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MAP OF
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PROVIDE MOTORCYCLES FOR HEALTH WORKERS
IN ILEAPE AND WULANG GITANG SUB-DISTRICTS,
July 2001 - June 2004
Submitted by:
Jl. Wch. Oematan 18A, Walikota, Kupang - Indonesia Telp: 62-380-827049 Fax : 62-380-833257 Email :c/o hfa_flores@telkom.net |
I. BACKGROUND
East Nusa Tenggara province is one of the poorest provinces in Indonesia, because the inequitable economic development practiced by Soeharto's (former Indonesian President) regime has made this province become a region having numerous limited social facilities, such as limited means of transportation, school, and health facilities. East Nusa Tenggara up to 2000 there are 208 public health centers and 24 hospital providing service for 3,5 million people. The number of doctors and para medical staffs who run those hospital are 137 doctos, 2.555 paramedical staffs and 1578 midwives. Most doctor work in Kupang municipality, numbering 20 doctors while the rest spread in the 13 districts of East Nusa Tenggara.1 The quality of service is also quite alarming, such as the complaint concerning inhospitable attitudes of medical staff and insufficient information offered to the patients who need it badly.2
From the analysis of health care budget in East Nusa Tenggara, it also shows a drastic decline for the last three years. Before the monetary crisis taking place in 1997, health care budget was US $ 12.00 per person (US$ 4.00 was subsidized and US$8.00 was shouldered by the people themselves). During the present crisis, it decreases to US$ 4.40 in East Nusa Tenggara. It obviously indicates the decline of the quality of service which is also aggravated with the decrease of people's ability to earn for their own health care. The limited health facilities as well as low people capacity contributes to the decline of people's health condition in East Nusa Tengara. If this situation is not overcome immediately, it will have the impact on the production of unhealthy generation and will absolutely weaken the capacity of human resources in East Nusa Tenggara. Eventually such a situation could be detected at the moment but the government understanding of health as a huge investation is never thought and explored thoroughly. At present East Nusa Tenggara has the highest maternal mortality rate, that is 9,11 out of 1000 alive delivery compared with maternal mortality in national level that is 4,5 out of 1000 alive delivery.3 Compared to other ASEAN countries, Indonesia also has the highest Maternal mortality rate, namely 425-650 out of 100.000 alive delivery.4 This show how women's health is managed so far. The perception that a mother's health is her own responsibility is a predominant factor causing so many mothers to shoulder their own sufferings without help of the husband or of close relatives.
In East Nusa Tenggara the data also show 57,61% delivery was assisted by traditional midwives, 15,75% by family members, 20,65% by midwives and 15,75% by the doctors. The same data indicates in difficult situation of delivery, numerous women can not be helped due to the limitation of knowledge of traditional midwives as well as of family members. The problems such as bleeding at the moment of delivery, the baby is not in the right position, placenta closing baby's way out or small hips, nearly cannot be handled and many of these problems bring about mothers' death.
East Nusa Tenggara are more vunerable to the infection of STDs and HIV/AIDS. This assumption is based on the following factors:
- Poor knowledge of STDs and HIV/AIDS. This situation is aggravated with limited places where they could have easy and open access of information. Speaking about STDs is not always easy due to the tendency to reveal the things which so far are taboo to talk about. Meanwhile speaking of HIV/AIDS is felt too absurd due to the inexistence of concrete example present amount.
- In several places, changing sexual partners is normal according to those customs/traditions. Even if becomes one of their traditional rites.
Beside those factors, there are other factors such as limited service, little knowledge owned by medical staffs about STDs and HIV/AIDS. Looking at the HIV/AIDS cases in East Nusa Tenggara, the case recorded up to April 2000 is 1 case but5 it should be noted that it is not the real data. The number of the infected can be assured more than the recorded data. Women and the youth with their complicated problems become groups who are extremely prone to the increase of the case.
Besides, the sad two health problems, there are several diseases which still have high rate of cases in East Nusa Tenggara, such as upper respiratory infection, Malaria, TBC, diarrhea, worms and bronchitis.
