Revisiting Community-Based Health Workforce From Community-Based Approach to Family-Based Approach Case of Indonesia

I. Introduction

Indonesia is the largest archipelago in the world with more than 17,500 islands with various cultures of people. They also have various customs and behavior. Indonesia is located between the Hindia ocean and the Pacific ocean. From the west to east the area of Indonesia is as largest as the North America continent which live a hundred of ethnics with different local language. The national language is Indonesian language; it is well known as Bahasa; although, in big city and business communication often people speak in English language. The country is divided by three time zone times those west, central and east Indonesian time.

Since 2001, Indonesia has applied decentralization policy which takes consequences increasing the number of provinces and districts/cities. Indonesia administratively is divided into 33 provinces , 444 districts and 91 cities. Those regions

II. Population

Indonesia’s population in 2005 was 218,668,790 with density 117,6 per sq km, and the growth of population rate was 1.26%. More than half population ( 58.1%) live in Java island. It is 21.03% of total population lived in Sumatera; 7.21% in Sulawesi; 5.53% in Kalimantan; 5.4% in Nusa Tenggara and only 2.12% lived in Maluku and Java island has highest population density. Meanwhile, other islands such as: Kalimantan, Sumatera, Sulawesi and Papua have low density population Papua. More than half (56.76%) population lived in rural area and 43.24% lived in urban area.

In 2005, it was 29.61% of population under 15 years of age while only 4.17% were aged 65 and over. Therefore, dependency ratio in 2005 was relatively high (52.26%). Male population relatively was balanced with female. Male population were 108,876,089 and female population were 108,196,257. Sex ratio in 2005 was 101.11. Population composition by sex and age indicated that the highest proportion were group of 10-14 years of age and 5-9 years of age.[2]

III. Economic Situation

For the last three years, the economic situation of Indonesia was relatively stable and indicated quiet satisfied progress. Economic performance in 2003 indicated 4.88% of growth and in 2004 up to 5.13%. The economic condition in 2005 was more better, that is indicated by the scaling up of economic growth up to 5.6%. In the year 2006 the economic condition was getting more stable which shown by it increased to 5.8%. Unfortunately, the increasing was not synchronized by inflation rate. Data from BPS-Statistics Indonesia mention that inflation rate in 2003 was 5.06%. It increased to 6.40% in 2004 and to 17.17% in 2005 (January – November 2005).[3] However, in 2006 inflation rate was sharply decreased to 6.5%. So, during the last three years our economic condition is relatively unstable. Meanwhile, Gross Domestic Product in 2004 was 10.5 million of Rupiahs and 2005 increased to 12.7 millions of Rupiahs. It was getting better in 2006 up to 15. millions of Rupiahs.[4]

Number of poor people in 2004 were 36.1 million people or 16.7% of total population. It was lower than poor people in 2003 (37.3 million or scaled down into 3.19%). In 2005, the number of poor were increased to the 35.1 million people ( 15.97%) and in 2006 were more increased up to 39.3 million (17.75%).[5]Percentage of poor people in rural area was higher than urban. It was 20.11% in rural and 12.13% in urban. Province with highest percentage of poor people was Papua (38.69%), and it was followed by Maluku (32.13%) and Southeast Sulawesi (29.01%). Meanwhile, province with lowest percentage of poor people was DKI Jakarta (3.18%); it was followed by Bali and South Kalimantan (7.19%). Province with the highest number of poor people was East Java (7.3 million of people or 20.23%). It were followed by Central Java (6.8 million or 18.93%) and West Java (4.6 million of people or 12.88%).[6]

