy analysis
The impact analysis was followed by
policy analysis and recommendations
for strategies to support maternal and
child health and nutrition programmes
during the pandemic (Box 2). The most
prominent follow-up actions suggested
by district offices and their partner university were improving the health information system; engaging the community
for action on maternal and child health
and nutrition programmes; and solving
underlying health-system problems such
as lack of staff and insufficient anthropometric measuring tools in field offices.
Discussion
We present our experience in developing
an approach to monitoring the impact
of the COVID-19 pandemic on key
Box 1. Challenges of implementing the intervention to maintain maternal and child
health and nutrition programmes during the COVID-19 pandemic, Indonesia
Challenges reported by staff of district health offices:
•
•
•
•
•
Backlog of work at the end of the year (44 respondents);
Small number of district office staff (27 respondents);
Poor internet access (19 respondents);
Rapid changes of staff of district office or community health centre (1 respondent);
Became ill with COVID-19 (1 respondent).
Challenges reported by staff of partner universities:
• Negative responses from the district office staff: slow or often late in giving response, did
not look interested or did not understand the aim of this study (31 respondents);
• Difficulty in coordination between university and district office or among programmes in
district offices (1 respondent);
• Poor communication between head of district office and maternal and child health and
nutrition implementer (1 respondent);
• Health office staff did not understand the type of data needed or how to analyse data (1
respondent);
• Prefer face-to-face monitoring and evaluation (1 respondent).
COVID-19: coronavirus disease 2019.
Note: The data are only from participants who offered their comments and therefore do not represent the
views of all participants.
components of the routine health-care
system in Indonesia.22 The intervention
allowed for rapid situation assessments
of the impact of the pandemic on mother
and child and nutrition programmes in
individual districts and nationwide. The
use of digital technology was effective
and time-efficient – factors which are
important in settings such as Indonesia
with a large population and diverse
geographical conditions, and during
external shocks such as a pandemic.
We found evidence of good feasibility of the online system. The health ministry fully supported using digital-based
routine data for monitoring essential
services, and strengthened the platforms
by further online training for district
offices after the required activities had
been completed. The intervention is in
line with World Health Organization’s
recommendation to use routine data
to maintain essential health services.22
The routine collection of nutrition and
maternal and child health indicators are
now digital-based and easier to use and
access. University staff found the online
system easier to operate and more efficient than paper-based and face-to-face
methods, especially after much of the
resources of district offices were diverted
to managing the COVID-19 pandemic.
Furthermore, the system was considered more convenient for universities,
particularly during travel restrictions.
University partners were enthusiastic
in assisting the district offices, in line
Bull World Health Organ 2022;100:144–154A| doi: http://dx.doi.org/10.2471/BLT.21.286636
with the culture of research and community service in higher education in
Indonesia.23 District offices recognized
the important role of universities in
improving their ability to analyse data
and make policy recommendations, and
the majority of them still communicated
with universities after the study ended.
There were challenges, however.
Fidelity to the intervention in terms
of adherence to standard protocols by
district office and university staff showed
some weaknesses. A major component
of the intervention was the analysis of
national routine data that were available
on the dashboard and were easy to access online for district offices. However,
several district officers preferred to use
their own data for analysis since they believed that these were more complete, up
to date and reliable than the data in the
national systems which were collected
by CHWs at integrated health posts who
were not properly trained. Furthermore,
data were not regularly updated by the
community health centre or district
offices due to limitations in human
resources, infrastructure and internet
access. These factors adversely affected
the completion of the intervention
activities by district offices, even with
supervision and encouragement from
their partner university. District offices
around the more remote eastern regions
and small islands of Indonesia were
especially affected. Poor adherence to
the intervention protocols highlighted
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Table 2. Challenges and innovations in the implementation of the intervention to maintain maternal and child health and nutrition
programmes during the COVID-19 pandemic, Indonesia, October–November 2020
Programme
component
Challenges
Innovations
Growth
monitoring
- Health ministry mandate to postpone services at
integrated health posts from March to August 2020 (but
still continue for areas with a high risk of COVID-19) led to
delays in growth monitoring
- Parents’ fears about COVID-19 meant that they did not
want to bring their child to integrated health posts for
anthropometric measurements
- Civil unrest in a district in Papua Province halted activities
at integrated health posts even before the COVID-19
pandemic started
- Some district offices reported that integrated health
posts did not have proper anthropometry gauges due to
shortages of human and financial resources
- Some district offices reported that they had not received
Supplementary
feeding
supplementary foods from the health ministry up to
September 2020
- District offices could not provide local supplementary
foods to mothers because of budget reallocation for
COVID-19 mitigation and delayed disbursement of foods
from the health ministry
- Civil unrest in a district in Papua Province halted activities
at integrated health posts even before the COVID-19
pandemic started
- Health workers had difficulty monitoring exclusive
Exclusive
breastfeeding
breastfeeding since services at integrated health posts
were halted and parents with newborns could not go to
community health centres. Health workers had to rely on
subjective answers from mothers in phone conversations
about exclusive breastfeeding
- Civil unrest in a district in Papua Province halted activities
at integrated health posts before the COVID-19 pandemic
started
- A district office in Bali Province reported that their CHWs
Vitamin A
supplementation
refused to distribute vitamin A supplements door-to-door
because of the risk of exposure to COVID-19
- Civil unrest in a district in Papua Province halted activities
at integrated health posts even before the COVID-19
pandemic started
Infant and young - District offices reported that budget reallocation for
child feeding
COVID-19 mitigation had led to postponement of the
infant and young child feeding programme
