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World Health Organization, Regional Office for South-East Asia. Sasakawa health prize: stories from South-East Asia.

1. Awards and prizes. 2. Community Health Services. 3. Community Health Planning. 4. Primary Health Care. 5. Family Health. 6. Child Development. 7. Rehabilitation Centers. 8. Health Education. 9. Health Services. 10. Leprosy.

ISBN 978-92-9022-411-2 (NLM classification: AS 911)

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This publication does not necessarily represent the decisions or policies of the World Health Organization.

Printed in India Contents

Preface ��iv Acknowledgements ��vi Introduction ��viii

SEWA Rural (Society for Education, Welfare and Action): 1985 (India) ��1

Sustaining health development in Ayadaw: 1986 (Myanmar) ��17

The three eras of primary health care: 1986 (Thailand) ��37

Family Welfare Movement (Pembinaan Kesejahteraan Keluarga - PKK) and its achievements in national development: 1988 (Indonesia) ��53

Integrated Child Development Scheme (ICDS): 1990 (India) ��69

Community-based rehabilitation: Improving the quality of life of people with less ability: 1992 (Indonesia) ��83

Paradigm shift through development programmes in selected villages of Haryana: Arpana Research and Charities Trust–India: 1993 (India) ��97

Society for Health Education (SHE): 1996 (Maldives) ��115

Mongar health services development project: 1997 (Bhutan) ��125

The triumphant journey of FPA Sri Lanka: Sasakawa and beyond: 2004 (Sri Lanka) ��147

International Leprosy Union (India): “Life is beautiful”: 2006 (India) ��171

Never give up: 2012 (Indonesia) ��183

Annexes Statutes of the Sasakawa Health Prize (as amended in January 1998) ��195

Sasakawa Health Prize Guidelines (as amended in January 1998) ��197

Recipients of the Sasakawa Health Prize ��199 The Sasakawa Health Prize was established in 1984 on the initiative of and with generous funding from Mr Ryoichi Sasakawa, Chairman of the Japan Shipbuilding Industry Foundation and President of the Sasakawa Memorial Health Foundation.

The Sasakawa Health Prize is awarded annually to one or more individuals, government institutions or nongovernmental organizations for outstanding and innovative work in health development such as the promotion of health programmes or notable advances in primary health care. The prize is awarded at a special ceremony during the World Health Assembly and consists of a statuette and a sum of US$ 100 000.

It is a matter of great satisfaction that candidates from South-East Asia have received the prize 12 times since its inception. This is testimony to the fact that the Region is committed to the principles of egalitarianism, social justice and equity in health as enshrined in the Alma-Ata Declaration of 1978 and the ensuing Health for All movement.

This publication attempts to capture the spirit of each of these award- winning experiences. It not only presents the historical perspectives of health development in South-East Asia but also the vast repertoire of initiatives and learning that can guide us in revitalizing primary health care.

A common thread that runs through the work of all the awardees is the primacy accorded to a people-centred and holistic approach to health development. A recurring theme in the projects is the recognition of good health as an essential component of “quality of life”. Another is a genuine attempt to reach out to social groups on the fringes of society. One can also discern that a large majority of these projects relied on traditional wisdom, values and beliefs, and community resources to work towards community empowerment. The spiritual ethos, volunteerism and altruism that are so integral to the culture of South-East Asia are clearly seen to be the guiding principles of these projects.

iv Sasakawa Health Prize: stories from South-East Asia Preface

The experiences described in this book are an eclectic mix of health interventions and projects by government agencies, nongovernmental organizations, the community and individuals. Each of these describes the challenges that were faced, how these were overcome and the opportunities that were harnessed to achieve goals. Indeed, these are real- life examples that exemplify the challenges of intersectoral coordination and show how individuals, communities, nongovernmental organizations and governments can work together for the common purpose of improving the quality of life of the people.

It is gratifying to note that not only has the prize-winning work been sustained but also that several projects have left a lasting impact on national health policies. The write-ups contain several examples of good practices that have been adopted by national development programmes.

In addition to its archival value, it is hoped that this publication will be found useful by policy-makers, health managers, public health professionals and others to design and further strengthen their health systems using the primary healthcare approach.

Finally, I wish to express my appreciation to the many individuals who helped to research the material and draft some of the chapters and to Dr Palitha Abeykoon who served as the overall editor of this publication.

Dr Samlee Plianbangchang Regional Director

v Acknowledgements

This publication required efforts of many individuals and institutions in the South-East Asia Region, for the collection of historical information, drafting and revising chapters, undertaking reviews and providing comments. Their contributions are deeply appreciated.

The following deserve special mention for preparing the first drafts:

•• Pankaj Shah, •• Anne Robinson and Aruna Dayal, Community Health and Managing Trustee Arpana Research & Charities Trust, Madhuban, SEWA Rural, Post: Jhagadia, Dist: Bharuch, Karnal, Haryana, India Pin: 393 110, State: Gujarat, India •• Asna Luthfee, •• U Than Sein, Programme Associate, Society for Health Former Director, WHO South-East Asia Region Education, Male, Maldives No.490, 1st Floor, Mahabandoola Road, Between Sonam Ugen, 29 & 30 Street, Pabedan Township, Yangon, •• Community Health Department, Myanmar Jigme Dorji Wangchuck National Referral •• Amorn Nondasuta, Hospital (JDWNRH), Former Permanent Secretary of Health, Founder Ministry of Health, Royal Government of Bhutan of the Primary Health Care System and President Sabina Omar, of Quality of Life Foundation in Thailand •• Family Planning Association of Sri Lanka, Bullers •• Palitha Abeykoon, Lane, Colombo 7, Sri Lanka Former Director, WHO South-East Asia Region S.D Gokhale, 17, Horton Towers, Colombo 8, Sri Lanka •• International Leprosy Union-Health Alliance, •• Handojo Tjandrakusuma, 1779/84, Gurutrayee, Near Bharat Scout Former Director of the CBR Development Ground, Sadashiv Peth, Pune-411030, India and Training Center (CBR-DTC) PPRBM Syamsi Dhuha Foundation (SDF) Prof.Dr.Soeharso – YPAC Nasional •• Jl. Ir. H. Juanda 369 Komp. DDK No. 1 Jl.LU.Adi Sucipto KM-7 Colomadu-Solo 57176 Bandung 40135 Indonesia Indonesia

Valuable comments were provided by:

•• U Ko Ko, •• U Mya Tu, Regional Director Emeritus, World Health Former Director of Health System Development, Organization, South-East Asia Region and WHO South-East Asia Region and formerly formerly President of the Myanmar Academy of Director-General of Department of Medical Medical Sciences, Yangon, Myanmar Research in Burma (Myanmar)

vi Sasakawa Health Prize: stories from South-East Asia

•• Agus Suwandono, •• Athula Kahandaliyanage Senior Researcher, Center for Biomedical and Director of Sustainable Development and Basic Health Technology, National Institute of Healthy Environment, WHO Regional Office for Health Research and Development (NIHRD), South-East Asia, New Delhi, India Ministry of Health Republic of Indonesia, Secretariat of PKK Gedung 4 Labdu Lantai 6, Jl. Percetakan Negara •• c/o Directorate General of Rural Community 29, Jakarta Pusat 10560, Indonesia Empowerment •• Monirul Islam Ministry of Home Affairs Republic of Indonesia Director of Health Systems Development, WHO Jalan Raya Pasar Minggu Km 19, Jakarta Selatan, Regional Office for South-East Asia, New Delhi, INDONESIA India

The following staff members of the WHO Regional Office for South-East Asia and WHO Headquarters (in alphabetical order) provided useful technical inputs and facilitated in the collection of historical information:

•• Boosaba Sanguanprasit •• Payden •• Ilsa Sri Laraswati Nelwan •• Prakin Suchaxaya •• Iyanthi Abeyewickreme •• Rajesh Bhatia •• Jigmi Singay •• Renu Garg •• Marie Sarah Villemin partow •• Sangay Thinley •• Myo Thet Htoon •• Sara Varughese •• Nyo Nyo Kyaing •• Sudhansh Malhotra •• Nyoman Kumara Rai Editorial: Chief Editor - Palitha Abeykoon Editorial Coordinator - Anchalee Chamchuklin Language Editor - Jitendra Tuli and Bandana Malhotra Layout - Puneet Dhingra, Subhankar Bhowmik and Chander Prakash Sharma References verification - A. K. Sharma Special thanks to Regional Director, Dr Samlee Plianbangchang, for his inspiration and guidance.

vii Introduction The Sasakawa Health Prize was established in 1984 at the initiative of and with funds provided by Mr Ryoichi Sasakawa, Chairman of the Japan Shipbuilding Industry Foundation and President of the Sasakawa Memorial Health Foundation.

The prize consists of a statuette and a sum of US$ 100 000 to be given to one or more persons, institutions or nongovernmental organizations that have accomplished outstanding innovative work in health development. The prize aims at further encouraging such work in health development, which extends far beyond the call of normal duties; it is not intended as a reward for excellent performance by a candidate of duties normally expected of an official occupying a government position or of a governmental or intergovernmental institution. The prize is awarded at a special ceremony during the World Health Assembly.

At the time the prize was established, the major criteria laid down for the assessment of the work to be recognized included the following:

(a). Contribution to the successful formulation and implementation of the national policy and strategy for Health for All by the year 2000;

(b). Promotion of and substantial achievement in advancing given health programmes, which have resulted in increasing primary health care coverage, and/or improving the quality of health care to the population, and a notable reduction in given health problems;

(c). Contribution to increased efficiency and management of health systems; policy development, health legislation and ethics, within the framework of primary health care;

(d). Innovative programmes to reach socially and geographically disadvantaged population groups;

This prize aims at appreciating accomplishments of work in the field of health development

Mr. Ryoichi Sasakawa

viii Sasakawa Health Prize: stories from South-East Asia

(e). Innovative efforts to train and educate health workers in primary health care;

(f). Successful and effective efforts at involving communities in planning, managing and evaluating primary health care programmes;

(g). Development and successful application of health systems research for the advancement of primary health care.

Since its inception, the prize, has been awarded to 12 winners, both individuals and institutions, from the South-East Asia Region. This is the largest number from a single Region of the World Health Organization (WHO). India and Philippines won the prize four times, the most by any one Member State, with the Indonesia ranking second (three times). Three individual winners from the Region have been honoured, personalities who have made a distinctive and outstanding contribution to health development – Dr Amorn Nondasuta, former Permanent Secretary of Health, Thailand; Professor B. N. Tandon, former Professor of Medicine at the All India Institute of Medical Sciences, New Delhi, India; and Dr Handojo Tjandrakusuma, the Founder of the Community Based Rehabilitation Development and Training Centre] from Solo, Indonesia.

This collection of Sasakawa Health Prize-winning stories from the South-East Asia Region of the World Health Organization (WHO) highlights the work done by the respective institutions and individuals, which earned them this prestigious award. As one of the main objectives of the prize is to encourage the further development of such work, a brief description of the contributions that have been made by them since the time they won the award have also been included, either as an epilogue or a post script or an “afterword” in some of the stories.

The health projects and programmes described in this publication depict a wide variety of innovative and interesting initiatives, each one based on the cardinal principles and practice of primary health care. There are many lessons that could be learnt from these experiences by all the leaders and practitioners of innovative health development, particularly those in South-East Asia.

An attempt has been made to be as faithful as possible to the original submissions that were made to WHO, limiting the editing to clarify and highlight certain significant points and principles. A few of the stories have been presented in part as first person accounts as they were experienced and evolved over time.

ix Dr Lata Desai, representative of SEWA, during the prize giving ceremony. WHO Photo

1 CHAPTER 1 1985

SEWA Rural (Society for Education, Welfare and Action), India[*]

Recipient: Sewa-Rural (society for education, welfare and action - rural) India

[*] The initial draft was prepared by Mrs Pankaj Shah. Community Health and Managing Trustee SEWA Rural, Post: Jhagadia, Dist: Bharuch, Pin: 393 110, State: Gujarat, India 2 EWA Rural is a voluntary organization involved in Sheath and development activities since 1980 in the rural tribal area of Jhagadia in south Gujarat

1. Introduction Gujarat In 1984, the Society for Education, Welfare and Action (SEWA Rural) had just completed four years of work among the rural, tribal and poor communities of south Gujarat in western India when nominations were sent for the Sasakawa Prize for the year 1985. SEWA Rural has now completed three decades of its community health and development work. This article recapitulates what was done by SEWA Rural in the early 1980s to earn the prestigious prize and how subsequent work evolved and developed. SEWA Rural endeavours to reach out and assist SEWA Rural is a voluntary organization involved in heath and development the poorest of the poor activities since 1980 in the rural tribal area of Jhagadia in south Gujarat. It was through various health started by a group of young professionals educated in India and abroad, and and development based on the ideas and ideals of Swami Vivekananda and Gandhiji. Over the programmes based on years, many like-minded youngsters have joined the organization. community needs and available human resources SEWA Rural endeavours to reach out and assist the poorest of the poor through various health and development programmes based on community needs and available human resources. It seeks to ensure that values are preserved and self- development, in the broader sense, is achieved simultaneously of those involved in the work. The focus of all programmes has been vulnerable members of the family, i.e. women, children and the elderly, and the poor sections of society.