IV. Health Situation

Based on huge and hard effort of the government, particularly in period 1970 to 1997, the health situation of Indonesian is getting better; even if we compare to some countries in region Indonesia is low behind. The economic crisis in 1998 that lead to the collapse of the socio-economic development. In health sector, the scarcity of resources made the health programs, particularly the community based health program could not work effectively. Majority of the Integrated Health Post (IHP) were fall down; since there was no resources to support this program. Concerning to this situation, since 2001, the Ministry of Health has conducted the revitalization of the IHP which ran some program to back up the program such as: training cadre, provide drug, health instrument and part of operational fund. Beside that, the government has been introducing the medicaid program for poor people. In the year 2007, the medicaid program covers more than 70 millions people; it means one third of the people are insured by this program. The some health indicators that are figured out the health status of the country as follows:[7]

• Crude birth rate : 19.3/1000
• Crude death rate : 6.9/1000
• Total fertility rate : 2,6
• Infant mortality rate : 35/1000
• Under-fives mortality rate : 46/1000
• Maternal maternity rate : 307/100,000
• Life expectancy (years) : 66.2
• Total expenditure for health as percentage of GDP : 2.7%

V. Community Based-Health Worker

History of CBHW in Indonesia come from long story. In exploring the CBHW, we can use the government political period and the community health organization those are exist in the village. Based on government period or political regime, we can divide the role of CBHW to three eras. First, we call as an Old order era. It started from the year 1945 to 1965. Second, the new order era which ruled between the year 1965 to 1997. The last is the reformation era from the year 1997 to the current. In each era, there are any differences and similarities of characteristics of CHW in Indonesia. Furthermore, to discuss the community based health worker (CBHW); we employ the community health organizations those are exist in the village. Based on our knowledge that the CBHW play role in the health program via this organizations. From this vehicles, the health program is usually conducted in community.

V.1 CBHW in The Old Order Era of Governmental Regime (1945 -1965)

In this period, there was no the community based action for health that is developed by people. We only know the CHW as traditional healer who treat their people in the community. In this era, there is no special program or institutions that was developed by government (MOH) to support the community based action for health. It seems that the involvement of government in development of CBHW was very limited. The health training for the TBA was started in the year 1952 by Ministry of Health (MOH).[8] The training program provide a knowledge and skill in the mother and child health care. However, most of traditional healers never get the elementary health training such as: cleanliness training to prevent the infection from bacteria and to increase the quality of services. In this era, we can find some kind of CHW such as:

a. Traditional Birth Attendant (TBA)

A TBA has been defined as person (usually woman) who assist the mother at childbirth and who initially acquired her skills delivering babies by herself or working with other TBAs.[9]

b. Herbalist

A Herbalis describes a traditional healer whose specialization lies in the use of herbs to treat various ailments. He is expected to be highly knowledge in efficacy, toxicity, dosage and compounding of herbs

c. Bone setter

A bone setter is specialist in one aspect of traditional healing, being skilled in the ability to treat fractures.[10]

d. Traditional Psychiatrist

The traditional psychiatrist’s main function is the treatment of madness but he may treat other diseases, and in his capacity as mediator between his community and the gods. He may be called upon in any crisis such as flooding or famine.[11]

e. Spiritualist or Diviner

Diviner get knowledge of secret or future things by means of oracle, omens or astrology, or contact with superhuman of divine sources. In the history of medicine divination has actually been used for diagnosis and prognosis of disease and for deciding upon the most effective remedies for treating it; and it is an instrument which has, in culturally homogeneous society, the secondary therapeutic effect of making the patient feel that the unseen world is supporting the therapist and is involved with him in the treatment.[12]

Majority of traditional healers (TH) are usually family heritage job; it means they get knowledge and skill from her/his ancestors. The THs are generally an older person; they could be female or male. They live in community which their practices. They give services everything related to the need of the community. For instance, the Traditional Birth Attendant (TBA) gives services related the childbirth such as: preparation, suggestion and massage the pregnant mother, delivery baby, massage the baby and provide special herbal for the mother. In generally, village pregnant woman prefer to visit TBA since they trust TBA, easy to access, and the cost relatively affordable. In this era, the most of the pregnant mothers especially who live in the village get delivery services from the TBA. They play key role in the mother and child health. So, in this era we can conclude that the community based health worker is unknown yet.

