By Ralalicia Limato and Rukhsana Ahmed
Most Significant Change (MSC) is one of several methods used by the REACHOUT Indonesia team to monitor and evaluate the first quality improvement cycle. The quality improvement cycle took place from January to August 2015 in Ciranjang sub-district in Cianjur district and focused on health promotion, supportive supervision and community engagement. The four villages selected for the study interventions were Ciranjang, Mekargalih, Karangwangi, and Sindangsari.
MSC is a participatory M&E process in which beneficiaries evaluate the success of a programme through stories. This approach creates better opportunities for communication between programme implementers, stakeholders and beneficiaries to feedback and to plan programme revisions. In addition, offers the opportunity for the programme implementers and stakeholders to understand why changes happen or do not happen after a programme is implemented. Furthermore, it can identify and strengthen the capacity of programme implementers and stakeholders.
The MSC process includes eight main activities: clarification of the aim of MSC approach, determining the domain (indicator), collecting and writing stories, selecting the most significant story, feeding back of the result, result verification, monitoring and secondary analysis and programme revision.
Preparation: Before conducting the MSC series, we held discussions with the stakeholders from the District Health Office, Cianjur and Puskesmas, Ciranjang and: raised their interest; developed instruments; determined the beneficiaries for the interviews; planned the panel discussion, data analysis, how to feedback and verify the results, and programme revision.
Collecting and writing stories: Three village midwives, eight kaders (village health volunteers) and four mothers participated in the interviews. The village midwives and kaders had participated in REACHOUT health promotion and/or supervision trainings. The mothers were those who routinely attended the Posyandu services before, during and after we conducted the trainings for the village midwives and kaders. Prior to the interviews, consent was obtained from the beneficiaries to record the interview and for the panel to select as the most significant story and to publish the story using the name of the beneficiary. The questions used to prompt the beneficiaries during the interview were “Have you observed or experienced any changes in the services and activities in the Posyandu in the last six months/after health promotion and/or supervision training?” “What are the changes?” “Amongst all the changes you observed, which one do you consider is the most significant change?” “What are the reasons for selecting it?” “Why has this change happen?” The interviews lasted between 15 to 30 minutes and the stories were written by the researchers according to how the story was related by the beneficiary, transcribed into Indonesian and translated into English.
Selecting the most significant story: The panel meeting to select the most significant story was held on 6 October 2015. The panelists consisted of those who are responsible for programme revisions in the future and included stakeholders from different levels of health system: Puskesmas (community health center), the District Health Office and programme implementers. The panel included the Head of Maternal and Child Health division and the Programmer of Maternal Health at the District Health Office, Cianjur, the Head of Puskesmas, the Midwife Coordinator and the Health Promotion Officer of the Puskesmas Ciranjang. The country coordinator and senior research associate from REACHOUT Indonesia represented the intervention implementers. Panelists were divided into two groups (A and B), each group consisted of one or two representative from the Puskesmas, DHO and REACHOUT Indonesia: four members in group A and three in group B. The facilitators divided the 15 stories between the two groups. The members of group A read seven stories and group B read eight stories. Each group panelist selected the story he/she considered the most significant and shared it with the rest of the group. After discussions on “for and against” each group selected the one most significant story. Thereafter, the two groups presented and discussed their selected stories to select one most significant story. This story was from Ms. Santi from Ciranjang village.
Ms. Santi is a mother who routinely visited Posyandu Kamboja for antenatal care during her pregnancy. The story of Ms Santi highlighted the success of the intervention from the client or mother’s view which was one important reason considered for the selection of the most significant story. She clearly stated the changes she had observed and experienced about the Posyandu services before and after the kaders had the health promotion training. As an example she stated that there was better Posyandu management, kaders were more knowledgeable and became more attentive after the training. In addition, she mentioned support from the head of neighbourhood association and community association. The most significant change that Ms. Santi experienced was that the health information the kaders delivered was more comprehensive and the kaders showed more attention to the Posyandu visitors. This story was verified by the Health Promotion Officer from the Puskemas, who mentioned that the kaders in Posyandu Kamboja had become more skillful in delivering health counseling.
Feedback and verification: The story was fed back to Ms. Santi, and she had no objection regarding the content of the story and how it was written. The truth of the story was also verified by village midwives and kaders after the panel discussion. The story will be submitted to the DHO, Puskesmas Ciranjang and village stakeholder for advocacy material.
Action plan: Several suggestions relating to the quality improvement cycle surfaced after the panel discussions and included the training of trainers of health promotion and supervision, advocacy with the district government to pay more attention to maternal health problems in Cianjur, monitoring and evaluation of village midwives and kaders and financing of the follow-up interventions in the next cycle. We will discuss this further in a series of small meeting to be held in the future.
Area: Puskesmas Ciranjang
Type of participant: Mother
“I think Posyandu Kamboja has become more comfortable and organized since kaders attended training. Back then, the service schedule between pregnant women and toddlers were not divided and it resulted in long queue and chaotic services because Posyandu visitors did not want to queue and everyone wanted to be served immediately. Now, after the service schedule between pregnant women and toddlers is divided, Posyandu becomes more organized and pregnant women feel more comfortable to tell kaders their problems because there is no distraction of the babies crying. Moreover, I see that kaders are more frequent in doing counseling, while previously only kader Enok, was doing the counseling. This situation is different from current situation where all kaders are more confident in delivering health counseling.
In my opinion, the most significant change happened in Posyandu is kaders deliver more comprehensive information after participation in the training. The way kaders communicate the information is better and it makes us understand more about the message. Previously, kaders were less knowledgeable, and when mothers shared problems to a kader, they day dreamed before answering the questions. Now, kaders give complete and detail information to us, and also directly practice it. Back then, only Ms. Enok who had good knowledge, the other kaders were only helping her. Now, kaders tasks are well distributed including writing KMS (healthy book), doing the weighing and recording data in the registration book. Previously, all tasks were done by Ms. Enok alone. Now, everything is organized because all kaders are capable to carry out their tasks.
Furthermore, after the kaders received training, I observed kaders were showing more attention to Posyandu visitors. For example, previously, the information about delivery was only delivered as a short notice from kaders. Now, kaders also give information that pregnant women with labour signs should seek helps immediately. I used to ask something to kader, but only Ms. Enok could answer it and other kaders were unable to answer. This is maybe because of their limited knowledge. Now, they are able to provide comprehensive information with some examples, and what the pregnant women must do if something happens. When I asked kader about nutrition for my child, kader explained me about the food that can be consumed by my child so I can prepare it at home. I think all the changes happen because of the willingness of the kaders to improve their knowledge, and also because the support from the head of neighborhood association and community association. The new head of community association is more attentive, displayed in their support to provide venue for Posyandu and it resulted in more organized Posyandu services. Previously, we used simple wooden baby weight scale and there was no private room for examination. Now, the head of community association provides space for Posyandu services.
I observed, after training, kaders are more prepared in responding our complaints. If someone is sick, kaders are ready to escort him/her to Puskesmas. The kaders also told us to immediately call them if we need help. I feel that the way kaders giving the information is very helpful because the community knowledge about health is still low. If I go for consultation with private doctor or private midwife, then I have to pay. Meanwhile I can obtain this information in Posyandu for free”.
This project is funded by the European Union.