- Several district offices from remote areas reported that
they did not have trained staff in community health
centres to carry out infant and young child feeding
education for CHWs or mothers
- Civil unrest in a district in Papua Province halted activities
at integrated health posts even before the COVID-19
pandemic started
Integrated
management
of childhood
illnesses
- District offices who planned to start integrated
management of childhood illness in 2020 reported that
budget reallocation for COVID-19 mitigation had led to
postponement of the programme
- Several district offices reported they did not have trained
staff in community health centres
- Civil unrest in a district in Papua Province halted activities
at integrated health posts even before the COVID-19
pandemic started
- Health workers or CHWs carried out home visits to monitor
children aged 0–59 months old at risk of undernutrition
- Health workers created a group mobile phone chat with
parents to monitor the health condition of children aged
0–59 months and share health information
- Parents of children aged 0–59 months made an
appointment with health workers in community health
centres for anthropometry measurement
- Parents who had a bodyweight scale and were able to
measure body height or length at home would examine
their children then report the results to the health workers
by telephone
- CHWs made door-to-door distributions of supplementary
foods for children aged 0–59 months
- Health workers asked parents and their children to come
to the community health centre for anthropometry
measurements and receipt of supplementary foods (mostly
for children aged 0–59 months with malnutrition)
- Health workers monitored the programme’s coverage
using a mobile phone chat application. However,
the methods could not ensure whether mothers had
exclusively breastfed or not
- Health workers asked mothers to come to the community
health centre or vice versa when there was a nutrition
counselling session. The counselling would be face-to-face,
private and limited to 30 minutes
- Since in February 2020 no COVID-19 case was found in
Indonesia and in August 2020 the cases number had
lowered, the distribution of vitamin A supplements in most
districts was relatively stable
- Most district offices reported that health workers and
CHWs were willing to distribute supplements for children
aged 0–59 months door-to-door
- For districts that had carried out the infant and young child
feeding programme, health workers used a mobile phone
chat application to communicate with CHWs and mothers
and carried out online nutrition counselling sessions in
groups
- Community health centres that had conducted the infant
and young child feeding programme could invite mothers
or CHWs (in small groups or privately) to attend for a
counselling session. This activity depended on the severity
of COVID-19 in the areas
- Health workers could give counselling on infant and young
child feeding, especially for mothers of malnourished
children aged 0–59 months, when they came to the
community health centre for growth monitoring
- Several district offices reported that, whenever possible,
health workers would go to the homes of children aged
0–59 months and check their health condition
- Community health centres which already had an
integrated management of childhood illness service
modified examination rooms to separate patients with and
without signs and symptoms of respiratory illness
(continues. . .)
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(. . .continued)
Programme
component
First antenatal
care
Challenges
Innovations
- Some health facilities were temporarily closed due to staff
shortages when staff became infected with COVID-19
- Some parents were afraid of being exposed to COVID-19
when visiting health facilities
- Telemedicine was used so that pregnant women could
seek information about their pregnancy via social media
managed by community health centres, mother and child
clinics or health workers. Consultation with a midwife or
other health worker could also be done online
- Pregnant women could make an appointment in advance
or register online with the health facility to avoid crowding
at facilities
- Pregnant women could make an appointment with the
health facility for an examination to avoid crowding at
facilities
Maternal services - Many health staff at community health centres and
coverage
hospitals were diverted to COVID-19 activities (e.g. testing,
tracking and treatment), while other areas lacked staff
even before the pandemic
Births at health
- Health ministry mandate required all mothers to have a
care facilities
swab PCR for COVID-19 before giving birth
- Health facilities had staff shortages due to existing
health workers being diverted to deal with the COVID-19
pandemic
Complete
neonatal visit
- Parents were afraid of exposing their children to COVID-19
when visiting health facilities
Complete basic
immunization
- Parents were afraid of exposing their children to COVID-19
when visiting health facilities
Maternal
mortality
number
- Some health facilities were temporarily closed. At the
beginning of the pandemic, many health workers
were infected with COVID-19, so health facilities that
experienced a shortage of health workers chose to
temporarily close until the infected health workers
recovered
- Some pregnant mothers were infected with COVID-19
- Some pregnant mothers were late for antenatal care
appointments because health facilities were limiting
the numbers of patients seen to reduce the spread of
COVID-19
- Restrictions on community activities and regional
movement restrictions imposed by local governments
hampered the supply chain of contraceptive devices in the
regions
Family planning
- Health facilities could modify special delivery rooms to
handle delivering mothers with COVID-19 (e.g. providing
negative pressure delivery rooms to reduce the possibility
of transmitting the virus and to get immediate help
without having to be referred to a hospital specifically for
COVID-19)
- COVID-19 screening was provided for pregnant women in
the third trimester
- Parents could make an appointment with the health-care
facility or register their child online to get immunizations
according to the schedule of the midwife or facility
- Door-to-door health-care services were provided, so that
health workers such as midwives could make home visits
to check the health of newborns while minimizing the
transmission of COVID-19
- Parents could make an appointment with the health-care
facility and schedule the time and duration of examination
to avoid crowding at facilities
- Health facilities could modify special delivery rooms to
handle delivering mothers with COVID-19 (e.g. providing
negative pressure delivery rooms to reduce the possibility
of transmitting the virus and to get immediate help
without having to be referred to a hospital specifically for
COVID-19)
- Pregnant women could have PCR swab examination at
37 weeks of gestation at the community health centre or
nearest hospital
- Women who use contraceptives such as intrauterine
devices, implants or injections could contact the nearest
midwife or health facility to enquire about the availability
of the desired contraceptive
CHWs: community health workers; COVID-19: coronavirus disease 2019; PCR: polymerase chain reaction test.