In all the activities, an attempt is made to incorporate as well as balance three basic principles: social service, a scientific approach and spiritual outlook. Activities include a community hospital, community health project, training centre in health, comprehensive eye care programme, community-based rehabilitation programme for the blind, vocational training centre, women’s development and empowerment programme (now under an independent

3 Sasakawa Health Prize: stories from South-East Asia organization, Sharada Mahila Vikas Society). The organization believes in taking assistance from all sectors of civil society, which include the local community, individual well-wishers and donors, voluntary organizations, government and private industries, charitable trusts, academic institutions and foreign agencies. Their whole-hearted support and encouragement have ensured that the fruits of development and growth in society ultimately reach the marginalized and underserved sections of society, i.e. women, tribals and the poor.

2. The beginning of the community health project

SEWA Rural started in 1980 with a small hospital given by a local community. The organization felt that curative support, the main strength of the initial group, would be essential for primary health work. After working in the community hospital for two years, building a reasonable community rapport and assessing the baseline health status, the community health project was launched in 10 villages in October 1982. Oxfam (UK) and Community Aid Abroad (Australia) provided financial assistance. To avoid duplication of services at the community level, SEWA Rural approached state health officials with a request that the responsibility SEWA Rural gradually for village-level workers (community health volunteers [CHVs], traditional expanded the scope and birth attendants [TBAs] and anganwadi workers [AWWs]) from selected coverage of its community villages be entrusted to SEWA Rural. Besides supporting and monitoring health project to cover village-based workers and further building community rapport, a weekly about 40 villages and mobile dispensary was also started in these villages so that minor ailments a population of 40 000 could be treated in the village itself. Meanwhile, the joint United States under the scheme Agency for International Development (USAID)/Government of India’s Private Voluntary Organisation for Health (PVOH) scheme was announced in 1983 to support voluntary organizations working for community health. Over the next five years, SEWA Rural gradually expanded the scope and coverage of its community health project to cover about 40 villages and a population of 40 000 under this scheme.

Dr Lata Desai, representative of SEWA, addressing the 38th World Health Assembly. WHO Photo

The focus of all programmes has been vulnerable members of the family, i.e. women, children and the elderly, and the poor sections of society

4 SEWA Rural

(Society for Education,

Welfare and Action),

India: 1985 (India)

3. Key innovations leading to candidature for the Sasakawa Health Prize

3.1 Maternal services in the community health project

Gujarat This component is given high importance as it has an impact on infant, perinatal and maternal mortality. Care is provided through the cooperative and collective efforts of CHVs, TBAs, AWWs, multipurpose health workers female (MPHW – female/FHW). The latter take active responsibility for providing this service in their respective target areas at the village level. FHWs make repeated visits to the home of every pregnant woman and provide a standard package of antenatal care (Inj. tetanus toxoid, tablet folic acid, medical examination,

Maternal services are referral and health education). given high importance It was observed that TBAs were not actively involved in antenatal care. They as it has an impact on were called only at the time of the delivery. Thus CHVs, who also lived and infant, perinatal and worked in the village, maintained the register of the expectant mother, which maternal mortality was passed on to the FHW during the biweekly meeting at the hospital or the latter’s field visit to the village. Following training, TBAs are now involved in providing antenatal care.

In rural India, most of the deliveries are conducted at home by a local birth attendant. It is not possible, desirable or necessary to replace them. What is needed is to train them in scientific techniques. Those TBAs who were not trained in the government primary health centre were provided training through the use of posters, slides and other audiovisual aids; those already trained were given refresher training. Four sessions were organized in less than a year. Training continued during the field and mobile visits to the villages. The self-esteem of the TBAs improved and they were given importance in the organization as a result of their involvement and cooperation. Their performance also improved markedly.

Presterilized delivery pack and its distribution system: The concept of a prepacked delivery pack is not new. However, there were two areas of innovation – how the delivery pack reaches the beneficiary and how monitoring is done

5 Sasakawa Health Prize: stories from South-East Asia to ensure that it had been used properly. Expectant women are given a prepacked delivery pack by the FHW during the later part of their pregnancy (either eighth or ninth month). The woman is given necessary relevant health education and also told about the importance about the delivery pack, which she is supposed to give to the TBA at the time of delivery. The health education component of the delivery pack is given a lot of importance. As a result, the mother, mother-in-law, neighbours as well as other pregnant women are informed about the importance and details of the delivery pack. The TBA has been already trained to use the pack. It contains pieces of gauze, cotton, thread and antiseptic solution all wrapped in the bag, which itself can be used as a towel on which to place the boiled instruments and equipment when they are spread open at the time of delivery. The standard dai kit contains other instruments for conducting a safe delivery such as a bowl, a pair of scissors, etc. The TBA conducts the delivery as per the training she has received. After delivery, the empty bag is retained by the mother in In rural India, most her home and not taken by the TBA who conducted the delivery. of the deliveries are conducted at home by “High-risk” mother approach and antenatal week: Systematic training is given a local birth attendant. to TBAs, FHWs and other staff with the important objective of teaching them It is important to train to identify “high-risk” mothers. The TBA is paid an additional honorarium these attendants in even if she has to send such a mother to the hospital for delivery. This scientific techniques prevents TBAs from conducting abnormal deliveries at home, which may be a risk to the mother and newborn.

The programme has a second tier of a “mobile health team”, which visits each village once a week to provide curative services and supervise village- level staff, among other work. Out of four weeks, one week is especially devoted to the identification and treatment of “high-risk” mothers, which is designated the “antenatal week”. High-risk mothers who have already been identified by the FHW and TBA are asked to be present at the mobile medical van. The Lady Medical Officer examines these mothers and gives appropriate advice. Some of them are advised to come to the community hospital, and the others to the hospital, keeping the TBA in the picture.

The programme has a second tier of a “mobile health team”, which visits each village once a week to provide curative services and supervise village-level staff

6 SEWA Rural

(Society for Education,

Welfare and Action),

India: 1985 (India)

3.2 Community health project and government participation

Rationale: Delivering primary health care in the interior rural areas has not been an easy task. Various agencies – the government, voluntary organizations (VOs), the private sector and practitioners of indigenous systems –have all tried to tackle Gujarat this problem in different ways. Each has a distinct role to play. The programme strategy needs to be formulated according to the local conditions. From the beginning, SEWA Rural’s approach has been to work with the government in a spirit of cooperation and coordination. The reasons for this approach include ensuring financial support from the government for long-term sustainability, the large amount of work required to implement primary health services, ensuring replicability, creating a demand from the community through health awareness, SEWA Rural’s approach and avoiding confusion and duplication of services. has been to work with the government in a The beginning: SEWA Rural approached the district panchayat and the state spirit of cooperation health directorate asking that responsibility for existing peripheral health workers and coordination (CHVs, TBAs and AWWs) be given to SEWA Rural. The workers came under the technical supervision and administrative control of SEWA Rural. A pre-test was done to assess the existing knowledge and skills of the workers, following which training was organized based on the findings. Slowly, rapport and confidence were built up with them. A unique experimental model of a collaborative partnership between a nongovernmental organization (NGO) and a government organization (GO) was launched in 1984. An area of about 40 villages with 40 000 population was handed over to SEWA Rural for total health care for five years. Of these, 21 villages would be in the first stage. SEWA Rural would be totally responsible for the health care of the people of this area. All national and state health programmes would be implemented only through SEWA Rural. All village-level health personnel (CHVs, AWWs and TBAs) would work under SEWA Rural, which would have total responsibility and power. Existing government middle-level MPHWs were given a choice; either to work under SEWA Rural on deputation or opt for a transfer to another part of the district. All existing village-level government buildings (sub- centres) would be handed over to SEWA Rural along with equipment and other fixtures. The government would financially assist SEWA Rural in paying salaries, buying medicines, etc. The organization would maintain financial and functional accountability. The district panchayat would appoint an evaluation committee consisting of three representatives of the district panchayat/state health directorates, three representatives of SEWA Rural and three members from an outside agency. 7 Sasakawa Health Prize: stories from South-East Asia

The process: Even though handing over total health care to SEWA Rural was accepted in principle, many details needed to be worked out, including the necessary government resolutions. Most of the existing middle-level health workers (MPHWs) refused to join SEWA Rural on deputation. Male MPHWs were recruited fresh and in-service training was organized. However, female MPHWs were difficult to find. SEWA Rural obtained approval as a field training centre for FHW students studying in nursing schools and recruited two qualified FHWs on deputation. Four local girls were selected by SEWA Rural and sent for the formal FHW training course. One male and one female supervisor were deputed to SEWA Rural from the government.

Though government officials at state and district levels were positive about the collaborative experiment, there was some resistance from district Though government and block panchayats, as they are controlled by different political parties. officials at state Intense efforts were required to ameliorate this situation through frequent and district levels meetings and dialogue with the respective stakeholders. were positive about 3.3 Referral system the collaborative experiment, there SEWA Rural was fully convinced that the community health programme was some resistance needed to be backed by adequate referral support in order to boost the from district and block confidence of the community in health workers and SEWA Rural, and panchayats, as they are for the project to have better outcomes. After identifying and providing controlled by different medical care to referred patients, further follow-up at the community level political parties also formed an integral part of the referral system.

3.4 Mobilization, motivation and participation in SEWA Rural

Most government and nongovernmental programmes have the necessary ingredients for achieving the desired results. The major problem is implementation of the programme, and human resources are a key factor for this. Systemic efforts were made to motivate staff members at all levels for better performance and self-development.

An area of about 40 villages with 40 000 population was handed over to SEWA Rural for total health care for five years

8 SEWA Rural

(Society for Education,

Welfare and Action),

India: 1985 (India)

3.5 Encouraging peripheral health workers

Over and above the fixed monthly honorarium, peripheral health workers are paid additional performance-based incentives, e.g. a CHV is paid extra for attending educational meetings or the mobile van, helping in the detection Gujarat of new tuberculosis (TB) patients, motivating people for family planning or conducting follow up. Emoluments are also given to the AWW for improving the status of high-risk children, maintaining cleanliness of the anganwadi, and for better attendance and adequate medical coverage of children. These workers are given importance at the mobile vans as well as at the hospital. SEWA Rural workers also try to be involved in the local festivals, customs and social gatherings along with the peripheral health workers. Thus, all efforts are made to Over and above convince the community that the peripheral-level health worker is fully backed the fixed monthly up by SEWA Rural and is part and parcel of the team. honorarium, peripheral health All peripheral health workers are encouraged and appreciated for their workers are performance during the regular sessions at headquarters. The good work done paid additional by workers is shared with all. Their present problems and difficulties are given performance-based due attention. However, any point of criticism is discussed in person. Combined incentives meetings with CHVs, AWWs and TBAs are organized regularly to build up team spirit and a sense of togetherness and better coordination.

Changing attitudes and creating self-confidence in the peripheral health workers is a very slow process, as they have remained neglected for many years. It requires a great deal of patience, perseverance and hard work to induce productive changes among peripheral-level village health workers who are envisaged by SEWA Rural as “change agents” of the future.

4. Epilogue

It is 25 years since SEWA Rural was awarded the Sasakawa Health Prize. Since then, there has been considerable development in its health service delivery. Other development programmes have been conducted not only in SEWA Rural but also in the larger society. These are given below.

9 Sasakawa Health Prize: stories from South-East Asia

4.1 NGO–GO collaboration for primary health care

A unique development took place following involvement of the Government of India/USAID to manage the health care of 40 villages. The Government of Gujarat handed over all existing health responsibility to SEWA Rural and transferred all their staff members (doctors, supervisors, health workers, etc.) elsewhere. Besides USAID funds for certain additional expenses, the State Government agreed to reimburse all middle-level staff-related and other routine expenditure, with SEWA Rural as a functional primary health centre during 1984–89. In spite of some limitations and difficulties, the experiment was effective, resulting in the Government of Gujarat granting formal primary health-care coverage of 40 villages (population of 40 000) to SEWA Rural for 10 years from 1989 to 1999. This was for the first time in India that the government had handed over health care and all aspects of management with It requires a great 100% financial assistance. deal of patience, Reviews of the community health project including NGO–GO perseverance and partnership hard work to induce productive changes Two reviews of the community health project were carried out by external among peripheral-level agencies. The first covered the project period between 1984 and 1989, and village health workers the second between 1989 and 1999, when the government entrusted primary health care to SEWA Rural for a decade. Beside improvement in various health indicators and involvement of frontline workers, both studies highlighted the NGO–GO partnership.

The first review: This focused on the strengths and shortcomings of the project, and helped SEWA Rural, as well as other interested organizations and individuals, to learn. As has emerged from this study, the achievements in terms of health improvement have been significant and indicate what can possibly be achieved in other rural areas through the existing pattern of health delivery.

Sewa rural workers are encouraged to get involved in the local festivals, customs and social gatherings along with the peripheral health workers

10 SEWA Rural

(Society for Education,

Welfare and Action),

India: 1985 (India)

Impact and achievements: Health service utilization targets for Health for All (HFA) 2000 had already been achieved. In the case of many of the vital indicators too, HFA targets for 1990 had been achieved, notably the birth rate, infant mortality rate, couple protection rate, and under-five mortality rate, among others. Maternal and perinatal mortality rates remained somewhat Gujarat higher as compared to HFA targets, though only maternal mortality was higher than comparable rates for Gujarat state. Measles had virtually ceased to be a killer in the project area and vitamin A deficiency in children had been controlled. Neonatal tetanus was rare as was severe childhood tuberculosis. Severe childhood malnutrition had declined, though modestly. Tuberculosis case detection was less than satisfactory, while case-holding was fairly high. Malaria continued to be a problem, though possibly less than elsewhere in the country. SEWA Rural experience Definitive figures for morbidity were not available to enable firm statements has been an almost lone about most other infectious diseases. Fertility control was satisfactory, with a success story among moderately high couple protection rate, and a relatively stable and low birth a series of NGO–GO rate. However, non-terminal methods of birth control were not used. Effective collaborations that have referral care had been established at a cost the community could afford. Data misfired, especially in the collection was accurate, with most events under scrutiny being captured. health sector However, retrieval of past records posed problems due to unsatisfactory cataloguing and storage.

