Improving Health Of The Left-Behinds: The Case Of Indonesia’s Nusantara Sehat A Quantitative Evaluation Study

The Ministry of Health, Government of Indonesia launched the Nusantara Sehat (NS), a team-based health workforce deployment program, in 2015. This program addresses the maldistribution of the health workforce in remote areas by deploying five mixed health workforces for two years in each selected site. In addition, this program aims to support the implementation of the Healthy Indonesia Program Through the Family  Approach (Program Indonesia Sehat dengan Pendekatan Keluarga: PIS-PK) to strengthen primary health services in remote, border, and underserved areas (Daerah Tertinggal, Perbatasan, dan Kepulauan: DTPK) through the preventive and promotive approach. The NS was initially deployed in 120 selected sites across 44 DTPK. As of February 2019, the program has been expanded to cover 216 community health centers (Pusat Kesehatan Masyarakat: Puskesmas) across 131 districts in 19 provinces.

In this study, we aim to evaluate the effect of NS deployment to support the achievement of PIS-PK indicators at the deployed sites. Although the randomized setting that is usually considered as the gold standard for evaluation was not possible, we minimized potential sources of bias by independently selecting the treatment and control groups from the same or nearby districts to obtain similar characteristics. In addition, we also used an evaluation method that is addressing the factors that might change the outcome in the absence of NS, such as the endowment effect and the macro trend factors.

The evaluation finds evidence to suggest that NS improved access to maternal health services, such as maternal delivery by a skilled health worker by 5.7 percentage point (pp) and pregnancy checks in Puskesmas 6.7 pp. NS also improves TB symptom detection by 2.9 pp. Regarding the quality of access, NS has also contributed to the growth and development of children under five years of age as it improves health promotion and counseling during Posyandu1 visits by 13.6 and 11.9 pp respectively. Furthermore, NS also enhanced knowledge related to the importance of Oralit treatment during diarrhea (14.2 pp), the importance of preventing dehydration in toddlers (14.4 pp), first aid for toddlers during fever (10.9 pp) and knowledge of JKN (Jaminan Kesehatan Nasional: National Health Insurance) for family planning services (8.1 pp). For the behavioral aspect, NS has encouraged the community to engage in more frequent physical activities (14.1 pp). As we only conducted an evaluation study over a one-year period, we might have some limitations in detecting effects on behavior that may take longer to change.

As there is still room for NS improvement, we recommend that the Ministry of Health conduct a more comprehensive pre-departure training for workforce teams. This should consist of modules or sessions that cover: (i) the soft skills needed to deliver health promotion and prevention activities at the community level, aligned with the PIS-PK main approach; (ii) advocacy skills with relevant stakeholders to gain support delivering the PIS-PK programs at the community level; and (iii) in-depth materials for each of the PIS-PK. 

To be more effective, NS would also need support from local governments. This support could come in many forms that would facilitate more effective delivery of NS activities in the field. In terms of budgeting, local governments could allocate some of their DAK-fisik, DAK-nonfisik, APBD,2, or the Village Fund to strengthen NS/Puskesmas’ activities.