Note: We analysed qualitative data extracted from the impact analysis documents written by district health office staff. Integrated health posts (posyandu) provide
community-based services focusing on maternal and child nutrition such as growth and development monitoring, nutrition counselling, immunization and
supplementary foods for malnourished children.
gaps in resources across Indonesia.
Furthermore, several district offices
reported that staff were reassigned to
handling the COVID-19 pandemic, and
therefore fewer staff were available to
manage maternal and child health and
nutrition programmes. High workloads
and administrative duties also hindered
the full participation of district offices in
the intervention activities.
We made several modifications to
accommodate the time-limitations and
the abilities of district offices since this
was their first experience with electronic
monitoring and evaluation. Despite
the circumstances, partner universities
continued to assist and supervise district
offices via online meetings, messages
and phone calls and to use available
routine health data for analysis. Universities emphasized the importance of
completing the activities in the protocol
and the benefits to district offices if they
were able to complete all the necessary
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documents for display on the dashboard, including gaining support from
the health ministry and stakeholders.
Nevertheless, several district offices
could not complete all the activities in
the given time.
The biggest challenge to effective
implementation of the intervention
was the inequalities in resources across
district offices and universities. Several district offices have few human
resources focusing on maternal and
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child health and nutrition programmes,
and some offices struggled to adjust
to an online-based work system. Furthermore, mobile phone and internet
networks are not equally available across
Indonesia, causing difficulties for several
participants. University staff too were
often unfamiliar with the data and how
the platforms worked, so additional
training was needed. Some university
staff were newly assigned to the district
offices, hence training for a consultant
role is continuously needed. Better
planning and leadership from the health
ministry is needed for the intervention
to be more effective.
Another weakness of the intervention was the uneven geographical distribution of partner universities, which
were mainly from highly populated Java
Island. To better assist the district offices,
a more diverse selection of universities
need to be engaged in the programme.
We also noted that district offices in
geographical proximity to universities
were more active and had better understanding about the COVID-19 impact
in their area.
The dashboard can rapidly display
the status of essential services across
regions or over time, which helped in
analysing the situation for further recommendations to relevant stakeholders.
After the dissemination of the results
of the monitoring and evaluation at
the end of 2020, there was a discussion
Fig. 2. Situation map of the severity of impact of the COVID-19 pandemic on maternal and child health and nutrition programmes across
Indonesian districts, 22 January 2021
Stunting priority districts
Maternal and neonatal mortality priority districts
Severe impact
Moderate impact
Mild impact
Impact could not be determined
No data available
COVID-19: coronavirus disease 2019.
Notes: Stunting priority districts (n = 260) and maternal and neonatal mortality priority districts (n = 120). Nutrition programmes were assessed based on six
indicators: Severe impact was defined as five to six out of six indicators being negatively affected by the pandemic, Moderate Impact was three to four indicators
affected, and Mild impact was one to two indicators affected. Cannot be determined was when there were insufficient reports to generate the composite index.
Maternal and child health programmes were assessed based on eight indicators: Severe impact was seven to eight indicators negatively affected by the pandemic,
Moderate impact was four to six indicators affected, and Mild impact was one to three indicators affected.
150
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Siti Helmyati et al.
among the health ministry, universities and family planning agency about
synchronizing the dashboards to the
routine national data collection platforms for nutrition and maternal and
child health indicators. Unfortunately,
the plan was postponed due to limited
funds from budget reallocation for handling COVID-19. The health ministry is
now focusing on strengthening routine
data use in community health centres
and district or provincial health offices.
The implementation was funded
by the health ministry at a total cost of
703.6 million Indonesian rupiahs, or
49 645 United States dollars (US$). The
funding was split into six categories:
implementation design, development
of programmes, training, analysis and
reporting, supervision of universities,
and universities’ fees, with the last
category receiving the largest share of
US$ 42 333. Given the large number of
district offices and universities involved
and the positive outcomes of the system,
we believe that the cost of the intervention was reasonable.