V.2 CBHW in The New Order Era of Governmental Regime (1965 – 1997)

In this era, we can find some origin of community based actions for health and the community health worker started to develop to tackle the health problem. In the year 1965 till 1976, the community health program was initiated by the non-government organization. First, genuine community based program, in 1970 the YAKKUM (Non Government Organization) developed a simple health fund in Solo city, Central of Jawa. The program provide an financial access to the member to get health services from the Health center. And then, the program enlarged to the prevention of disease and curative services. Furthermore, we find the other community participation in health development in Banjarnegara District, Central of Jawa in the year 1975. The community health program conducted several activities to provide the public health services for the community. The nutrition program conducted thru the child under five unit, control of diarrhea disease, immunization program, health treatment via village health post, and the family planning was conducted by the village family planning post.[13] Finally, the community participation in health program inspired the Health Office of Karang Anyar District to develop a project health program based on community involvement. The project are conducted in 5 villages and started with the household survey to explore the health status and problem in 1976.

Involvement of the community leaders in discussion and finding solution of the health problem was the key of action of the program. The solidarity of the people is the based of the action program to solve the village health problem. The village health fund and health training for cadres are key success of the program. The success story of those programs base on the philosophy that health program has to belong the people and come from people and benefit for the people. The concept of self help and self reliance based on the success story of the community based action for health in this period. It seems that the government role is limited on facilitating, training and motivating, but the village health worker play role dominantly in planning, executing and implementing the health program that comply to their needs.

Second, the Community Village Development for Health Era (CVDH 1976 - 1985).

The success of community participation in health development drove the MOH to develop the Community Village Development for Health (CVDH) in Indonesia The CVDH is a model of community based health program. In 1976, the concept of CVDH is accepted as the best approach to increase the coverage of health care. The CVDH is hoped that could improve the health status of the people. Thru some seminars and workshops; there are some agreements about the characteristics of the CVDH :

• The definition of the CVDH is the community action for health. Participation of the community is the potential component to conduct the CVDH. It means the role of CBHW is very important and a must to run the CVDH.
• The CVDH is an integral component of the village development as whole which should be simple and effective.
• Interconnection among sectors ( agriculture, health, family planning, and internal affair) are very needed to make the CVDH works well.

The program is conducted by people based on solidarity and self reliance to create social welfare and quality of life thru the improvement the health status. The health activities are an integral component of village development that supported by inter-sector and inter-program of the government. [14]

To develop the CVDH, the community leaders and the health personnel share roles. While the community leaders already committed; they usually create the health committee

which functions :[15]

• Identify the health needs of the community and decide the health priority. More often, they do know how to solve the health problems. Of course many of the villages need a help from the health personnel to facilitate village meeting for health program. Organize the solidarity community action such as: making toilet, nutrition garden, and water bamboo pipe.
• Select health cadres to be the health promoters. It is better the selection of cadres thru the village meeting so they are legitimate from the society.
• To facilitate and run the village health program
• To develop the network to inter-sector and inter program those are conducted in the village

The health center is the health organization which provide directly health services to the people. Relation to the CVDH, health personnel have roles :

• To help the community to decide the health problem and making the priority.
• To conduct health training for the cadres such as: eradication of communicable disease, mother and child health, nutrition, family planning, environmental health, first aid accident and treatment the common disease.
• To supervise and guidance. Even this function so important however this activity is relatively rare conducted. It is caused of lacking of the transportation facility and financial support.
• To facilitate a supply such as: simple medicines, leaflet, guidance book, audiovisual aids for promotion activity. To refer the patients which are needed health care to the health center.

Together with the community leaders evaluate the CVDH activity and make some corrections if needed and continue the good health program.