1 Reference : Health profiles in Indonesia, Health Departemen 2000
2 The Story of a mother in the Women Health Training, organized by Sanggar Suara Perempuan, March 1999
3 Health Profile of East Nusa Tenggara Province, Provincial Health Office of East Nusa Tenggara Province, 1997.
4 From the data publiced by UNICEF, 1996 : concerning Maternal Mortality Rates in several ASEAN Countries. Indonesia is the highest compared to the Philippines 142-280, Thailand 100-600.
5 Subdit Frambosia & AIDS Ditjen PPM&PLP, Indonesia Health Departement, August 1999.
The strategy of the government to provide cheap health care is to build public health centers. Public health centers are divided into 2 kinds, namely main public health center located in the capital of a sub-district and branch of health center situated in village and provide services for 3 - 5 villages. Naturally the facilities in the main health center are more complete but in the remote areas the facilities remain very limited. A main health center is ideally coordinated by a medical doctor assisted by 2 - 3 nurses or midwives, while the branch is managed by a nurse or a midwife. The designation of a midwife in a branch of health center is the strategy of the government to press the high rate mother mortality but it has not given any result up to the moment since mother mortality remains high.
It should be analyzed concerning the presence of a public health center, since it cannot render service for all the population in its area of coverage. We can imagine in case there are 20 villages n a sub-district with the distance among villages is tens of kilometers away without good road to pass. It is often found out there is a village lying at another side of a mountain lacking all the facilities including means of transportation except narrow passing road towards that certain village. A branch of health center is meant to reach out remote villages, but in many cases a branch of health center is empty without even a health worker. The midwife designated there prefers to stay in the town and only come to open the health center on particular days of the week. Another fact shows a village is so wide that a midwife could not reach out and offer health service to all people in the village. Ideally main health center exists I every village but seemingly this dream is still too far to realized in Indonesia.
Besides main health center and the branch, there is a community health center in every village which is intended to involve people in their own health care. It is coordinated once a month by a resident, the cadre of the community health center carrying out the activities of scaling the babies, giving nutrition supplement and giving information of mother and child health. Indeed the community health center is an effort to solicit the participation of the people but so far its implementation highly relies on the presence of the midwife. If the midwife does not go to visit the village, as it is often found, the community health center has no activity. Worse, during this time of economic crisis, giving nutrition supplement is a rare happening.
In January 2001, the new regime of Indonesian government started to enact regional autonomy policy. This new framework is a process of decentralization of governance in which all the decision-making process, including the expenditures of a region is under the responsibility of regional government in the district level. This regional autonomy can be seen from to sides. First, it is a democratization process that will give bigger space of mobility to the people to decide on their political role and will strengthen regional government. Secondly, regional autonomy will have negative impact on the life of the people particularly those living in the poor regions (because original income of the region is very minimal, and so far financially the running of the regional administration is subsidized by the central government).
East Nusa Tenggara province where Flores island is part of it, is one of the poorest provinces that will have the impact of the unpreparedness to implement regional autonomy, especially in the improvement of health quality of the people. Health care which up to the moment highly depends on the central government is still far from good, let alone on its regional responsibility. It has been predicted by many parties that health service in East Nusa Tenggara will be worse in line with the implementation of the regional autonomy. Such an apprehension is very much understandable for most part of East Nusa Tenggara region is dry and barren and very often experience natural calamity, such plan pest and flood which in effect makes this region difficult to fund its own expenditures.
Unpreparedness in the district level is also inevitable if district authorities do not perceive health problem as a problem that needs a special attention. It probably happens that the fee of health care which is so far quite cheap will become more expensive, since public health centers also have to think of how to survive. Another possibility that might emerge is district government perceives health as an important issue need to be prioritized, but due to the insufficient regional income, they will invite other parties, such as NGOs to be involved in offering cheaper health care. This last possibility is a situated expected in which the participation of different parties, including the people will become more real.
