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Panel 9

Community-based health care: Indonesia sets the pace

In 1973, a nutrition survey found that more than two thirds of Indonesia's 20 million children under five years old were undernourished. UNICEF and the National Planning Board had been discussing possible responses with various government agencies, including the Ministry of Health and the National Family Planning Board (BKKBN).

BKKBN had promised villagers that if they achieved government targets for contraceptive use they would be rewarded with better social services. The problem was that the contraceptive use was rising but the new services were nowhere in sight -- and a serious public relations problem was brewing in 500 villages. So BKKBN, the Ministry of Health and UNICEF initiated what was to become one of the pioneering community-based health programmes of the 1970s.

Photo: A lesson in nutrition for Indonesian mothers and their babies. ©

UNICEF agreed to provide a nutritional first-aid package for each village; the Ministry of Health and BKKBN ensured that the programme functioned at the village level. The agreed package included weighing scales and charts so that mothers could monitor their babies' growth; oral rehydration salts to manage diarrhoea; vitamin A and iron supplements; and immunization through health centres.

This programme became very popular. Mothers built social activities around the monthly weighings for their babies. The 'weighing post' -- a room borrowed for the purpose, or a shelter erected from village funds -- gradually became an established community fixture. UNICEF was soon asked to provide kits for an additional 1,500 villages. The Government also gave strong financial support. President Suharto established a national nutrition board and a special Treasury account to support village nutrition.

During Indonesia's third Five-Year Plan (1979-1984), monthly weighing and nutrition education activities expanded to 80,000 weighing posts located in 41,000 villages.

Other government departments also played a part. The Ministry of Agriculture sent workers to meetings to advise villagers on home gardening and livestock raising. The Religious Affairs Ministry reinforced health, nutrition and responsible parenthood messages with Islamic scriptures; religious leaders were offered materials to help them develop relevant sermons and talks.

In 1989, a study found that between 80 and 98 per cent of mothers brought their infants to village meetings. And by 1991, Indonesia had over 20 million children enrolled at 250,000 posts nationwide. Start-up costs for new posts ranged between US$2 and US$4 for each child, with recurring annual costs of around US$0.75 per child.

Today, about 1 million village volunteers sustain a nationwide network of village health posts. These are supervised by 20,000 health workers from 5,000 health centres. Around 90 per cent of Indonesian families live within easy reach of primary health care. This has contributed to an impressive improvement in health standards. By the end of 1990, immunization coverage against major diseases was more than 80 per cent. Between 1974 and 1989, deaths from diarrhoeal dehydration fell from about 400,000 to 58,000. And between 1960 and 1993, infant mortality per 1,000 live births fell from 127 to 71.

In the 20-year period of the village nutrition programme, malnutrition has been halved. In the same period, Indonesia has made great strides in reducing poverty, an effort that undoubtedly contributed to improving nutrition. A recent evaluation of the village programme concluded that it is likely that half the improvement in nutritional levels is due to the village nutrition programme -- a remarkable achievement.

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