Study Menjaga: A Cluster Randomised Control Trial of Continuous Quality Improvement to Improve Antenatal HIV, Syphilis and Hepatitis B Detection and Treatment in Indonesia

From the outset, MENJAGA was designed not only to increase testing coverage figures but to build a new culture within antenatal services — one emphasizing root cause analysis, daily use of data, and consistent incremental improvement.

In Bandung and Bogor, 22 intervention puskesmas applied Plan–Do–Study–Act (PDSA) cycles to map barriers at their facilities: from uneven distribution of reagent supplies and unclear referral pathways, to low test demand from pregnant women, and recording systems that made data difficult to track.

Through this process, puskesmas found that small changes could trigger significant impact. In Rumpin, Bogor Regency, the village-level innovation “BUMIL P3DE – Pregnant Women Tested for 3 at the Village” increased first-trimester testing coverage from 50% to 126.8% within months.

In Bandung, a network with private midwives was systematically established, so that triple elimination examinations previously fragmented across providers are now recorded, monitored, and mutually supportive.

One strength of MENJAGA lies in the relationships built with health workers. In Bogor, geographical challenges and access limitations initially raised doubts about whether change could occur quickly.

However, monitoring visits from the health office and the Indonesian Midwives Association (IBI) generated new motivation: puskesmas staff felt they were not working alone.

“Discussing with several puskesmas was very eye-opening. We learned that the challenges in each area are different, and from those differences, innovations emerge that are suited to field conditions.”

Health worker from Puskesmas Ciomas

The outcomes that followed were not only improved testing figures but a shift in mindset — that service improvement can emerge from collective strength.

In Bandung, the biggest challenge arose from inconsistent recording and reporting. With the CQI approach, health workers began to see data not as an administrative burden but as a tool for understanding risk and ensuring every pregnant woman received timely testing.

“The impact of CQI training on recording and reporting has been tremendous. We felt guided and reminded again of the importance of timeliness.”

Health worker from Puskesmas Ciomas

Collaboration with private midwives, cross-puskesmas learning forums, and the formation of cross-programme teams reinforced this improvement process from multiple directions.

The MENJAGA Study demonstrates that improving antenatal services does not necessarily depend on short-term projects or large additional resources.

When puskesmas are given space to analyze their own problems, lead change, and receive support from a cross-sector network, improvements in service quality can occur more quickly and sustainably.

Achievements ranging from increased testing coverage to the establishment of formal MoUs with private midwives confirm that health workers have considerable capacity to strengthen services when provided with the right tools and space.

The national dissemination of study findings in May 2025 marked an important milestone. Researchers hope that MENJAGA’s findings will serve not only as a research report but as the basis for national programme improvement.

With a spirit of collaboration, a data-driven approach, and the commitment of puskesmas to continuously improve systems from within, the MENJAGA Study offers new hope for achieving triple elimination in Indonesia — a significant step towards stronger, more inclusive, and sustainable maternal and child health services.