II. GENERAL VIEW OF ILEAPE AND WULANG GITANG SUB-DISTRICTS
Ileape is situated in Lembata island, East Flores region and consists of 18 villages. It has the population of 15.000 people and speak Lamaholot language, local language of East Flores. Agriculture becomes the main living of the people but many residents also try to look for additional life support by breeding cattle and fishing. Geographically the area is volcanic where the villages spreads around a volcano but looking from the topographic angle it is categorized as dry and barren having longer dry season while rainy season lasts for just 4 months. This topographic aspect has great influence on the economic life of the people whose mean income per year is extremely low, around Rp 1.000.000 or US$ 111.11/year/person and the condition is categorized as under poverty line (The report of East Nusa Tenggara Health Profile, 2000). As a consequence a good number of the population become migrant workers in Malaysia and in an industrialized island of Batam, Western Indonesia. Another picture of Ileape sub-district is the lack of clean drinking water.
Wulang Gitang is located in the Eastern part of Flores island and consists of 13 villages with the population of 10.000 people and as in Ileape people speak Lamaholot, local language in East Flores. Geographically the area is volcanic with the villages lie around two volcanoes standing side by side. Topographically the area is divided into two, namely mountainous area having longer rainy season and more fertile and low land area which is dry due to the longer dry season. Agriculture is the main living and those residing in the mountainous area are more better off compared to the ones living in the low land area. To earn additional income they have to breed cattle and do fishing and the mean income of the people per year in this district is about Rp 1.000.000 or US$ 111.11 /person/year.
Roads condition in both sub-districts is considerably bad due to the poor maintenance. Some parts of the road are asphalted but in a very poor condition, asphalt is destroyed leaving the holes everywhere, while in other parts the roads are left unasphalted and during rainy season, it is muddy and dusty during summer. However, these roads are still passable by motorcycles no matter apprehensive condition they are. By means of motorcycles one can reach all the villages. There are indeed public transportation called bemo but these bemos are very few and just pass along main roads, thus only the villages located along or near the main roads have easier access to the public transportation. The people living in the villages far from the main roads have to go on foot to take public transportation in order to reach other villages. In most cases, people merely walk to reach other villages due to the lack of public transportation.
Normally in every sub-district there is a main public health center located in the capital and there are several branches of health centers. In Ileape sub-district there are four branches of health centers and in Wulang gitang sub-district there are 4 branches, each is managed by a nurse or a midwife. So all in all in Ileape there 9 health workers, without a medical doctor, 5 people in the main health centers and 4 people in the branch of health centers, while in Wulang Gitang there are 25 health workers including 1 medical doctor. 21 health workers are in the main health center and 4 people in the branches. There are more people in the main health center of Wulang Gitang since this health center is also used for stay-in patients.
Most health workers have no means of transportation that makes their mobility very limited. They then have difficulty to render health services to other villages and just stay at the health centers waiting for the people to come. In case they have the vehicles in doing their works, it is mostly owned by their spouses or by their immediate relatives. In the main public health centers usually there is a 4 wheel drives vehicle intended for mobile clinic but in reality it is merely for personal use of the head of main health center. On the contrary even in the main health centers, health workers just wait for the patients to come. They just rely on the initiatives of the common people but the problem is this kind of people have not acquired a good health seeking behavior yet. They will go to a health worker once they really feel sickly or otherwise they will just look for traditional medication by referring to traditional practitioners. Who are not so well versed with modern medication.
Health information and education is also rather far from the common people in the villages. Health workers have no activity of giving health information and education since treating sickness is their foremost concern. As a consequence many people are ignorant of health information and also a great number of them are suffering or just die due to this ignorance as well as due to the absence of health workers. According to the report of East Nusa Tenggara health profile, 2000, the diseases popularly suffered by the people in these sub-districts are:
III. PROFILE OF HEALTH FOR ALL
Health for All is a local Non-Governmental organization aimed at developing transport resource management in order to increase health service, disseminate health information and education to the people in the villages by means of vehicles. The organization was founded in January 2001 and acquired its legal status on April 4, 2001 and a first ever kind of health approachbeing implemented in Indonesia. It was founded on the basis that a great number of people in the remote areas are suffering or just die from illnesses due to the absence of health workers who do lack means of transportation to reach out the people in the villages. The presence of Health for All is an effort to respond to the real problem being faced by the people by providing the vehicles, particularly motorcycles for health workers. The emergence of this program is in a great extent inspired by a similar program implemented by Riders for Health UK in several countries in Africa. Their experience shows health service and dissemination of information and education using the vehicles could improve health condition up to 300-400%.
www.riders.org
Health is a human rights (WHO declaration in Alma Alta, 1978), therefore every person has the right to have access to the health services. A healthy society depicts a general condition of a certain society and will certainly produce a healthy generation as well. Health for All envisions for the realization of a healthy society whose generation could gain needed capacity to participate actively in the development of a dreamed society.