Vital statistics from 1982 to 1989

Present status HFA Baseline 1987–1989 targets 1982–84 SEWA Government 1990 Rural Gujarat/India Crude birth rate 35.6 27.0 29.6 27.0 (CBR)/1000 population Maternal mortality 3.1 5.0 5.0 2.3 ratio/ 100 000 live births Infant mortality 172.0 89.2 104.0 87 rate/1000 live births Couple protection 36.9 61.8 42.7 42 rate (%)

11 Sasakawa Health Prize: stories from South-East Asia

Over the years, there has been an increase in the general level of health awareness in the community. Some programmes for socioeconomic upliftment have been launched and efforts in environmental sanitation have been initiated. However, community participation in most health programmes is at best modest, and self-reliance of the community remains elusive.

SEWA Rural experience has been an almost lone success story among a series of NGO–GO collaborations that have misfired, especially in the health sector. Undoubtedly, the Government of Gujarat deserves a fair share of credit in making this collaboration a success. However, it is necessary to be careful in drawing generalizations about such collaborative efforts based only on this study and other such experiences should be studied as well.

SEWA Rural feels that it has not been able to concentrate on important areas in health care largely because of having to adjust to the routine demands of the The strong points and government on less relevant and poorly prioritized issues. characteristics of SEWA Rural were excellent Second evaluation (2003): This review was conducted for the period 1989 to community rapport, 1999. The technical review team found that the quality and coverage of service project detailing, utilization had reached high levels and the impact on most mortality rates was commitment and empathy considerable. Most of the communicable diseases and epidemics had been of health workers, fairly well controlled. The prevalence of severe degrees of malnutrition among involvement of village- children had also been substantially reduced (from 16% to 2.5%). There was a level workers, meaningful higher level of awareness on various aspects of basic health in the community, and effective recording as seen from the increase in coverage of maternal care (from <25% to >85%) and reporting system and immunization coverage (from 10% to >95%).

The strong points and characteristics of SEWA Rural were excellent community rapport, project detailing, commitment and empathy of health workers, involvement of village-level workers, meaningful and effective recording and reporting system, etc. All the above became possible through a series of micro- level interventions and innovations. The organization achieved most of the Dr Lata Desai, representative of SEWA, receiving the Sasakawa Health Prize and Statuette from the hands of Dr Suwardjono Surjaningrat, President of the 38th World Health Assembly. WHO Photo

The achievements in terms of health improvement have been significant and indicate what can be an example for other rural areas towards health delivery

12 SEWA Rural

(Society for Education,

Welfare and Action),

India: 1985 (India)

targets of HFA by 2000 much earlier, and it has sustained them over a period of time in spite of working within the government system with its attendant constraints. It also introduced several innovations in management as well as service delivery, many of which were subsequently adopted by the government system and by many voluntary organizations. The project also brought out the Gujarat strengths and weaknesses on both sides, which may be profitably drawn upon if the government wants to involve more voluntary groups and the community in rural health care, particularly in interior areas, where government services are far from satisfactory.

Constraints: SEWA Rural experienced several constraints and hurdles while working with the government. Some of the operational difficulties were SEWA Rural satisfactorily resolved over time, while others remained unsettled. These experienced several included undue emphasis on achievement of targets, frequent delays in the constraints and release of grants and supplies, and interruption in the smooth partnership hurdles while working with the government due to frequent transfers of senior officials. There were with the government a couple of areas where SEWA Rural could not deliver to its own expectations and satisfaction. One of them was the inability to raise comprehensive community participation to its highest level, i.e. involving the community in all stages of planning, implementation, monitoring and reviewing the services and programmes. It was also unable to sustain the village health committees on a long-term basis. SEWA Rural could not do much to effectively address other important public health issues, such as the provision of safe drinking water and sanitation, and combating use of alcohol and tobacco.

Lessons learnt: The rich experience of managing a formal primary health centre by SEWA Rural provides many valuable and far-reaching lessons for different sectors and stakeholders. An important conclusion is that investment in strengthening and empowering the village-based cadre of health volunteers (TBAs, AWWs and MCH workers) is critical for any community-based intervention and in making the services reach every member of the community. It is important to adequately fulfil the community’s felt need in making curative care easily available at the village level with proper referral linkages. This would enhance the credibility and acceptance of health workers in promoting other preventive and health education/awareness-building services.

13 Sasakawa Health Prize: stories from South-East Asia

In order to foster an NGO–GO partnership, pragmatic understanding and a sense of appreciation of the strengths and weaknesses of both sides are required. It is imperative to grant some flexibility and relax bureaucratic norms so that distinct NGO characteristics such as innovativeness, creativity and volunteerism are preserved and nourished.

Encouraging fallouts of the NGO–GO partnership experiment: It is encouraging to note that the State Government has shown willingness to introduce some of the effective interventions tried out by SEWA Rural into their larger system. Examples of these are the use of pre-sterilized delivery packs, fixed days for different services, a simplified management information system (MIS) with the subcentre as a unit, involvement of workers in micro-planning and target- setting exercises, strengthening the cadres of grass-roots workers, etc.

The Karnataka Government has successfully experimented with a few It is encouraging to NGO–GO partnership models in recent years, based on the experiences of note that the State the SEWA Rural model. The Government of Gujarat has also entrusted the Government has shown responsibility of managing three community health centres and one primary willingness to introduce health centre to voluntary organizations. some of the effective interventions tried out 4.2 Handing back the primary health centre in 2000 by SEWA Rural into their larger system In 2000, SEWA Rural handed back the primary health centre to the government. It had hoped that the experiment would be replicated with many organizations getting involved in running government-entrusted PHCs. However, this did not happen. In addition, there were frequent and undue delays in release of grants. Following frequent transfer of senior district officers, SEWA Rural was required to repeatedly brief and explain the features of the programme. Lastly, emphasis on achievement of targets by the year end (31 March) affected SEWA Rural’s objectives of long-term planning, effectiveness and achievement.

Dr Lata Desai, representative of SEWA, being congratulated by Mr Ryoichi Sasakawa. WHO Photo

The rich experience of managing a formal primary health centre by SEWA Rural provides many valuable and far- reaching lessons for different sectors and stakeholders

14 SEWA Rural

(Society for Education,

Welfare and Action),

India: 1985 (India)

4.3 What next? Safe Motherhood and Newborn Care Project

Since 2003, SEWA Rural is managing a formal “Family-centred Safe Motherhood and Newborn Care Project” in the entire Jhagadia Block covering 168 villages (population 175 000) in partnership with district- and block-level Gujarat government health departments. The main aim of the project is to develop an evidence-based model to reduce maternal and neonatal mortality and morbidity in resource-poor settings.

4.4 Raining and resource centre for health

Different cadres of health workers from voluntary organizations, government staff and students from various academic institutions in India and abroad have Students from expressed keen interest to visit SEWA Rural and learn from its experiences in various academic community health, comprehensive eye care and rural development. To meet institutions in India such ever-increasing demands, a formal training centre was established in 1990 and abroad now at SEWA Rural’s main campus in Jhagadia. regularly come to SEWA Rural as part of Various types of customized courses are offered that are relevant to the needs their field placement, of the trainees coming from various NGOs as well as the government sector, dissertation or project including those for TBAs, CHVs, AWWs, Accredited Social Health Activists work in the fields of (ASHA), workers for community-based rehabilitation of the blind programme health management, (CBR workers), paramedics in health and eye care, health supervisors, project public health managers, doctors including ophthalmologists, government health officials and staff of mother NGOs and field NGOs. Students from various academic institutions in India and abroad now regularly come to SEWA Rural as part of their field placement, dissertation or project work in the fields of health management, public health, masters in social work, international development, etc.

4.5 Recognitions and associations

Apart from the Sasakawa award from WHO in 1985, SEWA Rural received the Bajaj Award in 1989 for the best managed rural hospital. It was also selected for an international award in the category of Creative and Effective Institutions: 2007 by the Mac Arthur Foundation (USA) for its pioneering work in saving the lives of mothers and their newborns.

15 Sasakawa Health Prize: stories from South-East Asia

SEWA Rural has been approved by the government as a recognized centre for its various schemes and programmes. SEWA Rural has been selected as Best Practice NGO and Service NGO by the state government.

4.6 Networking and advocacy

SEWA Rural is regularly invited for various meetings, workshops and conferences at the state and national levels to share its learning in ground realities and possible solutions in maternal and newborn care. SEWA Rural has been selected as a member of the District health Society, Bharuch under the Reproductive and Child Health Programme (RCH)- II and National Rural Health Mission (NRHM) for promoting NGO–GO partnership. SEWA Rural also actively partners with other like-minded NGOs in promoting the activities of the Dai Sangathan and Jana Swasthya Abhiyan at the state level. SEWA Rural is regularly invited for various Over the years, many of its small, micro-level innovations have been meetings, workshops and upscaled or introduced on a larger scale either by the government or conferences at the state other voluntary organizations. and national levels to share its learning in ground 4.7 Education, economic and empowerment programmes realities and possible solutions in maternal and Vivekananda Gramin Tekniki Kendra (Vocational Training Centre): This newborn care vocational centre was started in 1986 for the development and economic betterment of rural tribal youth. Every year, about 100 youth are trained. Thereafter, it is ensured that all the students are placed in jobs in nearby industries and a few are assisted to set up self-employment units to make them self-reliant.

Sharada Mahila Vikas Society: A new organization, Sharada Mahila Vikas Society, was formed in 2003 to facilitate the development, empowerment and well-being of women through their active participation. Awareness generation as well as economic activities are undertaken.

SEWA Rural has been approved by the government as a recognized centre for its various schemes and programmes. It has been selected as Best Practice NGO and Service NGO by the state government

16 Recipient of the second Sasakawa Health Prize. Dr U Than Sein, representative of the Ayadaw Township People’s Health Plan Committee (Myanmar). WHO Photo

17 CHAPTER 2 1986

Sustaining health development in Ayadaw (Ayadaw Township People’s Health Plan [ ] Committee) * [1] Recipient: Ayadaw Township People’s Health Plan Committee (Myanmar)

[*] Draft prepared by Dr. U Than Sein Former Director, WHO South-East Asia Region No.490, 1st Floor, Mahabandoola Road, Between 29 & 30 Street, Pabedan Township, Yangon, Myanmar The key individuals in Ayadaw who contributed to this project were: Chair of Township Health Committee – U Mya Maung; Township Medical Of- ficers – Dr Daw Khin Htay Pyae and Dr U Maung Maung Win; Township Health Officer – Dr U Win Shein 18 yadaw township is famous for its exemplary role in health Adevelopment in the early 1980s, for which it received the prestigious Sasakawa Health Prize awarded by the World Health Organization in 1986

1. Introduction

Myanmar Ayadaw township of Sagaing Divison is situated in the dry-zone area of central Myanmar in sandy and rocky terrain, about 120 km north-west of Mandalay. Ayadaw township is famous for its exemplary role in health development in the early 1980s, for which it received the prestigious Sasakawa Health Prize awarded by the World Health Organization in 1986.

After nearly three decades, Ayadaw has maintained its high standards both in The success and health and social development. The success and sustainability of health and sustainability of social development in Ayadaw is largely attributable to following the basic health and social principles of primary health care and Health for All, i.e. social justice, collective development in leadership, viable community organization and self-reliance; maintaining the Ayadaw is largely balance between local and national priorities, decentralizing planning and attributable to the management; grasping every opportunity and adapting practices for the benefit basic principles of of the local community; using appropriate interventions and technology; and primary health care having a strong health and other social infrastructure. and Health for All The main economy is agriculture-based, with 86% of the land under cultivation. Only 3% of the cultivated land is irrigated and the rest depends on the annual rainfall of 36 inches (with an average of 52 rainy days a year). Table 1 shows the status of Ayadaw Township’s health and social development, especially maternal and child health (MCH) care, water supply and sanitation, immunization programmes and access to essential health services.

2. Health development (MDGs 4 and 5)

2.1 Health facilities and human resources for health

Ayadaw has a township hospital that was established in the early 1960s with 16 beds, and upgraded to 25 beds in 2003. The township has five rural health centres and two station health units, each attached to a 16 bed hospital. There

19 Sasakawa Health Prize: stories from South-East Asia are 22 subrural health centres with basic health staff such as midwives and public health supervisors (grade II). An MCH centre attached with a town health unit has been established at Ayadaw town. The Ayadaw township branch of the Myanmar Maternal and Child Welfare Association (MMCWA) supports the functioning of this MCH centre. There is also a traditional medicine clinic at the township hospital to provide health care using traditional medicines and according to traditional practices. The number, types and staff strength of all basic health-care facilities in Ayadaw have not changed much during the past three decades. A few private allopathic medical clinics including one cooperative medical clinic have been functioning since 1984.