Furthermore, the Ministry of Health developed a pilot project of the CVDH in 12 provinces. In this period, the role of health personnel were getting more dominant. In generally, the initiative of the community health program usually come from the health personnel. In spite of that is any origin initiative come from the head of the village. He commonly asked the health center to train the health cadres to tackle the health problem such as: malaria and influenza. It seems that the villages those have initiative and high motive more success and sustainable in running the health program.

From this description, we can say that involvement of the village health cadre in the community health action are started in 1976. The criteria of the cadre are live in the village, minimum finished elementary school, having permanent income, and volunteer. The health cadres were trained for only 3 days which curricula such as: mother and child health, nutrition, family planning, environmental health, first aid accident and treatment the common disease. Furthermore, the activities of the CVDH were focused in decreasing of IMR and MMR. It was started with the joint order of the Ministry of Health, the Family Planning Coordination Organization and the Ministry of Internal Affair in 1984.

By that explanation, we see that the CVDH is the integrated program between health cadre with the health personnel. We can say that in this era the health cadres are derived to function in managing the village health program. However, slowly but certain that the health personnel’ roles are getting more dominant and that conflict to the concept of the CVDH it self. This situation could decreased the spirit and motive of self reliance of the CVDH.

Third, the Integrated Health Post (IHP 1985 - Current).

The CVHD as model of the CBHW is the success story. Furthermore, the model is adopted by government. The CVHD was transformed to be the Integrated Health Post (IHP) which are integrate the 5 health services (mother and child health, family planning, immunization, nutrition and preventing the diarrhea) in the one organization.

The activity of IHP is conducted by cadres and supported by health personnel. It was reported in 1991 that 1,8 million health cadres were trained. Duration of training only 3 days.[16] In term of number might be huge, but the question is how about the quality? Conceptually, the health cadres are volunteer, but in reality they get some incentives such as :

• transportation fee, usually Rp 5000 per H day ( $ 0.5 )
• free service treatment in the health center
• free uniform
• study tour
• acknowledgement as the best cadre election in the level of district,

province and country

The number of cadres in every IPH are 5 persons that are related to 5 tables system activities.[17]

The system of services of the IHP

Steps	Services	Operator
First	Admission of child under 5	Cadre
Second	Weighing	Cadre
Third	Fill in health card	Cadre
Forth	Health promotion	Cadre
Fifth	Medical services	Health personnel

In 1986. the IHP was launched by President of Republic of Indonesia as model of the CBHW that are implemented to every village. From this point, the CBHW has been drifting from the community health action that become more the government’s initiatives. To strengthening the IHP in 1990, the government introduced new program which is posted the midwife in every village. The objectives of this program to strengthen the program in decreasing of the IMR and MMR certainly. The IHP becomes the national program and tend to be more centralized.

In this period, many success story of the community-base health action were produced by Indonesia. The famous one is the family planning program that is recognized by the world. Some factors those have influenced the success story are consistence policy, good plan, community involvement (formal and informal leader), enough budget support and good implementation program. The most important factor is that it uses family–based action approach. The comprehensive plan of the program lead to sustainable program action in the field. It is reported by Chief of the Family Planning Coordination Organization that the program achieve 66% of acceptors among the reproductive couples in the year 2006. [18]

V.3 CBHW in The Reformation Order Era of Governmental Regime

(1997 – Current)

As the socio-economic crisis in 1998, it was reported that the IHP’s activities decreased and many of the IHP were no activity at all. Moreover, in 2001 the government ran the revitalization program of the IHP. The program provided a training for cadres, facilitated the health instrument and fund for activating of the IHP. However, it is predicted only 50% of the IHP are active.[19] Majority, in H day activity of IHP that only 2 cadres who actively assist the IHP program. They usually work in the table 1 (admission of child under 5), table 2 ( weighed the child) and table 3 (recording the result of weighing in the health card and the rest activities are conducted by the health personnel.

