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Good Health Begins at Home | ||||||||
| MDGs |
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| 4 | Child Mortality |
| 5 | Maternal Health |
For the ramshackle village of Tajepan, deep in Indonesia’s rural Central Kalimantan Province, the mighty Kapuas River brings life and livelihood— as well as death and disease.
The tenant farmers and fisherfolk, living in their simple wooden dwellings on stilts along its banks, draw on the river for their income and sustenance. They use it for washing clothes and dishes, bathing, and drinking. But it also serves as their toilet and waste dump.
“I am immune to any problems from the river water,” declares Basrah, who lives with her family in a wooden shack atop the river. At the back of her house is a platform at the water’s edge where she collects all her family’s drinking and washing water. Just above is the makeshift toilet, a small opening below which flows the murky brown river waters.
A weather-beaten and wizened 30 something—she has no idea of her exact age—she has borne six children, the second of whom died in infancy of diarrhea. But she does not make any connection with her contaminated water source.
“It was not the fault of the river water, it was just the season for diarrhea—everybody had it,” she says.
Changing such ingrained and unhealthy attitudes, which have a profound impact particularly on infant and child health, has been a slow process in rural areas where poverty, ignorance, and isolation form an unholy trinity against improving family health and nutrition habits.
But an ADB-funded Family Health and Nutrition Project has been making inroads into raising family sanitation and health standards in remote rural areas of five farflung provinces of Indonesia—Bengkulu, Jambi, Central and South Kalimantan, and North Sumatra.
"The most important issue has been to change the behavior of the community and create ‘family-friendly health centers’ that are more client oriented"
Sulistianto, South Kalimantan Project Coordinator
Approved in 1996 with a loan of $45 million, the project has been working in the villages to create partnerships between families and the staff of the puskesmas, the vast network of local health centers. Together they have been trying to improve family health and nutrition, lower maternal and infant mortality rates, reduce disease levels, and raise life expectancy— targets that today are also embraced in the Millennium Development Goals (MDGs).
“Through assistance such as this project, ADB has been supporting the basic priorities that have, subsequently, been formulated into the MDGs,” says Jacques Jeugmans, ADB Senior Social Sectors Specialist and original mission leader for the project.
By the early 1990s, when the project was being drawn up, Indonesia had made rapid progress in improving its health indicators. This trend continued through the project period, despite economic and political turmoil, and the fallout from growing decentralization.
According to ADB’s Key Indicators of Developing Asia and the Pacific 2003, Indonesia’s infant deaths declined from 46 per 1,000 live births in 1995 to 33 in 2001. Over the same period, maternal mortality per 100,000 live births more than halved from 470 to 213. Despite a narrowing gap, these figures are still high compared with Indonesia’s neighbors, such as the Philippines.
“Improving maternal and child health was the ultimate goal of the project,” says Sulistianto, the South Kalimantan Project Coordinator. “The most important issue has been to change the behavior of the community and create ‘family-friendly health centers’ that are more client oriented.”
Over the years, a combination of traditional beliefs and low-quality services had contributed to low use of health facilities. The project aimed to mobilize community groups, comprising 10 groups of 10 people in each village, to identify their problems and take responsibility for addressing them.
Under the project, village groups were set up to discuss and prioritize local health problems. “Among the issues that came up repeatedly were the need for clean water, which is more effective in the long term to fight diarrhea and skin diseases than drugs, and better nutrition,” Mr. Jeugmans adds.
The role of the health center is to provide medical advice and recommend solutions to the problems identified. Each family received a health card listing the priorities that had been established in their consultations with the local community. This gives a complete record of the family’s health status and basic needs.
Another priority identified under the project was raising incomes. The project, using also the Government’s counterpart funds, thus set up small loans to create income-generating schemes for the members, including cattle raising, duck farming, and savings and loan activities. Revolving funds were also made available for members to upgrade their homes.
For example, in Kurau, in the Tanah Laut district of Pelaihari, South Kalimantan, the fund was used as seed money to build family toilets. A small loan was given to two families. When they built their facility and repaid the loan, the repayment would provide funds and a model for the next families, and so on, in a chain. Now almost all families in the area have their own toilets.
To spread the message on health and nutrition, especially to those in more inaccessible areas, the health centers have resorted to varied means, including doorto- door outreach conducted by midwives (see story, p 29).
Fahrinawati, a midwife handling Haniljayam village about 3 kilometers from the Kurau health center, services about 30 women needing neonatal care or information about contraceptive options. “In the past, families came to the clinic only when they faced some serious illness,” she says. “Now we find it much more effective to go to the patients as part of our outreach.
While such midwives play a key role in maintaining personal contact with patients, there are other means of conducting health campaigns. For example, Kurau health center broadcasts its own community radio shows each morning, offering a mix of entertainment and music interspersed with health messages on sanitation and problem illnesses, such as malaria. In Pelaihari, staff visit schools where they sing, hold drawing competitions and traditional performances, and even sometimes teach in the classrooms directly.
The health centers’ message on the importance of sanitation, clean water, and a balanced diet that includes fruit and vegetables—all of which have a particular impact on child and maternal health— is getting through in some areas.
“The project has helped empower the community, making the people well informed and willing to access the health center,” says R.A. Vivi Mariana, who has been working for four years as the doctor in charge of the Pelaihari center as part of her government requirement to be assigned to remote areas for five years following medical training.
SAFETY FIRST Prenatal checks at Kuala Kapua’s Health Center, Central Kalimantan
“In the past, the focus was on curative treatment. Now we do outreach work on prevention and promotion,” she says. “People need to know how to come to the health center. But more important is how to prevent sickness in the first place.”
However, getting people to look for treatment from health professionals is only half the battle. They need better services once they get there. The project has trained health clinic staff to take more clientoriented approaches, working with the community health groups rather than imposing the central Government’s health priorities.
Still, as the case of Tajepan shows, health behavior cannot be changed overnight. “It will take years to see the full impact of the project as it takes a long time to alter people’s behavior,” says Manahan Pangaribuan, the new head of health services for South Kalimantan. “The challenge is how to replicate the project in other districts, as funds are limited.
“We have been persuading heads of districts to provide counterpart funding,” he says. “We will see later in the year if we have been successful. We are also hoping to find linkages with new and future ADB health projects.”
ADB recently approved a Second Decentralized Health Services Project (covering South and Central Kalimantan), which could continue the activities of the Family Health and Nutrition Project. To continue support to the Government in improving nutrition and household food security, ADB last year approved $500,000 for a technical assistance grant that will design an urban nutrition management model through a public-private partnership, in support of the first MDG of eradicating extreme poverty and hunger by 2015.
"Among
the issues that came up repeatedly were the need for clean
water and better nutrition"
Jacques Jeugmans, ADB Senior Social Sectors Specialist
For many, the Family Health and Nutrition Project, which closed at the end of 2003, has already marked a revolution in their approach to health, hygiene, and nutrition. Asmail Idup, one of the group leaders of the health membership scheme in Kurau, proudly shows off his new toilet and water faucet, provided under the project, at the back of his simple wooden dwelling.
“Before, we would just get water from anywhere and so suffered frequent ill health,” he says. “The project has taught us to use clean water and now we don’t have any big health problems.”
His wife, Samiah, adds: “The most important thing we have gained is knowledge about our health because, before, we didn’t have that. Being healthy is more precious than gold.”
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