Table 1: Progress of health development in Ayadaw, 1973–2008

Ayadaw National* Indicators 1973 1978 1985 1996 2008 2007 Infant mortality 63.1 52.8 50.1 35 15.1 79.0 rate per 1000 live births (MDG 4) Maternal 70 70 60 60 60 380 mortality ratio per 100 000 live births (MDG 5) The number, types % of population 1.0 1.0 97.0 100.0 100.0 80.0 with access to and staff strength of safe water supply all basic health-care (MDG 7) facilities in Ayadaw % of population 1.0 1.0 90.0 90.0 90.0 81.0 have not changed with access to safe sanitation much during the facilities (MDG 7) past three decades % of villages with 15.0 - 100.0 - 90.0 - primary health- care workers (volunteers) % of births 35.0 40.0 70.0 80.0 95.0 57.0 attended by trained personnel (MDG 5) % of under- 0.0 10.0 60.0 95.0 95.0 81.0 one-year children with full immunization (MDG 4) Per capita income 68.0 - 135.0 - 480.0 904.0 (US$) Sources: Than Sein, 1985;2 Thein Swe et al., 19963, Kyaw Shein, 2009;4 * National data from World Health Statistics, 20095 20 Sustaining health development in Ayadaw

(Ayadaw Township People’s

Health Plan Committee):

1986 (Myanmar)

Development of the national health system in Myanmar is an integral part of the national socioeconomic plan and seeks better health care for rural areas, with an emphasis on national needs and priorities through primary health care. The medium-term People’s Health Plan (National Health Development Plan) was implemented countrywide in phases starting from 1976–1977, through establishment of People’s Health Plan Committees at various levels of Myanmar administration, from the central down to village levels. These committees were responsible for planning, implementation and evaluation of the national plan in their respective jurisdictions.

The systematic development of health systems based on primary health care and Health for All principles included the following: Development of ll the national health Strengthening and expanding the staff and facilities for providing basic health system in Myanmar services, including traditional medicine; is an integral part ll Increasing the availability of trained volunteer health workers, i.e. community of the national health workers (CHWs), auxiliary midwives (AMWs), and ten-household socioeconomic health workers (THHWs); plan and seeks better health care ll Expanding the range of essential health care to cover all village tracts in for rural areas all townships, with particular attention to MCH, health promotion and education, nutrition promotion, prevention and control of major endemic and epidemic diseases including malaria and diarrhoeal diseases, and immunization;

ll Coordinating development work at different levels of administration under the guidance of People’s Health Committees; and,

ll Promoting self-reliance within the community and expanding basic health infrastructure and other support systems.

After the People’s Health Plan was launched in 1979 in Ayadaw, the township had a large number of health volunteers – CHWs, AMWs, and THHWs (see Table 2).

21 Sasakawa Health Prize: stories from South-East Asia

Table 2: Volunteer health workers in Ayadaw, 1979–2008

Types of health 1979 1986 1996 2008 volunteers Community health worker 25 146 146 132 (CHW) Auxiliary midwives (AMW) 15 26 42 66 Ten-household health 2500 1430 1000 workers (THHW) Sources: Kyaw Shein, 2009 and Thein Swe et al., 1996

CHWs are interested and motivated villagers selected from each village and trained for a period. Initially, the training period was three weeks for the first batch in 1979. Later, new batches of CHWs from 1982 onwards have been trained for a full month. After the initial training, CHWs are deployed back to their villages to serve as volunteers. When the programme started, one CHW was deployed for each village tract. After some years, as the number of trained CHWs increased, there was one worker per village. Frequently, the health authorities organized reorientation courses on health, especially on disease surveillance and health promotion.

The main tasks of CHWs are to carry out disease surveillance, provide health education and promotion, help basic health services (BHS) staff in essential The health health data collection, and provide essential primary health care with the authorities organize support and under the supervision of BHS staff. CHWs are initially provided reorientation with a kit containing materials for first aid and essential medicines, and these courses on health, are supposed to be replenished by local arrangement. especially on disease Local village girls are selected as AMWs, at least one per village/village tract, and surveillance and provided with training for six months (three months in a hospital setting and health promotion three months at village level). These AMWs are deployed to serve as volunteers in their own villages. Some villages have local arrangements to remunerate them in kind through some form of incentives, while a majority of them work as volunteers. Initially, one AMW was deployed for each village tract (1979–1995); by 2008, two AMWs were deployed per village tract.

Local village girls are selected as AMWs, at least one per village/village tract, and are provided training for six months in a hospital and at village level

22 Sustaining health development in Ayadaw

(Ayadaw Township People’s

Health Plan Committee):

1986 (Myanmar)

Dr U Than Sein, representative of the Ayadaw Township People’s Health Plan Committee, receiving the Sasakawa Health Prize from Dr Zeid Hamzeh, President of the 39th World Health Assembly. WHO Photo

The main work of an AMW is to provide essential health care for pregnant mothers, and to assist in safe deliveries at home. If any high-risk cases of pregnancy are identified, they have to refer them to the nearest health centre Myanmar and/or hospital. AMWs also assist the BHS staff during immunization or nutrition promotion sessions. Each AMW is provided with a basic midwifery kit and some essential medicines for mothers and infants, which are supposed to be replenished by local arrangement.

The ten-household health workers (THHW) are also volunteers; one person is selected from every ten households to be trained/oriented in basic health care With introduction including first aid. The main tasks of the THHWs are to provide first aid, guide of sanitation families on major health issues, collect essential health information, act as first campaigns and informers in disease surveillance, and assist families in an emergency, serving as a good disease emergency health squads. surveillance system, outbreaks of In addition to the above three categories of health volunteers, traditional birth diseases have been attendants (TBAs) and basic care providers for traditional medicine were also easily identified brought into the health system as volunteers after a short period of orientation/ and controlled training. About 186 TBAs and a few hundred basic traditional medicine workers were trained and deployed to work in their own areas. Their numbers have been reduced to a minimum after two decades. Till the early 1990s, community nutrition health workers were also mobilized but their work was also reduced for various reasons.

2.2 Principal epidemic diseases

Plague and cholera are infectious diseases with sporadic outbreaks in confined places. With the introduction of sanitation campaigns and a good disease surveillance system, outbreaks of these diseases as well as other infectious diseases have been easily identified and controlled. The last outbreak of bubonic plague was reported in Ayadaw in February 1999. With extensive education and sanitation measures, including rat control measures, no outbreak of plague in Ayadaw has been reported since then.

23 Sasakawa Health Prize: stories from South-East Asia

Trachoma and its sequel, trichiasis, were the major causes of blindness in the dry-zone areas of Myanmar. Ayadaw was one of the townships that was highly endemic for trachoma in the 1960s–1970s, and had an active case rate of 690 per 1000 population in 1979. An extensive and vigorous campaign was launched by the National Trachoma Prevention and Control Programme. This included provision of tetracycline eye ointment to all active cases, surgical repair for those with trichiasis, promoting the use of personal face towels and education on personal hygiene, along with provision of safe water. With these measures, the prevalence of active trachoma declined steadily. A routine survey done by the national programme in 2008 in Ayadaw showed that the active trachoma rate had gone down to less than 2 per 1000 population.

Leprosy was hyperendemic in Ayadaw, with an estimated prevalence of 3000 cases in 1973. By 1990, the registered leprosy cases decreased to 1550, all of which were on dapsone monotherapy. The National Programme for Leprosy Control, with multidrug therapy (MDT) for leprosy patients, was extended to Ayadaw in 1991. While the number of cases decreased during the next few years, nearly 100 new cases were still identified annually. In order to identify more new cases including hidden ones, a leprosy elimination campaign was launched as part of the national leprosy programme in 1998. In addition, a Leprosy was hyperendemic national leprosy awareness week was launched in 1999 using the mass media, in Ayadaw, with an public education and awareness, and school health education programmes. estimated prevalence Accelerated active case-finding by BHS staff and health volunteers was done of 3000 cases in 1973. in 1998–99. About 350 new leprosy cases were found the same year and all By 1990, the registered of them were put on MDT. Since 2001, the number of new leprosy cases has leprosy cases decreased decreased to around 10–15 a year. Taung-Hmwar village in Ayadaw was famous to 1550 for its high prevalence of leprosy during the early 1980s due to the presence of one leprosy case in every three households. In a village of less than 100 households, a total of 73 cases were registered in 1985. All leprosy cases were put on MDT in 1991. Despite active case searching, no new leprosy cases have been found in the village since 2005.

A routine survey done by the national programme in 2008 in Ayadaw showed that the active trachoma rate had gone down to less than 2 per 1000 population

24 Sustaining health development in Ayadaw

(Ayadaw Township People’s

Health Plan Committee):

1986 (Myanmar)

Dr U Than Sein (Myanmar) addressing the 39th WHA on behalf of the Ayadaw Township People’s Health Plan Committee, one of the recipients of the second Sasakawa Health Prize. WHO Photo

Measles, tetanus, diphtheria, poliomyelitis and whooping cough were major killers or disabling diseases among children before immunization against Myanmar these diseases was introduced in 1978. In the initial stages of the Expanded Programme on Immunization (EPI) launched in 1979 in Ayadaw, the coverage was low, around 60%–70%. With people’s participation and the use of health volunteers as campaign workers, a continuous supply of vaccines and an effective cold chain system, the BHS staff was able to organize the EPI to reach a coverage level of over 95% of all eligible children in all the villages. By

Measles, tetanus, 1990, with the National Universal Child Immunization (UCI) Programme, the diphtheria, coverage with all vaccines (polio, measles, DPT3 and BCG) was nearly 100%. poliomyelitis and Vaccination against hepatitis B was introduced as part of the UCI programme whooping cough in 2005. No poliomyelitis or measles cases have been reported since 1990. were major killers Routine immunization coverage under the national UCI Programme has been or disabling diseases maintained at above 95% till date. among children before 2.3 Maternal and child health care immunization against these diseases was Maternal and child health care are part of the essential health-care services introduced in 1978 provided by BHS staff and health volunteers. In 1979, the attendance by health centre midwives at birth was around 40%, while a very small proportion of births, less than 2%, took place in hospitals. With the introduction of AMWs since 1980, the attendance at delivery by trained personnel in hospitals or at home has improved. The number of hospital deliveries went up to 12% of all births by 2008, while coverage of births attended by midwives at home increased from 40% in 1990 to 70% by 2008. The remaining deliveries were attended by AMWs. This showed the increasing confidence of mothers in trained volunteers, BHS staff and hospitals for antenatal care and delivery. Despite this high coverage of deliveries by trained health personnel, nearly 60 mothers die annually due to pregnancy and childbirth. An intensive verbal autopsy of these maternal deaths will provide an insight as to the causes.

25 Sasakawa Health Prize: stories from South-East Asia

3. Water supply and sanitation (MDG 7)

Water is such a scarce commodity in Ayadaw that safe water supply received a high priority and inhabitants adopted a slogan, “We want water, not gold”.6 Concerted community efforts were made for safe water supply under the policy guidance of the National Safe Water Supply Programme. The safe water supply programme in Ayadaw started in 1974 with three deep tube-wells, pumping stations and storage tanks, and a distribution system for the town water supply. An intensive community effort, with financial and human resources support, was initiated to have one tube-well at least in every village tract. By 1979, the number of tube-wells increased to 63, and by 1985, it reached 141 (with one tube-well for almost every village). Each tube-well was installed with a pumping machine, water storage tank(s), and a distribution system with multiple points.

The entire programme was supported by the Rural Water Supply Unit of the Agricultural Mechanization Department (later named as the Water Resources Utilization Department). After 1990, the programme was managed through the City and Rural Development Agency. A number of artesian wells were also drilled through community initiatives and each well was installed with water storage tanks/ponds and locally produced hand-pumps. By 2008, a total of 987 tube-wells had been installed, of which 217 were artesian wells. The The safe water supply water from these artesian wells was not only used for individual and household programme in Ayadaw consumption, but also for animals and agriculture. started in 1974 with

As a consequence of the whole population of Ayadaw having access to an three deep tube-wells, adequate and safe water supply, the average daily consumption of water per pumping stations and capita of nearly 16 litres in 1974 increased to more than 80 litres per capita in storage tanks, and a 2008. In some villages, safe water reaches almost every household through a distribution system for piped water distribution system. The time adults spend in fetching and carrying the town water supply water from a distance is now negligible. The time saved has resulted in an increase in economic activities.

Water is such a scarce commodity in Ayadaw that safe water supply received a high priority and inhabitants adopted a slogan, “We want water, not gold”

26 Sustaining health development in Ayadaw

(Ayadaw Township People’s

Health Plan Committee):

1986 (Myanmar)

When the National People’s Health Plan was implemented in Ayadaw in 1979, there were very few households with sanitary latrines (less than 300 latrines for the entire township). After securing a safe water supply in 63 villages with deep tube-wells, the township sanitation campaign started with the installation of low-cost sanitary pit-latrines. A total of 27 model villages that had a moderate economy and a moderate-sized population were selected initially, with most Myanmar of them being situated on main access roads. The villagers from these model villages accepted the challenge of constructing latrines for at least 80% of their households.

A health education and health promotion campaign was launched in the model villages. This dealt with infectious diseases caused by unsafe water and human The promotion of the waste, the benefits of a safe water supply, personal hygiene and safe sanitation, sanitation campaign and the measures that the villagers could undertake to combat those infectious was a constructive diseases. Local masons were trained in the construction of sanitary pit-latrines competition among using plastic pans, as well as the production of ferro-cement squatting plates. participating villages The pit-latrines initially introduced in Ayadaw were odourless, fly-proof, by giving prizes for comfortable, easily accessible (latrines were built in the same compound as the the best villages house or a nearby compound), and required a small amount of water. The most based on the criteria important aspect was to provide safety for girls (since they would not need to of various measures go out of the village late in the evening or at night). The villagers were involved used for safe water from planning to evaluation, and various designs of sanitary pit-latrines were supply and sanitation constructed using locally available materials. The successes achieved in the model villages were disseminated to neighbouring villages by the village leaders. The prestige of the model villages was enhanced by publicizing the successful implementation. Another factor in the promotion of the sanitation campaign was constructive competition among participating villages by giving prizes for the best villages, based on the criteria of various measures used for safe water supply and sanitation.