This study has some limitations.
First, the evaluations of fidelity and
feasibility were limited. We could only
identify participants’ adherence to standard protocols. Moreover, our primary
measure of adherence and exposure
were observations and questionnaire
surveys, although the latter could
not reach all participants. We did not
evaluate district offices on the quality of
training and development activities they
received, the professional supervision by
universities or the convenience of the
dashboard. The information we gathered was not measured through direct
surveys or evaluations. Second, there
was no comparison group to compare
the quality and delivery of training and
supervision. Third, the duration of the
monitoring and evaluation from planning to implementation was short, only
3 months, and operated at the end of the
year when district office staff reported
a backlog of work. The short timescale
of the intervention likely influenced
the willingness of district offices and
universities to complete the programme.
The implementation of the intervention has had some positive outcomes.
First, the health ministry, universities,
district health offices and other stakeholders have begun to appreciate the
benefit of routine health data and use
of information technology systems for
rapid health system assessment. Routine
Fig. 3. Impact analysis of the overall severity of impact of the COVID-19 pandemic on
key nutrition indicators across 260 priority districts, Indonesia, 22 January 2021
Vitamin A supplementation
80
Exclusive breastfeeding
77
Supplementary feeding
156
59
13 11
17
123
107
84
Growth monitoring
15
38
224
0
50
15 8 13
100
150
200
250 260
No. of health districts
Impacted by pandemic
Impact unclear from data
Not impacted by pandemic
No data available
COVID-19: coronavirus disease-2019.
Notes: Nutrition services were assessed based on six indicators but the chart shows only the four
indicators measured by quantitative methods; the other two indicators were based on subjective
opinions from the district health offices. Severe impact was defined as five to six out of six indicators
being negatively affected by the pandemic, Moderate impact was three to four indicators affected,
and Mild impact was one to two indicators affected. We also made a note of districts where there were
insufficient reports to generate the composite index. The numbers shown are the number of districts. For
nutrition programmes, Impacted means that the programme’s coverage in the district was negatively
impacted by the COVID-19 pandemic marked by a decrease of the coverage during the pandemic. Not
impacted means that the programme’s coverage was not negatively impacted marked by the stable
coverage during the pandemic. Impact unclear from data means the data and information provided was
ambiguous so no conclusions could be drawn.
Fig. 4. Impact analysis of the overall severity of impact of the COVID-19 pandemic on
key maternal and child health indicators across 120 priority districts, Indonesia,
22 January 2021
Family planning
25
Maternal mortality number
95
34
86
Complete basic immunization
66
54
Growth monitoring
89
Complete neonatal visit
31
54
66
60
Births at health-care facilities
60
91
Maternal services coverage
29
72
First antenatal care
0
20
48
40
60
80
100
120
No. of health districts
Impacted by pandemic
Not impacted by pandemic
COVID-19: coronavirus disease 2019.
Notes: Maternal and child services were assessed based on eight indicators: Severely affected was seven
to eight indicators negatively affected by the pandemic, Moderate impact was four to six indicators
affected, and Mild impact was if one to three indicators were affected. The numbers shown are the
number of districts. For maternal and child health programmes, Impacted means that the programme’s
coverage was negatively impacted by the COVID-19 pandemic marked by a decrease of the coverage
during the pandemic. Not Impacted means that the programme’s coverage was not negatively impacted
marked by stable coverage of the programme during the pandemic.
health data also avoid the need for and
reliance on costly health surveys. Participants understood the importance of
data quality and validity and the efforts
needed to improve the health information system. There is now an established
Bull World Health Organ 2022;100:144–154A| doi: http://dx.doi.org/10.2471/BLT.21.286636
network between universities and district
offices managing maternal and child
health and nutrition programmes, including data validation, which could lead
to better collaboration to improve the
quality of services delivery in the future.
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We also observed a positive longerterm impact following the intervention.
In 2021, the health ministry began using
training activities to further scale up
the use of national health routine data
for decision-making by district offices
Box 2. Strategies to support maternal and child health and nutrition programmes
during the COVID-19 pandemic, Indonesia
Adjusting to COVID-19 situation
•
•
•
•
Using information technology
Adding appropriate anthropometric measuring tools
Adding system for patients to book health centre appointments or home visits
Adding more protective equipment against COVID-19
Capacity-building
• Adding staff if needed
• Providing assistance for field officers
• Providing continued assistance for the district or provincial health offices
Strengthening intersectoral coordination
• Increasing interagency commitment to reducing the prevalence of maternal and child health
and nutrition problems (e.g. stunting and maternal and neonatal deaths)
• Ensuring that nutrition and health programmes can be carried out safely in conflict-affected
areas
Strengthening management system
• Increasing the role of the national routine databases as the basis for decision-making
• Adding information technology staff if necessary
Potential partners
•
•
•
•
•
•
•
•
Health ministry
Provincial health offices
District health offices
Provincial or district informatics and technology offices
Leaders of districts or provinces
Department of public works and public housing
District or city food security service
Community leaders, traditional leaders, religious leaders
and started collaborating with various
universities to strengthen the routine
data collection systems for maternal
and child health and nutrition indicators. The national population and family
planning agency, an agency mandated to
reduce stunting prevalence in Indonesia,
is now planning to cooperate with universities to assist districts in implementing, monitoring and evaluating stunting
reduction programmes.