Numerous people in the remote areas are still distant from health facilities. They have no access to health services nor to health information and education which in effect brings about severe health problems. On the other hand, health workers have no means of transportation to reach out the villages located far from the Public Health Centers. Knowing this situation, Health for All strives to provide access to health services by developing transport resource management in order to increase health service, health information and education for the people in the villages.
Presently Health for All is based in Kupang, East Nusa Tenggara Province, Indonesia. Our address is the following:
Tel. : 62 - 380 - 827049
Fax : 62 - 380 - 833257
Email : c/o wilibalawala@yahoo.com
In order to implement such a program, 2 sub-districts in Flores, East Nusa Tenggara province have selected as pilot project, one in East Flores district and another one in Lembata district. Both sub-districts are selected based on the fact that the people there have very limited access to health services. Besides, the road condition could allow health workers to reach out the villages driving motorcycles. In the future the program could be expanded to other districts in East Nusa Tenggara Province, even to other places in Indonesia where our presence is of help for the people in the villages.
Health for All was founded by Wilibrordus Bala, Leonard Simanjuntak, Maria A. P. Noach, and Antonius suban Kleden who currently become board members. These people have been involved in different NGOs and have special concern for health issues, that is why they crave to unite their efforts and thoughts in order to help solve the problems of the marginalized people. Wilibrordus Bala who is presently the Executive Director of Health for All for 2,5 years worked with Medecins Sans Frontieres as the Manager of Outreach Program. To start this program he has undergone Training on Transport Resource Management and Exposure to the program being implemented in Harare, Zimbabwe organized by Riders for Health.
IV. GOAL AND OBJECTIVE OF THE PROGRAM
The goal of the program is to increase health service and disseminate health information and education to the people in the villages by means of providing motorcycles for health workers.
- Build network with Ministry of Health (MoH) with the purpose of preparing the framework of working together starting from the step of planning, implementation, monitoring and evaluation with the targets agreed upon together.
- Prepare trained staff so that he can train the drivers on how to drive properly and how to do basic services.
- To train and to increase the skill of health workers on how to drive motorcycles properly and how to do basic services so that they can reach all villages under their own coverage.
- Build network with NGOs working in the health issues, with People's Organizations and Community Leaders.
- Increase the access of health information for people in the villages.
V. LOGICAL FRAMEWORK
Objectives Output Indicators Assumptions 1. Build collaboration with Ministry of Health (MoH) 1. Meeting with MoH in the district level to socialize the program 1. MoH in district level accepts the program as an joint program 1. MoH in district level consider this program important to be developed 2. Meeting with MoH in subdistrict level to socialize the program 2. MoH in sub-district level is ready to implement the program 2. MoH in sub-district level sees the program relevant to real need. 3. Workshop to make framework of working together involving MoH in the district, subdistrict and village levels 3. Produce a document of working together signed by MoH in district and subdistrict level and Health for All 3. MoH is ready to work together to make the Framework. 4. Monitoring meeting in sub-district level in every 3 months 4. There is meeting held in every 3 months participated by health workers using motorcycles, Head of public health centers, representatives of NGOs, People's organization (POs) and community leaders 4. Health workers using the motorcycles and Head of public health centers do not see the program as a burden 5. Monitoring meeting in district level in every 6 months 5. There is meeting held in every 6 months participated by all health workers using motorcycles, head of public health centers, head of MoH district, representative of NGOs, POs, Community leaders. 5. MoH in district level perceives monitoring as an important process. 6. Evaluation meeting of midterm program all parties concerned in all level 6. Produce a document as a result of midterm evaluation and agreed as inputs to improve the effectivity of work for the next step of the program. The meeting is participated by MoH in all levels, representatives of NGOs, POs, community leaders. 6. All the parties involved could see the use of midterm evaluation meeting. 7. Evaluation meeting at the end of the program involving all parties concerned in all level. 7. Produce a document as a result of end of program evaluation which gives the picture of strength and weaknesses of program and the opportunity to continue to develop the program. 