By expanding the sanitation campaign to more villages, the whole township became a model for the country by 1985. A total of 23 200 sanitary latrines were built and used, covering 87.5% of the total households in Ayadaw. After 10 years, in 1996, this number fell to 17 600 (65.6%), mainly due to lack of supervision, and inadequate moral and material support. With the introduction of the national campaign of “sanitation week” and education programme in

27 Sasakawa Health Prize: stories from South-East Asia

1996, the latrine construction and rehabilitation programme was revived. By 2008, a total of 27 300 sanitary latrines and 1400 “pucca” latrines with septic tanks were constructed, covering 90% of the population.3

4. Education

Literacy is a foundation for universal life-skills. As a tool, literacy has the potential to meet the vital needs of the people, and to stimulate social, cultural, political and economic participation, especially for disadvantaged and underprivileged groups. Literacy skills are fundamental to informed decision- making, personal empowerment, as well as active and passive participation in the local and global social community. The benefits of literacy are transferable, and can thus empower an individual and families. An empowered individual or family would have a greater and more positive impact on the community.

Helping individuals to become literate, in turn, creates positive changes for the community and society. Unprejudiced literacy programmes can empower the individual, help assuage ethnic disparities, and ultimately facilitate the move towards a more united nation. The empowering role of literacy and a literate society can be best understood by understanding the role of literacy. Literacy can facilitate access to information on scientific and technical development, The villagers were make it easier to understand and communicate legal information, understand involved from planning health knowledge and medical instructions, help in enjoying the benefits of to evaluation, and having the latest information, and make effective use of the mass media both for various designs of those seeking greater access and those with no access. sanitary pit-latrines were constructed The people of Ayadaw missed the opportunity of having a good formal using locally available education programme due to local insurgency till 1962. In those days, children materials in Ayadaw villages were sent to their local monasteries for basic education, and only a few were sent for middle and high school education in nearby townships. There was only one middle school in Ayadaw town. After the national literacy campaign was launched in 1973, the people realized the value of a formal education system. Community funds were raised to open many primary and

The benefits of literacy are transferable, and can thus empower an individual and families. An empowered individual or family would have a greater and more positive impact on the community

28 Sustaining health development in Ayadaw

(Ayadaw Township People’s

Health Plan Committee):

1986 (Myanmar)

middle schools. By 1974, there were 44 primary schools, three middle schools and one high school. By 1984, the number of primary, middle and high schools increased to 81, 24 and five, respectively, with nearly 20 000 students enrolled. By 2008, Ayadaw had 118 primary schools (three schools per each village tract), 17 middle schools and nine high schools. Modern communication systems (such as radio, cassette players, video-house, television, journals and newspapers) Myanmar have reached many villages and, with the increasing availability of electricity, local people are now accessing the latest media and news through television and video-plays, newspapers and journals.

5. Economy

Ayadaw has traditionally been an agriculture-based township, well known for its Domestic industries cotton produce. With the introduction of a high-yield cultivation programme in such as cotton-weaving 1981, the output per acre of cotton increased from 250 kg in 1983 to 720 kg in looms, tailoring and 2008. The government agencies for agriculture and livestock (see Table 3) have sewing machines, rice supported villagers to sow cash crops (cotton, wheat, groundnut and vegetables) mills, oil mills, noodle and introduce multiple crops (pulses and beans) with increased productivity factory, ice factory per acre; in some cases, threefold. Domestic industries such as cotton-weaving and seed grinding looms, tailoring and sewing machines, rice mills, oil mills, noodle factory, machines, etc. have ice factory and seed grinding machines, etc. have expanded in the past two expanded in the past decades. Livestock breeding also improved (Table 3). two decades. Livestock breeding has also Table 3: Livestock breeding in Ayadaw, 1973–74 to 2008 improved Sr. No. Livestock 1973–74 1983–84 1996 2008 1. Cattle 48 900 66 000 111 000 79 000 2. Pigs 2 300 5 400 8 000 20 000 3. Goat/Sheep 14 000 25 000 30 000 43 000 4. Chicken 14 000 69 000 150 000 16 000 Sources: Thein Swe et al., 1996; Kyaw Shein, 2009

Two major cash crops were introduced in the past four decades in Ayadaw. One is called thannakha. It is a tropical forest tree grown in the dry-zone area of Myanmar, whose bark and trunk are used to make a paste that is used as a cosmetic by ladies. Myanmar thannakha is famous for its oil-absorbing capacity, good scent, and protection against sunburn. Myanmar ladies are famous for

29 Sasakawa Health Prize: stories from South-East Asia the colour and quality of their skin due to the regular use of thannakha since childhood. The demand for thannakha led to heavy cutting of thannakha trees from the natural forest. The natural trees were almost depleted and became a rarity. In the 1980s, many thannakha trees were planted as part of household gardening and people started earning by cutting and selling the tree trunks only. The tree regrew and was sold again every five years. A one foot, 20-inch diameter thannakha tree trunk costs around US$ 10/- in the retail market. An acre with 12 000 thannakha trees could provide an income of nearly Myanmar Kyat 17 million (approximately US$ 170 000/-) every five years.

Another crop is the betel vine leaf (Piper betle), of which there are large plantations of several acres. The Myanmar version of paan or betel quid (called kun-ya) is chewed to freshen the breath, cleanse the mouth and for digestive purposes. It is prepared with different flavours and contents, but normally contains the basic materials, i.e. betel vine leaf, combined with areca nut (betel nut) and slaked lime paste. Chewing betel quid (kun-ya) is deeply rooted in the traditional culture of Myanmar, as in all South- and South-East Asian nations. The Myanmar people argue that kun or kun-ya (betel nut and betel vine leaf), hsey (tobacco – cigarettes/cheroots) and laphet (fermented tea-leaves) are the three essential delicacies which should be served to guests at home, weddings and at other ceremonies. People feel that it would be impolite to refuse a betel quid or cigarette/cheroot, when someone offers it as a token of friendship and Myanmar thannakha hospitality, particularly in rural areas. People attending marriage receptions or is famous for its ordination ceremonies are usually offered betel quid, a cigarette or cheroot as a oil-absorbing gesture of welcome. capacity, good scent, and protection Chewing betel leaf with areca nut and tobacco (betel quid) is a major cause of against sunburn oral and laryngeal cancer. Despite education campaigns and prohibiting paan- spitting in public places, chewing betel quid by males and females (especially those between 10 and 30 years of age) has increased in Myanmar in recent years. The increasing number of people chewing betel and tobacco can be noted from the mushrooming of betel quid (kun-ya) kiosks in every street corner, both in rural and urban areas.

With the introduction of a high-yield cultivation programme in 1981, the output per acre of cotton increased from 250 kg in 1983 to 720 kg in 2008

30 Sustaining health development in Ayadaw

(Ayadaw Township People’s

Health Plan Committee):

1986 (Myanmar)

After obtaining surplus water from artesian and deep tube-wells, the people of Ayadaw started planting betel vines. Ayadaw has over 1000 acres of betel vine plantations with an annual production of 12.5 million kg. This has created an additional regular income for the people, but they have to be aware of the danger of chewing betel quid. Myanmar

Another “first” for Ayadaw was the use of alternative fuel in lieu of forest firewood. Ayadaw has a small forest area, and most of the dried and cut branches of trees including dried leaves were used as fuel. After demonstrations that alternative charcoal made out of wheat and rice husk and other waste- burning materials was the best alternative fuel source for household use, Chewing betel leaf Ayadaw was the first township in Sagaing Division where all villages immediately with areca nut and adopted the use of such an alternative fuel in 1992. tobacco (betel quid) is a major cause of oral In 1979, a 27-mile tar road connecting Ayadaw with the district town of and laryngeal cancer Monywa was built. Till 1985, it was the only motorable road in Ayadaw. In 1996, the road was extended to the east to connect with Shwebo, another neighbouring district town. All villages are connected with Ayadaw town by all-weather gravel roads. Now, cargo trucks, passenger buses, jeeps, trollergies (tractor-trolleys), and motorcycles have become the main modes of transport. The number of motor vehicles increased to 94 and trollergies to 360 by 2008.

Till 1986, there was one telephone exchange with about 50 landline connections mainly for government offices. This exchange will be upgraded in 2011 to a digital exchange with many landline connections, even to neighbouring villages. Each village track is connected with magnetophones and modern satellite phones.

With the construction of a township electrical power station with a capacity of 1585 KVA in 1991, and connecting a few villages with electrical lines, Ayadaw’s water supply systems have been revived. In some villages, water supply pumping stations had been idle for some years due to shortage of fuel. With the improved availability of electricity, these pumping stations are back to normal. In 12 villages, electricity generation with biogas was initiated with a total

31 Sasakawa Health Prize: stories from South-East Asia power output of 270 KVA. In 28 villages, the villagers themselves collectively established local generators for their own consumption. The total annual power production in Ayadaw is now around 2.5 megawatts.

6. Financing

Community self-reliance and self-determination are the main pillars of Ayadaw’s development. The long tradition among Myanmar people of say-ta-na (deeds of the heart and soul without any remuneration) and a strong spirit of community self-reliance provided the right impetus for continuous social and health development in Ayadaw for nearly four decades.

Improvement in health status as well as in the economy goes hand-in-hand. Over and above the support given by the government for health development such as drugs and vaccines, drilling rigs, pipes and pumping machines, cement, plastic pans, and training, the community contributes to the main costs of development of health facilities, water supply systems, sanitary latrines, etc. through cash donations and by contributing voluntary labour. The people of Ayadaw raised a total of Kyat 11.5 million (US$ 1.6 million) between 1975 and 1985 for capital expenditures such as building health centres, community health posts, water pump houses and water distribution systems, community latrines, school water supply and sanitation facilities, etc. The recurrent costs for remunerating volunteer health workers and pump operators; for school mid-day Community meals; replenishing essential medicines and equipment for health workers and self-reliance and facilities; and subsidising fuel for water pumps amounted to Kyat 9 million (US$ self-determination 1.3 million) annually. Various financing mechanisms have been established to are the main collect and manage such funds. pillars of Ayadaw’s development The community donated the buildings for hospitals, residential quarters for doctors and nurses, and major hospital equipment such as an X-ray machine for the township hospital during 2001–2007 at a cost of Kyat 40.5 million (US$ 40 000). The community also supported the construction of a residential

32 Sustaining health development in Ayadaw

(Ayadaw Township People’s

Health Plan Committee):

1986 (Myanmar)

building-cum-clinic for three rural sub-health centres at a cost of Kyat 68 million in 2006. In 2007, it donated the hospital building, residential quarters for doctors and nurses, electricity generator and other electric appliances, furniture, etc. for one station hospital at a cost of Kyat 73 million.

Myanmar Constructive competition among villages for promotion of water supply and sanitation was introduced in Ayadaw in the 1980s. This process of competition, which sustains outstanding performance in health and social development, has remained active till date, with some modifications. The Sasakawa Health Prize money received by the township was deposited in a bank as a trust fund, supplemented with some donations. The interest Sectoral professionals earned from this fund was used as prize money for the winners through work with the villagers a prize awarding system. The prize-giving ceremony was held every by contributing ideas three to four years. The model village from the southern part of Ayadaw and support for received the first prize for three years, due to the sustained involvement implementation of the of the community in becoming a healthy village with healthy people and a common objectives healthy environment. Outstanding performances of basic health staff and of improving living health volunteers were also awarded prizes, which served as incentives. standards and health 7. Successive leadership and perseverance of plan

Despite the changes in administration that have taken place since the time of the Socialist Party and People’s Council in the 1970s–1980s to the State Peace and Development Council in the 1990s, the health and social development activities at the local level have continued. There is perseverance in adapting and adopting national policies and plans, both in the social and economic sectors. Village-level development depends largely on the ability of the community to plan, implement, supervise and evaluate their own efforts. Sectoral professionals work with the villagers by contributing ideas and support for implementation of the common objectives of improving living standards and health. The focus is on local development, especially in agriculture, education, health, basic needs, and infrastructure.

33 Sasakawa Health Prize: stories from South-East Asia

The collective responsibility for raising funds by the community on a large scale for the construction of tube-wells and pump houses, water storage and distribution systems, buildings for health facilities, health equipment and essential medicines, as well as sustaining the large workforce of health volunteers are endeavours that have continued for almost three decades. This could not have been done as satisfactorily without an effective community organization as seen in Ayadaw. Formation of such community groups in various villages requires representation from the local administration, technical personnel and the support of local leaders and the community themselves, who are ready to assist each other.

8. Sustaining primary health care

In sustaining the primary health care and Health for All principles, the basic health workers and health volunteers need to be continuously reoriented in supervisory skills and community organization. Constant surveillance for infectious diseases, especially preventable diseases, through immunization against tetanus, diphtheria, measles, etc. has to be undertaken since children who miss the immunization in some areas might contract such diseases. Proper epidemiological investigations for sporadic outbreaks of some infectious diseases, such as plague, cholera, dengue, etc. should be undertaken. Verbal autopsy of all maternal deaths during pregnancy and childbirth should be introduced in order to identify the main reasons for such deaths, and to develop Volunteer health an appropriate strategy to further reduce maternal deaths. workers have been the backbone of Volunteer health workers have been the backbone of health development in health development Ayadaw, and the national programme needs to be reviewed and revived in in Ayadaw order to use them effectively. The staffing pattern and coverage of rural health units have to be reviewed, in order to strengthen their services.