Data integration would be important to improve maternal and child
health and nutrition programmes as
many of the variables are collected by
different units within the district offices
or by external agencies. This would allow
for more rapid analysis and programme
planning or recommendations.
The implementation of the electronic monitoring and evaluation has
offered the potential for better use
of routine health data in programme
monitoring and evaluation. The online
platform allows for better coverage
across countries with vast geographical areas and large populations. While
several modifications and continuous
improvement are pertinent, we propose
that a similar approach could be scaled
up to other programmes and beyond the
pandemic period. ■
Acknowledgements
TM is also affiliated with Nossal Institute
for Global Health, University of Melbourne, Parkville, Australia.
COVID-19: coronavirus disease 2019.
Competing interests: None declared.
ملخص
تأثرت خدمات صحة األم والطفل،النتائج يف غالبية املناطق
،الرئيسية وخدمات التغذية بشكل معتدل أو شديد نتيجة اجلائحة
تنوع.وال سيام متابعة نمو الطفل وخدمات الرعاية السابقة للوالدة
ولكن النظام ُيعد أسلو ًبا،التقيد بربوتوكول التدخل عرب املناطق
عمل ًيا لتوسيع نطاق التدخل ليشمل املناطق والربامج الصحية
ومكتب، إن االستيعاب الكبري بواسطة وزارة الصحة.األخرى
أدى إىل توفري املنصة بجهود، والرشكاء من اجلامعات،املنطقة
.تعاونية لتعزيز النظم الصحية
االستنتاج يمكن تنفيذ النظام اإللكرتوين للمراقبة والتقييم
وإكامله مع العديد من التعديالت الستيعاب مكاتب املقاطعات
هناك إمكانية لتوسيع نطاق التدخل من خالل تنفيذ.واجلامعات
.أفضل للتخطيط والتدريب
152
إندونيسيا،مراقبة استمرار خدمات صحة األم والطفل
الغرض تنفيذ نظام عرب اإلنرتنت لتقييم تأثري جائحة مرض فريوس
،( عىل صحة كل من األم والطفل19 )كوفيد2019 كورونا
.وخدمات التغذية الصحية األساسية يف إندونيسيا
ملساعدة،الطريقة قمنا بتطوير نظام إلكرتوين للمراقبة والتقييم
مكاتب الصحة يف املقاطعات يف إجراء تقييامت رسيعة لتأثري كوفيد
، وبرامج التغذية يف منطقتهم، عىل صحة كل من األم والطفل19
تم إجراء بحث.ويف تطوير االستجابات للسياسات والربامج
يف2020 كانون أول/أيلول إىل ديسمرب/التنفيذ هذا من سبتمرب
تكونت االسرتاتيجيات من املساعدة الفنية ملكاتب. منطقة304
وتطوير لوحة معلومات، جامعة رشيكة21 املقاطعات بواسطة
.عرب اإلنرتنت لتحليل املواقف وإعداد التقارير عىل وجه الرسعة
،قمنا بجمع بيانات نوعية حول اجلدوى من التدخل وااللتزام به
باإلضافة إىل بيانات كمية من قواعد البيانات الصحية الروتينية
وكذلك، عىل صحة كل من األم والطفل19 لتحليل تأثري كوفيد
.مؤرشات التغذية
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Siti Helmyati et al.
摘要
印度尼西亚 :监测母婴健康服务的连续性
目的 印度尼西亚实施电子系统来评估 2019 年冠状病
毒病 (COVID-19) 疫情对母婴健康和营养基本卫生服
务的影响。
方法 我们开发了一个电子监测和评估系统,以协助地
区卫生办公室快速评估新冠肺炎对其所在地区母婴健
康和营养计划的影响,并制定相关政策和计划响应。
该项研究于 2020 年 9 月至 12 月在 304 个地区实施。
这些战略包括由 21 所合作大学为地区办公室提供技
术援助,和开发用于快速分析和报告情况的在线仪表
板。我们收集了有关干预措施的可行性和依从性的定
性数据,以及来自常规健康数据库的定量数据,来分
析新冠肺炎对母婴健康和营养指标的影响。
结果 在大多数地区,重要的母婴健康和营养服务,特
别是儿童生长监测和产前护理服务,受到疫情的中度
或严重影响。各地区对干预方案的遵守情况各不相同,
但该系统是一种可行的方法,可以推广到其他地区和
卫生计划。卫生部、地区办公室和大学合作伙伴的高
度接受,为该平台提供了加强卫生系统的合作努力。
结论 电子监测和评估系统可以在进行修改后进行实施
和完成,以便适应地区办公室和大学。可以通过更好
的实施规划和培训,来扩大干预范围。
Résumé
Surveillance de la continuité des services de santé maternelle et infantile en Indonésie
Objectif Instaurer un système en ligne pour évaluer l'impact de la
pandémie de maladie à coronavirus 2019 (COVID-19) sur les services
essentiels de nutrition et de santé maternelle et infantile en Indonésie.