Meanwhile, it is reported that in 2006 the number of IHP are 242, 211. Beside that, there are 25,723 the village maternity homes and 11,032 village drug post. If the number could be trusted; it means every month there are 21 million child under five are weighed and monitored the growth, got additional of food and Vitamin A twice a year.[20]

Later on, the Village Health Post (The VHP) is introduced by MOH (2006)

The VHP has established in the village in order to provide or to bring closer basic health care for the village community. Village Health Posts are health facilities which are the meeting point between community efforts and Government support. The activities of Village Health Posts are expected to be able to implement health care activities for the village community, at least:

• Simple epidemiologic surveillance on diseases, especially communicable diseases and diseases which have the potency to create outbreaks and its risk factors (including nutrition status) as well as the health of risky pregnant mothers.
• Disease control, especially communicable diseases and diseases which have the potency to create outbreaks and its risk factors (including malnutrition).
• Preparedness and disaster control and health emergencies.
• Basic medical care, according to its competence.

Village Health Posts are implemented by health manpower (a midwife at the minimum) from public health centre and assisted by at least 2 (two) cadres. Building physical facilities, health supplies and equipment should be available for the implementation of Village Health Post services. It is also necessary for the Village Health Posts to have communication facilities (telephones, cellular phones, or courier) in order to communicate with the community and health facilities (especially health centers).

Finally, MOH have run a new program that is called the Alert or Steady village (the SV) that is developed from the village health post (2007). The steady villages are description of a community who are aware, willing and able to prevent and overcome various threats towards community health such as malnutrition, communicable diseases and diseases which are potential to trigger outbreaks, disasters, accidents, and others, by utilizing local potentials through mutual cooperation.

In the year 2009, the program is targeted that 69,000 villages will become the steady villages. Characteristics the steady village as follows:

• has village health post that could be developed from the village maternity home
• has community based surveillance device for diseases, nutrition, environmental health and healthy life behavior
• has emergency services system
• has self health fund system

The program will post one health personnel in every village in Indonesia. The competency of personnel are midwife plus health environment and nutrition competencies. The program objective is that the health personnel could be acted as agent of change and the motor of the steady village. It seem the program is so ambitious; the program will distribute about 69,000 health personnel to post in every village in Indonesia. In my point of view, the program seems good but it should be supported with hard work of health personnel and enough operational budget in implementation.

If we see in term of the number of CBHA, number of health personnel and the number of cadres that government might be has achieved some success. Even, some health indicators show that are decreasing of IMR and MMR, but comparison to same countries in region, Indonesia is still low behind. As well, the UNDP reported that HDI of Indonesia (114) is still high comparison with Philipine (84), Thailand (74) and Malaysia (61).[21]

VI What is the CBHW in Future? Is the Family Based Health Action a Solution?

In this section, I want to present my point of view on the issue of the CBHW. Based on literature review, academic discussion, and my experience, I will introduce the concept of the Family-Base Health Action (FBHA) that could be a solution to solve the health problem in community. I believe that the FBHA will be more workable since it uses a process approach to the right target. the FBHA focus to facilitate to empowerment of the family, so they able to overcome their health problems.

Lets see, after more 3 decades, we have conducted the community-base health program. It seems that we achieve some objectives. However, we still face the similar health problems a long the years. The problems of TBC, Malaria, Dengue, AIDS, Malnutrition, and local diseases such as: Frambusia and Rabbies are still exist if not worsen. In addition, we countenance too the re-emerging infectious disease such: polio and new emerging diseases such as: SARS and Avian flue. Those problems, could be used as indicators of performance of the community-base health program. Do we really in the right tract in eradicating the community health problems?