Village-level development depends largely on the ability of the community to plan, implement, supervise and evaluate their own efforts.

34 Sustaining health development in Ayadaw

(Ayadaw Township People’s

Health Plan Committee):

1986 (Myanmar)

9. Conclusion

Ayadaw is a quietly growing township that was used as a model for health and development in Myanmar during the 1980s. Various indicators and case studies show that, even today, Ayadaw remains a model. The development activities illustrate the importance of viable community organization and collective Myanmar leadership, having a large proportion of people with high basic literacy, focusing on health, economic and social development, proper planning and management, commitment to change and to further improvement, effective intersectoral collaboration, and joint community actions, which all are keys to success, as well as sustaining the high status of development over the long term. The policy of constructive competition with built-in evaluation is another Winning the motivating factor. Winning the Sasakawa Health Prize in 1986 made the people Sasakawa Health of Ayadaw feel justifiably proud, and the spirit of health and development will Prize in 1986 made remain alive even after another 30 years. the people of Ayadaw feel justifiably proud

Pre-Services Training of Midwives

35 Sasakawa Health Prize: stories from South-East Asia

10. References

1 World Health Organization. Thirty-ninth World Health Assembly evaluates progress towards health-for-all. WHO Chronicle. 1986; 40: 94. 2 Than Sein. Health and development, a case of Ayadaw. Yangon: Department of Health, Ministry of Health, Myanmar, April 1985. (Background document presented for application of Sasakawa Health Prize to WHO in 1985, unpublished). 3 Thein Swe, Nilar Tin, Pe Thet Htoon. Revisit to Ayadaw township after ten years, 1986–1996. Yangon: Department of Health, Ministry of Health, Myanmar, 1996. (unpublished) . 4 Kyaw Shein. Ayadaw progress report. Yangon: Divisional Health Department, Sagaing Health Division, Ministry of Health, Myanmar, October 2009. (unpublished). 5 World Health Organization. World health statistics 2009. Geneva: WHO, 2009. 6 U Tin U et al. We want water, not gold. World Health Forum. 1988; 9: 519–525.

Refresher Training of Midwives

36 Dr Amorn Nondasuta (Thailand), recipient of the 1986 Sasakawa Health Prize. WHO Photo

37 CHAPTER 3 1986

The three eras of primary health care[*]

Recepient: Dr Amorn Nondasuta (Thailand)

[*] Draft prepared by Dr Amorn Nondasuta Former Permanent Secretary of Health, Founder of the Primary Health Care System and President of Quality of Life Foundation in Thailand 38 he evolution of primary health care from the beginning Tup to the present time can be grouped into three eras, each with its own distinctive characteristics

1. Introduction

Thailand This article reflects the experiences of Dr Amorn Nondasuta in the development of primary health care in Thailand and in other countries. It is hoped that the article may shed some light on how primary health care could be further developed.

The evolution of primary health care from the beginning up to the present time can be grouped into three eras, each with its own distinctive characteristics. Before the concept of primary health 2. The first era of primary health care care came into being, health services heavily Before the concept of primary health care came into being, health services emphasized the heavily emphasized the provision of curative medical services. Coverage provision of curative of the population was a pressing need, especially in rural areas. However, medical services health infrastructure was limited, both in quantity and quality. The immediate concern was how to reach the majority of the people. To increase coverage was the main strategy of health development at that time. The strategy evolved with the mobilization of extra human resources from the community. The first evidence of the community being brought into the picture was the formation of “village health committees”. Subsequently, as the situation improved and knowledge and practice developed, the emphasis began to shift. The new focus was on health promotion and disease prevention, which was further expanded to cover management of the environment. Public health interventions began to include high-risk populations as target groups, beginning with mother and child.

The turning point came in 1978 when the World Health Assembly introduced the concept of Health for All and Primary Health Care in the Alma-Ata Declaration. Since then, the community has been the main focus of health development.

generally the responsibility of family elders family of responsibility the generally

on Thai culture, in which care for the sick was was sick the for care which in culture, Thai on

The idea was to create health volunteers based based volunteers health create to was idea The

Dr Amorn was a part of this avant garde project. project. garde avant this of part a was Amorn Dr

condition is under control. control. under is condition

prevalence of protein–energy malnutrition has steadily declined and the the and declined steadily has malnutrition protein–energy of prevalence

of volunteers and expansion of the community nutrition programme, the the programme, nutrition community the of expansion and volunteers of

and charting children’s growth. Gradually, with an increase in the number number the in increase an with Gradually, growth. children’s charting and

recognize the nutritional problems of their children through regular weighing weighing regular through children their of problems nutritional the recognize

application of primary health care in its work design, mothers were taught to to taught were mothers design, work its in care health primary of application

projects was nutrition. This was introduced in the early years. Through the the Through years. early the in introduced was This nutrition. was projects

The other element that was included in the community involvement for health health for involvement community the in included was that element other The

approximately 1 million 1 approximately

the total number is is number total the

in remote areas. remote in

increased and, at present, present, at and, increased

market was created. Water-sealed latrines can be purchased everywhere, even even everywhere, purchased be can latrines Water-sealed created. was market

volunteers has steadily steadily has volunteers

trained to produce water-sealed latrines. The idea eventually caught on and a a and on caught eventually idea The latrines. water-sealed produce to trained

The number of health health of number The

sanitation was brought up. Again, selected members of the community were were community the of members selected Again, up. brought was sanitation

In the quest to develop the concept further, the problem of environmental environmental of problem the further, concept the develop to quest the In

volunteers reached a critical mass, no major epidemic has occurred. occurred. has epidemic major no mass, critical a reached volunteers

the prevention and control of disease outbreaks. In fact, since the number of of number the since fact, In outbreaks. disease of control and prevention the

total number is approximately 1 million. They have played crucial roles in in roles crucial played have They million. 1 approximately is number total

The number of health volunteers has steadily increased and, at present, the the present, at and, increased steadily has volunteers health of number The

WHO Photo WHO

World Health Assembly. Health World

as free medical care for the volunteers and their family members. members. family their and volunteers the for care medical free as Prize, addressing the 39 the addressing Prize,

second Sasakawa Health Health Sasakawa second

no salary was paid to the volunteers. Instead, other incentives were given such such given were incentives other Instead, volunteers. the to paid was salary no

(Thailand), recipient of the the of recipient (Thailand),

Dr Amorn Nondasuta Nondasuta Amorn Dr design adhered strictly to the prevailing cultural dimensions, which meant that that meant which dimensions, cultural prevailing the to strictly adhered design

been naturally doing in their daily life, but in a more systematic manner. This This manner. systematic more a in but life, daily their in doing naturally been

volunteers”. Practically, the role of village health volunteers was what they had had they what was volunteers health village of role the Practically, volunteers”.

and trained in health matters. These volunteers were called “village health health “village called were volunteers These matters. health in trained and

Volunteers were selected from family members using the sociometric technique, technique, sociometric the using members family from selected were Volunteers

village health committees, and formed a part of the development strategy. strategy. development the of part a formed and committees, health village

family elders. Health volunteers were the second community asset after the the after asset community second the were volunteers Health elders. family

on Thai culture, in which care for the sick was generally the responsibility of of responsibility the generally was sick the for care which in culture, Thai on

part of this avant garde project. The idea was to create health volunteers based based volunteers health create to was idea The project. garde avant this of part

concept of community involvement in health was tried out. Dr Amorn was a a was Amorn Dr out. tried was health in involvement community of concept

all people. Faced with the problem of a shortage of human resources, the the resources, human of shortage a of problem the with Faced people. all Indonesia needed to make health-care services available and accessible to to accessible and available services health-care make to needed Indonesia

sectors. In order to rally other sectors, the term “quality of life” was introduced, introduced, was life” of “quality term the sectors, other rally to order In sectors.

One of the problems that stood out was the absence of involvement of other other of involvement of absence the was out stood that problems the of One

the previous operation of community involvement for health was reviewed. reviewed. was health for involvement community of operation previous the

ratified after the Alma-Ata Declaration. To effectively carry the concept forward, forward, concept the carry effectively To Declaration. Alma-Ata the after ratified with the responsibility of implementing “Health for All”, which the government government the which All”, for “Health implementing of responsibility the with

In 1986, the “Health for All” drive started to fizzle out. Dr Amorn was entrusted entrusted was Amorn Dr out. fizzle to started drive All” for “Health the 1986, In

The second era of primary health care care health primary of era second The 3.

Era Era

1978

Era Era 2

1986

Era Era 3

2010

Concep

primary health care health primary

the subsequent eras of of eras subsequent the

Concep

applied throughout throughout applied

theory that has been been has that theory

time and become the the become and time

The three eras of primary healthcare development healthcare primary of eras three The 1: Figure

endured the test of of test the endured

The concept has has concept The primary health care. care. health primary

become the theory that has been applied throughout the subsequent eras of of eras subsequent the throughout applied been has that theory the become

the better the chances of success. The concept has endured the test of time and and time of test the endured has concept The success. of chances the better the

and a good community financing scheme. The stronger the three components, components, three the stronger The scheme. financing community good a and

organization, community human resources as represented by the volunteers, volunteers, the by represented as resources human community organization,

elements of the community that had to be developed, i.e. community community i.e. developed, be to had that community the of elements

Through these experiences, it could be concluded that there were three three were there that concluded be could it experiences, these Through

Thailand

the basics of financial management. financial of basics the

to make basic essential drugs available, but also to introduce to the community community the to introduce to also but available, drugs essential basic make to

this programme, community drug funds were established. The aim was not only only not was aim The established. were funds drug community programme, this

was included in the try-out of the concept of community involvement. Under Under involvement. community of concept the of try-out the in included was

The provision of essential drugs was another primary healthcare element that that element healthcare primary another was drugs essential of provision The

T ( 1986 ) hailand

: : are c lth ea h y ar im r p

T of eras ree th e h

ratified after the Alma-Ata Declaration Alma-Ata the after ratified

implementing “Health for All”, which the government government the which All”, for “Health implementing

Dr Amorn was entrusted with the responsibility of of responsibility the with entrusted was Amorn Dr In 1986, the “Health for All” drive started to fizzle out. out. fizzle to started drive All” for “Health the 1986, In

has been applied in the Region. the in applied been has

BMN concept was tried in the Eastern Mediterranean Region. Since then, BMN BMN then, Since Region. Mediterranean Eastern the in tried was concept BMN

approval of the Regional Director, Dr H.A. Al Gezairy, the first experiment of the the of experiment first the Gezairy, Al H.A. Dr Director, Regional the of approval

in trying out the concept and practice in EMRO. Due to the keen interest and and interest keen the to Due EMRO. in practice and concept the out trying in

a real-life experience. One of the participants from Jordan became interested interested became Jordan from participants the of One experience. real-life a

meeting and a field trip to the project sites was organized for participants to have have to participants for organized was sites project the to trip field a and meeting

organized in Nakorn Rajasima province. The BMN project was introduced to the the to introduced was project BMN The province. Rajasima Nakorn in organized

for the Eastern Mediterranean (SEARO/EMRO) interregional conference was was conference interregional (SEARO/EMRO) Mediterranean Eastern the for

A few years later, a WHO Regional Office for South-East Asia/Regional Office Office Asia/Regional South-East for Office Regional WHO a later, years few A

A sojourn into the Eastern Mediterranean Region Mediterranean Eastern the into sojourn A 3.1

life experience life

grass-roots-level planning. grass-roots-level

participants to have a real- a have to participants

BMN indicators have been modified many times and have become the basis for for basis the become have and times many modified been have indicators BMN

sites was organized for for organized was sites

(thanks to the strategy of setting up office at the National Planning Board). The The Board). Planning National the at office up setting of strategy the to (thanks

and a field trip to the project project the to trip field a and

as part of the national monitoring instruments to be implemented nationwide nationwide implemented be to instruments monitoring national the of part as

introduced to the meeting meeting the to introduced

Governor was the key player, the government adopted the BMN indicators indicators BMN the adopted government the player, key the was Governor

The BMN project was was project BMN The

After a number of field tests in Nakorn Rajasima province, in which the Deputy- the which in province, Rajasima Nakorn in tests field of number a After

health sectors were happy to be involved in implementing the new concept. concept. new the implementing in involved be to happy were sectors health

This strategic action made the indicators acceptable to most people and the non- the and people most to acceptable indicators the made action strategic This

develop a set of “BMN indicators”. Sectors other than health were invited to join. join. to invited were health than other Sectors indicators”. “BMN of set a develop

National Socio-economic Board Office, which was the national planning body, to to body, planning national the was which Office, Board Socio-economic National

need” in a meaningful way. Brainstorming sessions were organized at the the at organized were sessions Brainstorming way. meaningful a in need”

The hurdle that needed to be overcome was how to interpret “basic minimum minimum “basic interpret to how was overcome be to needed that hurdle The

decided to proceed with the idea. idea. the with proceed to decided

organizations, if not completely rejected, but Dr Amorn and his colleagues colleagues his and Amorn Dr but rejected, completely not if organizations,

minimum need (BMN) approach was not appreciated by many individuals and and individuals many by appreciated not was approach (BMN) need minimum

As with any new concept and idea, initially, the quality of life and basic basic and life of quality the initially, idea, and concept new any with As

of life” concrete and measurable, it was associated with “basic minimum need”. minimum “basic with associated was it measurable, and concrete life” of

more comfortable in being associated with the project. To make the term “quality “quality term the make To project. the with associated being in comfortable more

which did not denote any particular sector and would make other sectors feel feel sectors other make would and sector particular any denote not did which