Méthodes Nous avons mis au point un système électronique de
surveillance et d'évaluation afin d'aider les bureaux de la santé des
districts à identifier rapidement les effets de la COVID-19 sur les
programmes de nutrition et de santé maternelle et infantile dans leur
région, et à déployer des politiques et programmes capables de les
contrer. Cette étude de mise en œuvre a été menée de septembre à
décembre 2020 dans 304 districts. Les stratégies prévoyaient de fournir
une assistance technique aux bureaux de district avec le concours de
21 universités partenaires, et de créer un tableau de bord en ligne
servant à établir rapidement des analyses et rapports de situation. Nous
avons récolté des données qualitatives sur la faisabilité et l'adhésion à
l'intervention, ainsi que des données quantitatives issues des bases
de données sur les soins de routine, en vue d'analyser l'impact de la
COVID-19 sur les indicateurs de nutrition et de santé maternelle et
infantile.
Résultats Dans la majorité des districts, les principaux services de
nutrition et de santé maternelle et infantile ont été modérément
ou gravement touchés par la pandémie, en particulier le suivi de la
croissance des enfants et les soins prénatals. Bien que le respect du
protocole d'intervention ait varié d'un district à l'autre, le système
constitue une approche envisageable pouvant être étendue à d'autres
régions et programmes de santé. La participation active et les efforts
conjoints du ministère de la Santé, des bureaux de district et des
partenaires universitaires ont permis à la plateforme de renforcer les
systèmes de santé.
Conclusion Le système électronique de surveillance et d'évaluation
pourrait être appliqué et accompagné de plusieurs modifications
pour s'adapter aux différents bureaux de district et universités. Cette
intervention peut être amenée à se développer en améliorant la
formation et la planification de la mise en œuvre.
Резюме
Внедрение электронной системы для поддержки программ в области охраны здоровья матери и
ребенка во время пандемии COVID-19, Индонезия
Цель Внедрить онлайновую систему для оценки влияния
пандемии коронавирусной инфекции 2019 года (COVID-19) на
основные услуги в области охраны здоровья и обеспечения
питания матери и ребенка в Индонезии.
Методы Авторы разработали электронную систему мониторинга
и оценки, чтобы помочь районным отделениям здравоохранения
быстро оценить влияние COVID-19 на программы в области
охраны здоровья и обеспечения питания матери и ребенка в
своем регионе, а также разработать политику и программные
меры реагирования. Такое имплементационное исследование
проводилось с сентября по декабрь 2020 года в 304 районах.
Стратегии вк лючали техническую помощь районным
отделениям со стороны 21 университета-партнера и разработку
онлайновой информационной панели для быстрого анализа
ситуации и отчетности. Были собраны качественные данные о
целесообразности и последовательном исполнении данного
мероприятия, а также количественные данные из стандартных
баз данных о здравоохранении для анализа влияния COVID-19
на показатели состояния здоровья и питания матери и ребенка.
Результаты В большинстве районов основные услуги в области
охраны здоровья и обеспечения питания матери и ребенка
пострадали от пандемии в умеренной или серьезной степени,
особенно услуги по мониторингу развития детей и дородовой
помощи. Соблюдение протокола мероприятия разнилось в
зависимости от района, но эта система представляет собой
вполне реализуемый подход, который можно внедрять в других
регионах и программах здравоохранения. Высокая популярность
платформы на уровне Министерства здравоохранения, районного
отделения и университетов-партнеров послужила основой для
сотрудничества по укреплению систем здравоохранения.
Вывод Электронную систему мониторинга и оценки можно
внедрять, а также можно вносить в нее изменения с учетом
районных отделений и университетов. Существуют возможности
для расширения масштабов мероприятия за счет лучшего
планирования его внедрения и подготовки кадров.
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Resumen
Supervisión sobre la continuidad de los servicios de salud maternoinfantil en Indonesia
Objetivo Aplicar un sistema en línea para evaluar los efectos de la
pandemia de la coronavirosis de 2019 (COVID-19) en los servicios
sanitarios esenciales de salud y nutrición maternoinfantil en Indonesia.
Métodos Se desarrolló un sistema electrónico de supervisión y de
evaluación para ayudar a las oficinas distritales de salud a realizar
evaluaciones rápidas sobre los efectos de la COVID-19 en los programas
de salud y nutrición maternoinfantil en su zona y a elaborar respuestas
normativas y programáticas. Esta investigación de aplicación se llevó a
cabo de septiembre a diciembre de 2020 en 304 distritos. Las estrategias
consistieron en la asistencia técnica a las oficinas de distrito a cargo de
21 universidades asociadas y el desarrollo de un tablero de mando en
línea para realizar análisis rápidos de la situación y presentar informes.