Some lesson learns from the Indonesian experience give us some explanations of the community based health program as follows :

• the IHP in term concept might be good, however it works less than it’s plan. It is caused the IHP works based on structural approach. The IHP becomes a satellite of the community health center (CHC) and the CHC is sub-ordinate of the District Health Office. Therefore, many of the IHP tends like a bureaucracy and depends on the personnel of the CHC. It means that the activity of the IHP tend to depend on the activity of the CHC. If the IHP is supported by the good of the CHC; that could be the IHP works actively.
• the centralized and homogenized the program are not workable. For instance, in Jakarta, the chief of the Family Welfare Program orders to the Community Health Center (CHC) that the H day of IHP has to open on 27^th every month. It can not be supported by every CHC since that is not enough health personnel. As consequences, some the IHP run without any health personnel. That means the table 4 and table 5 do not provide the services. The question is how the IHP works in other province and specially in the remote area? Of course, in other provinces the situation could be different. Many provinces, the H day of IHP opens depend on the cooperation between health personnel and the cadres. As a result, they can work together smoothly.
• the lacking of knowledge and skill of health cadres since only get training 3 days that leads to the limitation of cadre’ role since lack of competency
• high rate of cadre’s turn over. It could be understood since the cadre base on the volunteer. It is so difficult to maintain by every the CBHA in the long term. However, this problem is an universal that will be faced by every country.
• the government’s role too dominant that lead to demolish of people initiatives and motives
• the government does not allocate enough fund for the promotion and prevention in the Community Base-Health Program.

It is understood that the concept of CBHW hard to solve the people problem. One important factor that could be dominant in making the CBHW does not work effectively is it works in the level community. Meanwhile, the true health problems are in the family or household. Therefore, we have to focus the program to the family health. Only the member of family is really concern and accountable to the health status of family. Only the member of family who want to pay and take care if one of the family member get sick. Only the member of family who want to be sacrifice if one of the family member has to hospitalized. Thus, the community empowerment should be worked in family level; since the family health is considered as an asset and capital in the village development. Every family should be motivated and encouraged to actively take part in promoting good healthy behavior as bottom of development of community health. In simple word, the CBHA should be changed to the family based health action.

In the FBHA, all the activity of public health programs are focus to facilitate to empowerment of the family. It means the core of the public health program is family health. In the FBHA, the program should be focused to:

• the FBHP base on the functional or process approach
• the target of the FBHA is family
• the cadre is member of the family
• every member of family is accountable to health status of family
• train family cadre to solve the health problem of his/her family
• empowerment the cadre to help his/her family to get an access on health services

The role’s of the government in development of the FBHP as follows:

• provide an opportunity and facilitate that family has ability to maintain the member of family healthy
• the community health center, the integrated health post, and the health personnel in village should work base on the family health. It means those entities have close relationship to the every family in their working area. The information system should be developed and implemented base on the health status of family. As a result, the health personnel know exactly condition every family. We should rename the community health center to the family health center and the integrated health post to the family health post.
• the promotion, the prevention and curative program base on the family needs. Subsequently, the health program could solve the health problem that lead to the healthy family and then healthy village.
• Activity of the health personnel have to in the family level, therefore they have to enough facility to reach the family such as: transportation vehicle, supply, promotion aid, audiovisual aid and operational budget.
• converse the pyramid health budget; the family health allocation must get the biggest proportion of the budget. The biggest proportion health budget have to allocate to the family health in the village level. So, the best concept in FBHA could work effectively.

To make clear the concept of the FBHA, we develop the flow chart that explain the role of the government and health entities in every level of administration. We can see the process of development how the Healthy Indonesia could be achieved in 2020.

VII Conclusions

The CBHP has been conducting for more than 30 years in Indonesia. It seems that the CBHP does not work effectively since it faces some barriers that are described above. In the future, we should introduce a new concept of self help and self reliance in development of people health. The FBHP is the concept of health development that focus on the family health. The FBHP base on the family member as health cadre that could be sustainable in running the health program in household level. The FBHP base on the functional or process approach.

Oleh : Dr. Drg. Yaslis Ilyas, MPH, HIA, MHP