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa

care system. The best way to make a referral system effective was to develop develop to was effective system referral a make to way best The system. care

system should not be a stand-alone one, but an integral part of the health- the of part integral an but one, stand-alone a be not should system

system that would link primary care with secondary and tertiary care. The The care. tertiary and secondary with care primary link would that system During the same period, the crucial role was recognized of a good referral referral good a of recognized was role crucial the period, same the During

Back to Thailand to Back 3.2

flourished in EMRO Member countries till date. till countries Member EMRO in flourished

programme became the “community-based initiative” (CBI), both of which have have which of both (CBI), initiative” “community-based the became programme

EMRO named the concept “basic development need” (BDN) and the the and (BDN) need” development “basic concept the named EMRO

The BMN approach had been proven worthwhile and survived all criticism. criticism. all survived and worthwhile proven been had approach BMN The

crucial to the success of the project. the of success the to crucial

development

not be the first priority of the people. Thus, the involvement of other sectors is is sectors other of involvement the Thus, people. the of priority first the be not

were happy with the the with happy were

be developed as an integral part of the quality of life, and health alone may may alone health and life, of quality the of part integral an as developed be

and the people there there people the and

Somalia), which was one of the BMN categories. This proved that health must must health that proved This categories. BMN the of one was which Somalia),

successfully launched launched successfully

was their basic needs for livelihood (goat-raising in that case, the same as in in as same the case, that in (goat-raising livelihood for needs basic their was

of the project, it was was it project, the of

Naturally, when decision-making was entrusted to the villagers, their first priority priority first their villagers, the to entrusted was decision-making when Naturally,

on the organization organization the on

have time to work work to time have households and getting the people involved. involved. people the getting and households

colleagues did not not did colleagues cluster representatives as an extension of services in the hope of reaching all all reaching of hope the in services of extension an as representatives cluster

Dr. Amorn and his his and Amorn Dr. This time, Dr Amorn had a chance to introduce the concept of household- of concept the introduce to chance a had Amorn Dr time, This

Despite the fact that that fact the Despite kick off the project. After a short introduction, BMN indicators were developed. developed. were indicators BMN introduction, short a After project. the off kick

from the Queen Noor Foundation. A village by the Dead Sea was chosen to to chosen was Sea Dead the by village A Foundation. Noor Queen the from

give advice on the project. He formed a team with Dr S. Bahous and colleagues colleagues and Bahous S. Dr with team a formed He project. the on advice give

The second project was implemented in Jordan. Again, Dr Amorn was invited to to invited was Amorn Dr Again, Jordan. in implemented was project second The

from the internal warfare that erupted shortly after Dr Amorn left the country. the left Amorn Dr after shortly erupted that warfare internal the from

people there were happy with the development. The project area was spared spared was area project The development. the with happy were there people

Thailand

to work on the organization of the project, it was successfully launched and the the and launched successfully was it project, the of organization the on work to

be done to get the project going. Despite the fact that they did not have time time have not did they that fact the Despite going. project the get to done be

BMN indicators, select a pilot area and lay some groundwork on what should should what on groundwork some lay and area pilot a select indicators, BMN

and his colleagues spent a few weeks there to help the country develop a list of of list a develop country the help to there weeks few a spent colleagues his and

Amorn Amorn Dr Somalia. in implemented was project pilot first The advisers. project’s

To initiate the project, EMRO invited Dr Amorn and his colleagues to be the the be to colleagues his and Amorn Dr invited EMRO project, the initiate To

T ( 1986 ) hailand

: : are c lth ea h y ar im r p

T of eras ree th e h

households and getting the people involved people the getting and households

extension of services in the hope of reaching all all reaching of hope the in services of extension

of household-cluster representatives as an an as representatives household-cluster of Dr Amorn had a chance to introduce the concept concept the introduce to chance a had Amorn Dr

to their needs and aspirations. and needs their to

People must be able to design and run their own programmes according according programmes own their run and design to able be must People

volunteers, and the selection technique was applied to all. to applied was technique selection the and volunteers,

subsequent development, all health communicators were converted to health health to converted were communicators health all development, subsequent

and dependable, and would provide voluntary services. However, during during However, services. voluntary provide would and dependable, and

chance of picking the right person, someone who was socially acceptable acceptable socially was who someone person, right the picking of chance

from a pool of village health communicators. This method provided a good good a provided method This communicators. health village of pool a from

using a sociometric technique and the village health volunteers were selected selected were volunteers health village the and technique sociometric a using

communicators” and “village health volunteers”. The former was selected by by selected was former The volunteers”. health “village and communicators”

In the beginning, there were two types of volunteers, “village health health “village volunteers, of types two were there beginning, the In

Function determines human resource characteristics. resource human determines Function 2.

From that point onward, other functions were added. added. were functions other onward, point that From

by the people since they valued treatment of ailments more than anything else. else. anything than more ailments of treatment valued they since people the by caring for the sick the for caring

treatment of common diseases and injuries. This function was readily accepted accepted readily was function This injuries. and diseases common of treatment the local custom of of custom local the

primary health care. Primary health care was designed around appropriate appropriate around designed was care health Primary care. health primary is deemed a part of of part a deemed is

This was the guiding principle in the original design of human resources for for resources human of design original the in principle guiding the was This Simple medical care care medical Simple

caring for the sick. the for caring

Simple medical care is deemed a part of the local custom of of custom local the of part a deemed is care medical Simple 1.

based on the Alma-Ata Declaration. Among them were the following: the were them Among Declaration. Alma-Ata the on based

to start a programme. The country developed additional working concepts concepts working additional developed country The programme. a start to

The guidelines provided in the Alma-Ata Declaration were not detailed enough enough detailed not were Declaration Alma-Ata the in provided guidelines The

The working concepts working The

Lessons learned Lessons 3.3

which covers more than 95% of the population. the of 95% than more covers which

institutionalized it into the national health security scheme, now backed by law, law, by backed now scheme, security health national the into it institutionalized

a vehicle to refer cases. Eventually, the government took up the idea and and idea the up took government the Eventually, cases. refer to vehicle a

insurance called the “health card programme” was developed and used as as used and developed was programme” card “health the called insurance

a mechanism to support the system. To this end, a voluntary prepaid health health prepaid voluntary a end, this To system. the support to mechanism a

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diseases and transformation of the people’s health behaviour. health people’s the of transformation and diseases

of the population. This is particularly true for the prevention of communicable communicable of prevention the for true particularly is This population. the of

of volunteers must be large enough to reach a certain (critical) level of coverage coverage of level (critical) certain a reach to enough large be must volunteers of of health volunteers. But if the desired result is to be sustainable, the number number the sustainable, be to is result desired the if But volunteers. health of

As mentioned, primary health care started off by defining the roles and functions functions and roles the defining by off started care health primary mentioned, As

of the programme have to be adequate. adequate. be to have programme the of

If the benefits of primary health care are to be appreciated, the size and functions functions and size the appreciated, be to are care health primary of benefits the If

top is indispensable. is top

paradigm shift on both sides, which is challenging. Strong policy support from the the from support policy Strong challenging. is which sides, both on shift paradigm

while the health staff assumes a facilitative role. Such a change requires a 180° 180° a requires change a Such role. facilitative a assumes staff health the while

With the primary healthcare strategy, the people become the initiators and actors actors and initiators the become people the strategy, healthcare primary the With

down in design. In such an arrangement, the people were at the receiving end. receiving the at were people the arrangement, an such In design. in down

paramedical personnel paramedical

hospitals and health centres. The whole system was service oriented and top– and oriented service was system whole The centres. health and hospitals

doctors, nurses and and nurses doctors,

by health staff. Consequently, the emphasis of the health system was on building building on was system health the of emphasis the Consequently, staff. health by

majority of which were were which of majority

personnel. Medical and public health technologies were limited to those used used those to limited were technologies health public and Medical personnel.

human resources, the the resources, human

of human resources, the majority of which were doctors, nurses and paramedical paramedical and nurses doctors, were which of majority the resources, human of

and availability of of availability and

health. The health system was developed around the categories and availability availability and categories the around developed was system health The health.

around the categories categories the around

In the past, development started with creating categories of human resources for for resources human of categories creating with started development past, the In

was developed developed was

The health system system health The

Primary health care needs a paradigm shift of both the health staff and the people. the and staff health the both of shift paradigm a needs care health Primary

sectors and the public. public. the and sectors

“quality of life for all” was effectively used to obtain the collaboration of other other of collaboration the obtain to used effectively was all” for life of “quality

developed to secure collaboration with other sectors. In this connection, the term term the connection, this In sectors. other with collaboration secure to developed

experience showed that such collaboration was not easy. A good strategy must be be must strategy good A easy. not was collaboration such that showed experience

Collaboration with other relevant social sectors is essential. However, past past However, essential. is sectors social relevant other with Collaboration Thailand

Primary health care must be part of a comprehensive development strategy. development comprehensive a of part be must care health Primary

prevention, and changes in individual health behaviour. health individual in changes and prevention,

were community-owned programmes and projects in health promotion/disease promotion/disease health in projects and programmes community-owned were

To make health equitable for all, two conditions were indispensable. These These indispensable. were conditions two all, for equitable health make To

T ( 1986 ) hailand

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T of eras ree th e h

be integrated in the health service system service health the in integrated be

an independent entity by design, needs to to needs design, by entity independent an The primary healthcare system, although although system, healthcare primary The

brought about. brought

Have faith in the capability of the people and believe that change can be be can change that believe and people the of capability the in faith Have 2.

programmes.

Use the right concept and strategy when developing primary healthcare healthcare primary developing when strategy and concept right the Use 1.

The following factors were found to be critical to the success of the programme: the of success the to critical be to found were factors following The

is the key. key. the is

programme are natural and should be expected and understood. Perseverance Perseverance understood. and expected be should and natural are programme

the intensity of implementation of various components. Ups and downs in the the in downs and Ups components. various of implementation of intensity the

it the function of the volunteer, the interest of those involved at all levels, or or levels, all at involved those of interest the volunteer, the of function the it

underwent continuous changes and adjustments. Everything is dynamic, be be dynamic, is Everything adjustments. and changes continuous underwent

and aspirations and It was observed that the development that took place over the past 30 years years 30 past the over place took that development the that observed was It

express their health needs needs health their express

that was solely health-oriented to one that was social development-oriented. social was that one to health-oriented solely was that opportunities for people to to people for opportunities

measures. These required a shift in the role of the health volunteer, from one one from volunteer, health the of role the in shift a required These measures. developed to provide provide to developed

transitions and challenges: a multidisciplinary approach and social intervention intervention social and approach multidisciplinary a challenges: and transitions A mechanism must be be must mechanism A

to behaviour-related diseases necessitated new approaches to meet these these meet to approaches new necessitated diseases behaviour-related to

The effect of globalization and a shift in health problems from communicable communicable from problems health in shift a and globalization of effect The

Critical factors for success for factors Critical 3.4

Such inputs are important for formulating the national health policy and strategy. and policy health national the formulating for important are inputs Such

their health needs and aspirations. and needs health their

A mechanism must be developed to provide opportunities for people to express express to people for opportunities provide to developed be must mechanism A

continuity of care. Referral schemes must be developed and put in place. in put and developed be must schemes Referral care. of continuity

patients with chronic illnesses should be referred back to the community for for community the to back referred be should illnesses chronic with patients

appropriate health services from health personnel or specialists. Likewise, Likewise, specialists. or personnel health from services health appropriate

effective for the majority of illnesses, but more severe cases must receive receive must cases severe more but illnesses, of majority the for effective

Medical care well illustrates the above statement. Simple treatment may be be may treatment Simple statement. above the illustrates well care Medical

needs to be integrated in the health service system. service health the in integrated be to needs

The primary healthcare system, although an independent entity by design, design, by entity independent an although system, healthcare primary The

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa

level or strengthening the capacity of the community and people so that they they that so people and community the of capacity the strengthening or level

strengthening health service institutions such as the health centre at the district district the at centre health the as such institutions service health strengthening

There are two possible options for strengthening the district health system: system: health district the strengthening for options possible two are There

The third era of primary health care health primary of era third The 4.

r anpowe eM inanc F

ts rojec mP ogra Pr Non

y ommunit C

ogrammes Pr

Health

Plans

Organization

development)

Era two: integration/quality of life (shift towards towards (shift life of integration/quality two: Era 2: Figure

and aspirations and

sustainable behavioural change. behavioural sustainable

their health needs needs health their

Only through the three strong pillars of self-reliance can one hope for a a for hope one can self-reliance of pillars strong three the through Only

people to express express to people

factors are interdependent and need to be simultaneously developed. developed. simultaneously be to need and interdependent are factors

opportunities for the the for opportunities

resources, and a good community financing scheme. These three three These scheme. financing community good a and resources,

to provide provide to

a strong community organization, knowledgeable community human human community knowledgeable organization, community strong a

Develop mechanisms mechanisms Develop

organization, (ii) human resources, and (iii) financing, so that there is is there that so financing, (iii) and resources, human (ii) organization,

Strengthen the three pillars of self-reliance of the community: (i) (i) community: the of self-reliance of pillars three the Strengthen 7.