Se recopilaron datos cualitativos sobre la viabilidad y la adhesión a la
intervención, así como datos cuantitativos de las bases de datos de salud
sistemáticas para analizar los efectos de la COVID-19 en los indicadores
de salud y nutrición maternoinfantil.
Resultados En la mayoría de los distritos, los servicios clave de salud y
nutrición maternoinfantil se vieron moderada o gravemente afectados
como consecuencia de la pandemia, en especial la supervisión del
crecimiento infantil y los servicios de asistencia prenatal. La adhesión
al protocolo de la intervención varió en los diferentes distritos, pero el
sistema es un método viable que se puede ampliar a otras regiones y
programas sanitarios. La participación activa del ministerio de sanidad, la
oficina del distrito y los socios universitarios proporcionó una plataforma
de colaboración para el fortalecimiento de los sistemas sanitarios.
Conclusión El sistema electrónico de supervisión y de evaluación podría
aplicarse y completarse con varias modificaciones que se adapten a las
oficinas de distrito y a las universidades. Existe la posibilidad de ampliar
la intervención mediante la mejora de la formación y la planificación
de la aplicación.
References
1.
[Main results of the basic health research 2018.] Jakarta: Indonesian Ministry
of Health; 2018. Indonesian. Available from: http://www.depkes.go.id/
resources/download/info-terkini/hasil-riskesdas-2018.pdf [cited 2019 May
13].
2. Global nutrition reports: country nutrition profiles [internet]. Bristol:
Development Initiatives Poverty Research Ltd; 2016. Available from: https://
globalnutritionreport.org/resources/nutrition-profiles/latin-america-and
-caribbean/central-america/mexico/ [cited 2021 Feb 12].
3. United Nations Children’s Fund, World Health Organization, International
Bank for Reconstruction and Development/World Bank. Levels and trends
in child malnutrition. Geneva: World Health Organization; 2019. Available
from: https://www.who.int/nutgrowthdb/jme-2019-key-findings.pdf [cited
2020 Aug 30].
4. Global health observatory. Maternal mortality: situation by country
[internet]. Geneva: World Health Organization; 2020. Available from: https://
www.who.int/gho/maternal_health/mortality/maternal/en/ [cited 2020
Aug 30].
5. Global health observatory data repository: child mortality. Geneva: World
Health Organization; 2020. Available from: https://apps.who.int/gho/data/
view.main.CM1300R?lang=en [cited 2021 Feb 12].
6. Under-five mortality [internet]. New York: United Nations Inter-agency
Group for Child Mortality Estimation; 2020. Available from: https://data
.unicef.org/topic/child-survival/under-five-mortality/ [cited 2021 Feb 12].
7. Nutrition capacity in Indonesia. Jakarta: United Nations Children’s Fund
Indonesia; 2018. Available from: https://www.unicef.org/indonesia/media/
1816/file/Nutrition Assessment 2018.pdf [cited 2021 Feb 12].
8. Monitoring, evaluation, accountability and learning – MEAL. Country
dashboard 2018: Indonesia [internet]. Geneva: Scaling Up Nutrition; 2018.
Available from: http://bit.ly/sunmeal [cited 2021 Feb 12].
9. [100 priority districts/cities for stunting intervention] [internet]. Jakarta:
National Team for the Acceleration of Poverty Reduction; 2017. Indonesian.
Available from: http://www.tnp2k.go.id/images/uploads/downloads/Buku
Ringkasan Stunting.pdf [cited 2020 Aug 30].
10. [Situation of stunted toddlers in Indonesia.] Jakarta: Indonesian Ministry of
Health; 2018. Indonesian. Available from: https://pusdatin.kemkes.go.id/
download.php?file=download/pusdatin/buletin/Buletin-Stunting-2018.pdf
[cited 2020 Aug 30].
11. Maintaining essential health services: operational guidance for the
COVID-19 context, interim guidance, 1 June 2020. Geneva: World Health
Organization; 2020. Available from: https://www.who.int/publications/i/
item/WHO-2019-nCoV-essential_health_services-2020.2 [cited 2020 Aug
30].
12. Akseer N, Kandru G, Keats EC, Bhutta ZA. COVID-19 pandemic and
mitigation strategies: implications for maternal and child health and
nutrition. Am J Clin Nutr. 2020 Aug 1;112(2):251–6. doi: http://dx.doi.org/10
.1093/ajcn/nqaa171 PMID: 32559276
154
13. Headey D, Heidkamp R, Osendarp S, Ruel M, Scott N, Black R, et al.;
Standing Together for Nutrition consortium. Impacts of COVID-19 on
childhood malnutrition and nutrition-related mortality. Lancet. 2020
Aug 22;396(10250):519–21. doi: http://dx.doi.org/10.1016/S0140
-6736(20)31647-0 PMID: 32730743
14. Ratcliffe R. Covid patients turned away as hospitals in Indonesia face
collapse. The Guardian. 2021 Jan 26. Available from: https://www
.theguardian.com/world/2021/jan/26/covid-patients-turned-away-as
-hospitals-in-indonesia-face-collapse [cited 2021 Feb 13].