7. All the parties involved specifically government could be open to see the strengths and weaknesses of the program. 2. Prepare trained Health for All staff 1. Training for trainers for Health for All staff. 1. 2-3 Health for All staff are ready to train health workers 1. Health of All staff possess capacity are ready to become trainers 2. There is a training Module 2. Trainers can use training module adjusted to the local condition. 2. Trainer can easily comprehend and implement the module 3. Field trip to the partner of manufacturer in Indonesia 3. Health for All staff have deeper knowledge of how to use and maintain motorcycles. 3. There is motorcycle manufacturer in Indonesia who is willing to become partner of Health for All. 3. Increase the skill of health workers in driving and maintaining motorcycles 1. Training for Health workers on how to drive properly and how to do daily maintenance 1. 10 Health workers participate in the training. 1. Trained health workers can drive properly and maintain the motorcycles well. 2. Monitoring on the used maintenance of motorcycles for health workers 2. There is monthly records on the use and maintenance of motorcycles for every driver. 2. Monitoring can be done well. 4. Build network with NGOs, People's Organization (POs) and Community Leaders 1. Network meeting to socialize the program 1. There is realization of the meeting to agree upon network involvement in the program 1. NGOs, POs and community leaders have common perception of the program. 2. Participation of NGOs, POs and community leaders in the monitoring and evaluation. 2. NGOs, POs and community leaders attend and participate actively in the monitoring and evaluation meetings. 2. The participation of NGOs, POs and community leaders is not seen as a problem for the government. 5. Increase the access of health information to the people in the villages. 1. One day seminars on dissemination of health information with human rights perspectives. 1. 10 health workers and 100 other health workers in the whole district participate in the seminar 1. Health workers have interest to participate in the seminar. 2. Increase the number of reading materials and medium tools for health workers 2. Frequency of dissemination of information increases. 2. There is enthusiasm of health workers to disseminate information
VI IMPLEMENTATION OF ACTIVITIES
This program is planned to be implemented within the span of 3 years starting from July 2001 up to June 2004.
In order to achieve the objective of this program, Health for All has 5 strategies that will be implemented in the span of 3 years. Those strategies are the following:
Each strategy consists of several activities with the details as the following (elaboration of each activity is included):
1.1. Socializing the Program
The program is socialized to the MoH in district and sub-district level, aiming at acquiring common perception of the program and obtaining an agreement to make a common framework starting from the process of planning up to the evaluation. Socialization in the sub-district level will be facilitated by MoH district.
1.2. Workshop to formulate a common framework
This workshop is the follow-up of the socialization process in which between MoH and Health for All have had consensus on the kind of working together that should be built. The workshop will produce a document containing sharing of responsibilities, field implementation, monitoring and evaluation process. The participants will be the persons responsible of MoH district and sub-district levels and several field health workers.
1.3. Monitoring
The monitoring process will be carried out in every 3 months in sub-district level and every 6 months in district level. To obtain an objective monitoring process, besides the involvement of MoH, Health for All, health workers using motorcycles, there will be also the participation of NGOs, POs and Community Leaders where the program is implemented.
1.4. Evaluation
The evaluation is carried out in 2 phases within the span of 3 years. The first phase is called mid-term evaluation undertaken in the first half of the program. The second phase is undergone in the end of the program. As in the monitoring process, evaluation meeting is also participated by NGOs, POs and Community Leaders together with MoH and Health for All.
2.1. Training for Trainers
This training is intended for the staffs of Health for All who will then train health workers. Training module is developed from the training module of Riders for Health Zimbabwe that will be adjusted to the local condition.
2.2. Comparative Study
In order to increase the skill of Health for All staffs, it is of a great importance to undergo comparative study, specifically in the motorcycle manufacturer that becomes the partner of Health for All. Considering that motorcycle maintenance is the key issue in this program, staff development then is focussed on how to manage zero-breakdown in the running of motorcycles.