15. Indonesian health system might collapse soon: COVID-19 task force. The
Jakarta Post. 2020 Sep 22. Available from: https://www.thejakartapost.com/
news/2020/09/22/indonesian-health-system-might-collapse-soon-covid
-19-task-force.html [cited 2021 Feb 13].
16. Hodge A. Coronavirus: Jakarta hospitals at point of collapse. The Australian.
2021 Jan 21. Available from: https://www.theaustralian.com.au/world/
coronavirus-jakarta-hospitals-at-point-of-collapse/news-story/e6
af297922ee5fc3cd34d1c4d8d3971f [cited 2021 Feb 13].
17. Food and nutrition network [internet]. Jakarta: Jaringan Pangan dan Gizi;
2021. Available from: https://jpg-indonesia.net/ [cited 2021 Dec 15].
18. Maternal and child health [internet]. Jakarta: Kesehatan Ibu dan Anak; 2021.
Available from: https://kesehatan-ibuanak.net/ [cited 2021 Dec 15].
19. National COVID-19 impact situation map: nutrition programmes [internet].
Jakarta: Pulih COVID-19 Gizi; 2021. Available from: https://pkmk-ugm
.shinyapps.io/PulihCovidGizi/_w_60a9edbf/ [cited 2021 Dec 15].
20. National COVID-19 impact situation map: maternal and child health
programmes [internet]. Jakarta: Pulih COVID-19 Gizi; 2021. Available from:
https://pkmk-ugm.shinyapps.io/pulihcovid/_w_59d4904b/ [cited 2021 Dec
15].
21. Helmyati S, Dipo DP, Adiwibowo IR, Wigati M, Safika EL, Hariawan MH, et
al. Electronic monitoring and evaluation system to maintain maternal and
child health programmes during COVID-19 pandemic in Indonesia: an
implementation research. Supplementary files [data repository]. London:
figshare; 2021. doi: http://dx.doi.org/10.6084/m9.figshare.17170739doi:
http://dx.doi.org/10.6084/m9.figshare.17170739
22. Analysing and using routine data to monitor the effects of COVID-19 on
essential health services: practical guide for national and subnational
decision-makers. Geneva: World Health Organization; 2021. Available from:
https://www.who.int/publications/i/item/who-2019-nCoV-essential-health
-services-monitoring-2021-1 [cited 2021 Feb 13].
23. Istambul MR. The impact of i-performance in changing the work culture of
lecturers to increase the productivity of three pillars (tri dharma) of higher
education in Indonesia. Univers J Educ Res. 2019;7 4A:15–21. doi: http://dx
.doi.org/10.13189/ujer.2019.071403
Bull World Health Organ 2022;100:144–154A| doi: http://dx.doi.org/10.2471/BLT.21.286636
Research
Monitoring maternal and child health programmes, Indonesia
Siti Helmyati et al.
Table 1. Feasibility of the intervention to support maternal and child health and nutrition programmes during the COVID-19 pandemic,
Indonesia
Implementation
outcome
Feasibility
Fidelity
Data availability
Impact of the
COVID-19 pandemic
on maternal and child
health and nutrition
services
Staff development
programmes
Dashboard
University supervision
Dashboard development
Feasibility of universities
providing assistance to
several district health offices
within a certain period of
time
Universities’ compliance in
providing assistance to the
district offices in accordance
with predetermined standard
operating procedures
Suitability of the online
dashboard to be developed
and synchronized with the
national data collection
system
Suitability of the online
dashboard as a platform to
provide data analysis and
policy recommendations
quickly, precisely and
accurately
Availability of data to display
information in the online
dashboard
Observations,
questionnaire
surveys
The programme was feasible
for district health offices and
universities with good internet
access
Observations,
questionnaire
surveys
Some modifications were made
to accommodate the timelimitations and abilities of district
health offices
Observations,
questionnaire
surveys
Not every district health office
had available data in the online
dashboard to be analysed
Availability of information
about the impact of the
pandemic on maternal and
child health and nutrition
services
Observations,
discussions,
questionnaire
surveys
The majority of district health
offices were able to complete
the documents for assessing
the impact of the pandemic on
maternal and child health and
nutrition services
NA
Observations,
discussions
Availability of website and
online dashboard that can
be used to display and
find information about the
impact of the pandemic on
maternal and child health
and nutrition services
Observations,
discussions
Capacity-building was provided
for universities to become
consultants to district health
offices. Training was given to
universities and district health
offices on quantitative and
qualitative data collection and
analysis. Participants were
introduced to the dashboard
as the main platform of the
programme
Websites and example
dashboards are available
online17–20
Availability of data in district
offices to be analysed into
information about the impact
of the COVID-19 pandemic
Availability of documents
prepared by the district
offices, as supervised by
universities, as a source of
information about the impact
of the pandemic on maternal
and child health and nutrition
services
Type of staff development
programme delivered to
universities and district offices
NA
Data sources
Outcome
COVID-19: coronavirus disease 2019; NA: not applicable.
Bull World Health Organ 2022;100:144–154A| doi: http://dx.doi.org/10.2471/BLT.21.286636
154A