3.1. Training on How to Drive Motorcycle Properly and How to Do Daily Maintenance for Health Workers
Such a training is conducted for field health workers selected from the place of operation. The objective is to improve the quality of his/her service using motorcycles. Besides the technic of how to drive motorcycle properly, the topics of the training will also be about how to do thorough maintenance of the motor used.
3.2. Health Service by Motorcycle
This activity is the very core of all activities contained in this program. In order to monitor the effectivity of motorcycle use in the improvement of health care, Field Coordinator will record every progress and irregularity committed by health workers. The records taken will become valuable inputs for the evaluations.
4.1. Network Meeting to Socialize the Program
This kind of meeting will be organized in the beginning of the program. The aim is to involve these interested parties in the process of monitoring and evaluation. POs and Community Leaders Involved are from the areas where the health workers work so that they can participate in giving the appraisal of the effectivity of the program. Out of this meeting, it is expected to have written commitment concerning the participation of the network members in the implementation of the program.
4.2. Participate in the Activities of NGO Network both in Regional and National Level.
The participation of Health for All in NGO network both in regional and national level is very important. There have been 2 NGO networks in the region formed for some times ago, namely NGO Forum in East Flores in the region level and Eastern Indonesia Women's Health Network in the national level. The said 2 networks have the mechanisms of regular meeting, member empowerment and intensive dissemination of information. Such mechanism can be very beneficial for the capacity building of Health for All staffs, Health workers, POs and Community Leaders.
5.1. One day seminar on health in the human rights perspectives for health workers.
The objective of the seminar is to give wider and deeper information of the importance to see health problems in the human rights perspectives. Besides, Besides the service that values a patient's rights, the dissemination of information should also be grounded on the understanding that every individual has the rights to have health information, particularly health issues that pertain him/herself. So far the information disseminated by health workers is very unproportional and frequently there is a an assumption emerging claiming that because ordinary people do not understand medical problems, it is not necessary for them to know. By means of this seminar, such kind of perception can be slowly reduced Besides organized for health workers involved in the program, this seminar will also involve other health workers in the area.
5.2. Purchase and Disseminate Reading Materials of Health to the Health Workers and Members of NGO Network
Reading materials of health in Ileape and Wulang Gitang sub-districts are still very limited in number, while NGOs in Western Indonesia have developed simple media for various health information. Reading materials will be greatly helpful for health workers who will disseminate the information to the people.
5.3. Multiply Health Medium Tools for Health Workers
Medium tools are effective means for health workers to be able to give clear and complete information. Up to the present health workers hardly have sufficient medium tools that often times health information is given in the form of lectures which often boring for the people.
As the representative of government being responsible for the people's health care, MoH has a crucial role, namely coordination with health workers involved in the program. MoH also gives the assurance that this program will runs smoothly without requesting additional salary nor management fee from Health for All. Besides, MoH has great responsibility for the sustainability of the program, for instance, actively think of how to develop such program to other areas if the pilot project implemented in the said 2 sub-districts proves to be effective to improve the quality of health service to the people.
NGOs, POs and Community Leaders have important role in the monitoring and evaluation during the implementation of the program . NGOs are groups that are quite close to the people, while POs and Community Leaders are part of the community itself. It is expected they could render objective appraisal concerning the implementation of the program.
Health for All is responsible for looking for fund, build network with the regional government, NGOs, POs, Community Leaders, management of zero-breakdown to the motorcycles and for the implementation of overall program which will be accounted for, not only to the donor agency but also to the people but also to the people as the beneficiaries. In general, it could be underlined Health for All is the main party responsible for the program. The accountability will be in the form of fund accountability as well as progress reports.
Riders for Health is expected to give technical assistance to Health for All taking into account that this program is adopted from the program of Riders for Health being implemented in several countries in Africa. And this program is the first being implemented outside Africa. Technical assistance can be given in the form of training, visit to the field and long distance discussion. Besides, technical assistance, Riders for Health also help look for fund and approach motorcycle manufacturers that are potential to give help and to become partners.
(Separate Sheet flo01wrk.xls 28kB)
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