(1:100 has been proven to be effective). be to proven been has (1:100

A critical ratio of volunteers to people under coverage must be reached reached be must coverage under people to volunteers of ratio critical A 6.

and confidence in each other, which are the cornerstones of success. of cornerstones the are which other, each in confidence and Thailand

Both parties (people and health staff) should have credibility, respect, trust trust respect, credibility, have should staff) health and (people parties Both 5.

their health needs and aspirations. aspirations. and needs health their

Develop mechanisms to provide opportunities for the people to express express to people the for opportunities provide to mechanisms Develop 4.

Put “quality of life for all” ahead of “Health for All”. for “Health of ahead all” for life of “quality Put 3.

T ( 1986 ) hailand

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should be done, must be based on evidence on based be must done, be should

the people and community, as well as how this this how as well as community, and people the

health service institutions and development of of development and institutions service health The decision to balance the improvement of of improvement the balance to decision The

implementing primary health-care programmes today. programmes health-care primary implementing

been designed and developed to answer most, if not all, of the challenges in in challenges the of all, not if most, answer to developed and designed been

context, the “strategic route map” is the instrument of choice because it has has it because choice of instrument the is map” route “strategic the context,

that help people change their health behaviours in a systematic manner. In this this In manner. systematic a in behaviours health their change people help that

behavioural change should be permanent. This requires effective instruments instruments effective requires This permanent. be should change behavioural

health improvement as the final destination should be highlighted. Such Such highlighted. be should destination final the as improvement health

Obviously, the importance of behavioural change that leads to sustainable sustainable to leads that change behavioural of importance the Obviously,

they will only be temporary. temporary. be only will they

institutions. This kind of strategy may bring about results in the short term but but term short the in results about bring may strategy of kind This institutions.

contrast to improvement of the service strategy, which is done mainly by health health by mainly done is which strategy, service the of improvement to contrast

when this destination is reached can one truly achieve the MDGs. This is in in is This MDGs. the achieve truly one can reached is destination this when

under this intervention must be geared towards this final objective. Only Only objective. final this towards geared be must intervention this under

objective is thus to achieve the target group’s behavioural change. All activities activities All change. behavioural group’s target the achieve to thus is objective

of all health problems is “health behaviour” of the target groups. The final final The groups. target the of behaviour” “health is problems health all of

A simple root-cause analysis of these problems will reveal that the real cause cause real the that reveal will problems these of analysis root-cause simple A development

the maternal mortality ratio, infant mortality rate, and under-five mortality rate. rate. mortality under-five and rate, mortality infant ratio, mortality maternal the to the whole process of of process whole the to

Millennium Development Goals (MDGs) 4 and 5? The answer is a reduction in in reduction a is answer The 5? and 4 (MDGs) Goals Development Millennium strategy and is crucial crucial is and strategy

question. For example, what health output or outcome is being envisaged for for envisaged being is outcome or output health what example, For question. major component of the the of component major

destination or final objective is to eliminate the root causes of the problems in in problems the of causes root the eliminate to is objective final or destination “Destination” is the first first the is “Destination”

to the whole process of development. In public health interventions, the the interventions, health public In development. of process whole the to

“Destination” is the first major component of the strategy and is crucial crucial is and strategy the of component major first the is “Destination”

and take up as their own? their as up take and

vision be translated into a clear destination that the people themselves accept accept themselves people the that destination clear a into translated be vision

to be developed, the question is, what vision does everyone have? Could this this Could have? everyone does vision what is, question the developed, be to

Such decisions will direct the strategy to be used. If the people’s capability is is capability people’s the If used. be to strategy the direct will decisions Such

community, as well as how this should be done, must be based on evidence. evidence. on based be must done, be should this how as well as community,

improvement of health service institutions and development of the people and and people the of development and institutions service health of improvement

it should strike a balance between the two. The decision to balance the the balance to decision The two. the between balance a strike should it

This does not mean that the country must choose one option or the other; other; the or option one choose must country the that mean not does This

the meaning of “health system”, the latter option is a better choice. choice. better a is option latter the system”, “health of meaning the

can independently take care of their own health and environment. Going by by Going environment. and health own their of care take independently can

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa 49

management” must be used in order to move forward. forward. move to order in used be must management”

strategy into account and bring them in order. In other words, “strategy “strategy words, other In order. in them bring and account into strategy What is needed now is to bring all the diverse aspects of the Health for All All for Health the of aspects diverse the all bring to is now needed is What

Development

Attributes

Quality Characteristics

Human-Resource Human-Resource

Data-information Data-information Organization Organization

Process

Application Communication System Communication Management

SRM SRM Information/Education/ Innovation Innovation

Partner State Agencies State

Organization

Local Government Local

Community Community Screening Systems Screening

People

Surveillance/

Measures

People's Projects People's

Social Intervention Intervention Social

Behavioral Change Behavioral

Target Group Group Target

Components that spell success of a program a of success spell that Components

The strategic linkage model (SLM) model linkage strategic The 4: Figure

Thailand

p Ma

age Model age Link

Destinations

e Rout Strategic c Strategi

orm ansf Tr Simplify

Mapping destinations Mapping 3: Figure T ( 1986 ) hailand

: : are c lth ea h y ar im r p

T of eras ree th e h

cooperation among developing communities” technique communities” developing among cooperation

can take place using the adapted WHO’s “Technical “Technical WHO’s adapted the using place take can Models are built and certain criteria are met, expansion expansion met, are criteria certain and built are Models

has not been seen before. seen been not has

is envisaged that the health scenario will change for the better by a degree that that degree a by better the for change will scenario health the that envisaged is

assume major responsibility for developing health programmes of their own. It It own. their of programmes health developing for responsibility major assume

implemented in all administrative divisions of the country. By then, people will will people then, By country. the of divisions administrative all in implemented

In Thailand, the target set is that by the end of 2010, SRM will be be will SRM 2010, of end the by that is set target the Thailand, In

communities” technique, which has been successfully used earlier. used successfully been has which technique, communities”

place using the adapted WHO’s “Technical cooperation among developing developing among cooperation “Technical WHO’s adapted the using place

Once models are built and certain criteria are met, expansion can take take can expansion met, are criteria certain and built are models Once

SRM to make people self-reliant. people make to SRM

However, the country should proceed to Era 3 as soon as possible and apply the the apply and possible as soon as 3 Era to proceed should country the However, period of time of period

in a relatively short short relatively a in

from Era 1 of primary health care development to Era 2. Era to development care health primary of 1 Era from

and bring about changes changes about bring and

changes in the health situation. This is the immediate benefit if a country moves moves country a if benefit immediate the is This situation. health the in changes

predefined destination destination predefined

and community funds, are put to work effectively, the stage is set for dramatic dramatic for set is stage the effectively, work to put are funds, community and

development towards a a towards development

administration, community human resources (health volunteers and the like) like) the and volunteers (health resources human community administration,

expedite the process of of process the expedite

intervention needed. When all three pillars of self-reliance, i.e. local local i.e. self-reliance, of pillars three all When needed. intervention

the SRM is that it can can it that is SRM the

In simple terms, the more self-reliant people become, the less the external external the less the become, people self-reliant more the terms, simple In

One of the benefits of of benefits the of One

What should we do now? now? do we should What 5.

the same destination. destination. same the

synergistic effect that occurs when all stakeholders are striving together to reach reach to together striving are stakeholders all when occurs that effect synergistic

agree and set out to reach the destination together, bringing about the elusive elusive the about bringing together, destination the reach to out set and agree

of administration, including the workers and the target population, could could population, target the and workers the including administration, of

defined and the appropriate route can be chosen. Everyone at every level level every at Everyone chosen. be can route appropriate the and defined

The beauty of the SRM is that the routes towards the destination are clearly clearly are destination the towards routes the that is SRM the of beauty The

destination and bring about changes in a relatively short period of time. time. of period short relatively a in changes about bring and destination

SRM is that it can expedite the process of development towards a predefined predefined a towards development of process the expedite can it that is SRM

the “strategic route map” (SRM) can be applied. One of the benefits of the the of benefits the of One applied. be can (SRM) map” route “strategic the

by the end of the MDGs in 2015. In order to do so, an instrument called called instrument an so, do to order In 2015. in MDGs the of end the by

of WHO-SEAR, which defines clearly the state of development to be reached reached be to development of state the clearly defines which WHO-SEAR, of

In this context, Member countries can get together to develop a destination destination a develop to together get can countries Member context, this In

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa

the most important aspect of all development, including health. including development, all of aspect important most the

those at the grass-roots level, to take development into their own hands. This is is This hands. own their into development take to level, grass-roots the at those

Let us stop to think whether we believe in the power of our people, especially especially people, our of power the in believe we whether think to stop us Let

Have faith in people in faith Have

6.3

Director-General of WHO, we should see the opportunity to move forward. move to opportunity the see should we WHO, of Director-General

Now that primary health care is being revitalized, thanks to the initiative of the the of initiative the to thanks revitalized, being is care health primary that Now

Soul-searching 6.2

development and are applicable in any country. country. any in applicable are and development

The three pillars of self-reliance could be used as a basis for programme programme for basis a as used be could self-reliance of pillars three The

from relevant sectors, and guarded against unfavourable conditions. conditions. unfavourable against guarded and sectors, relevant from

insects. Likewise, people’s projects must be supported with the right technology technology right the with supported be must projects people’s Likewise, insects.

be damaged, protected from harmful diseases, and guarded against marauding marauding against guarded and diseases, harmful from protected damaged, be

tended. They must be appropriately fertilized to ensure that the soil would not not would soil the that ensure to fertilized appropriately be must They tended.

Good gardening practices: After sprouting, the seedlings must be carefully carefully be must seedlings the sprouting, After practices: gardening Good

applicable in any country any in applicable

development and are are and development

policy to empower the people to make decisions must be there. be must decisions make to people the empower to policy

as a basis for programme programme for basis a as

place in order to keep the plant alive. Above all, as light is essential for plants, a a plants, for essential is light as all, Above alive. plant the keep to order in place

reliance could be used used be could reliance

strengthened and empowered. Water, or a financing scheme, must be put in in put be must scheme, financing a or Water, empowered. and strengthened

The three pillars of self- of pillars three The

Good soil with light and water: The community, i.e. the soil, must be be must soil, the i.e. community, The water: and light with soil Good

in some situations, it would not sprout. not would it situations, some in

environment in order to sprout. If the environment is not conducive, as is found found is as conducive, not is environment the If sprout. to order in environment

Good seed: The concept of BDN/SRM is like a good seed. It needs the right right the needs It seed. good a like is BDN/SRM of concept The seed: Good

seed, good soil with light and water, and good gardening practices. gardening good and water, and light with soil good seed, Thailand

produce a good yield, at least three favourable components are needed: good good needed: are components favourable three least at yield, good a produce

The realization of primary health care is analogous to horticultural practice. To To practice. horticultural to analogous is care health primary of realization The

An analogy of success of analogy An 6.1

In retrospect In 6.

T ( 1986 ) hailand

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T of eras ree th e h

health staff, which may go against this concept this against go may which staff, health

dealt with at an early stage is the attitude of the the of attitude the is stage early an at with dealt

has shown that the challenge that must be be must that challenge the that shown has Experience in dealing with primary health care care health primary with dealing in Experience

needs before being widely implemented. widely being before needs

elsewhere but should be tried, tested and modified according to the country’s country’s the to according modified and tested tried, be should but elsewhere

to other countries. The concepts and lessons learned in a country may be valid valid be may country a in learned lessons and concepts The countries. other to

on record. This is not to propose a ready-made model to be exported “as is” is” “as exported be to model ready-made a propose to not is This record. on

their own hands own their

health care during the past 30 years. The main purpose is to put his experiences experiences his put to is purpose main The years. 30 past the during care health

development into into development

This document presents the concepts and experiences of Dr Amorn in primary primary in Amorn Dr of experiences and concepts the presents document This

roots level, to take take to level, roots

those at the grass- the at those

Epilogue 7.

people, especially especially people,

the power of our our of power the

keep building on innovations. Anything is possible! is Anything innovations. on building keep

We must believe in in believe must We

do, then we should have the courage to hold on to what we believe in and and in believe we what to on hold to courage the have should we then do,

ourselves if we have faith in the people and in what we will do for them. If we we If them. for do will we what in and people the in faith have we if ourselves

We should look at primary health care with a new perspective. We should ask ask should We perspective. new a with care health primary at look should We

past 30 years has been proved a failure. failure. a proved been has years 30 past

people because they are at the receiving end. This approach taken during the the during taken approach This end. receiving the at are they because people

“service outlook” with no clear-cut destination as to what would happen to the the to happen would what to as destination clear-cut no with outlook” “service

us. But If the answer is “no”, then our programme will assume the same old old same the assume will programme our then “no”, is answer the If But us.

health care will assume a new look. A whole new world will open up before before up open will world new whole A look. new a assume will care health

could embark on a road that leads to a totally new destination and primary primary and destination new totally a to leads that road a on embark could

ready to change our concepts and attitudes?” If the answer is “yes”, then we we then “yes”, is answer the If attitudes?” and concepts our change to ready

It is time to do some soul-searching. “Do we believe in our people? Are we we Are people? our in believe we “Do soul-searching. some do to time is It

happen. happen.

may go against this concept. A paradigm shift is necessary before good things things good before necessary is shift paradigm A concept. this against go may

that must be dealt with at an early stage is the attitude of the health staff, which which staff, health the of attitude the is stage early an at with dealt be must that

Experience in dealing with primary health care has shown that the challenge challenge the that shown has care health primary with dealing in Experience

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa Mrs Kardinah Soepardjo Roestam, President of the Indonesian Family Welfare Movement, which received the Sasakawa Health Prize. WHO Photo

53 CHAPTER 4 1988

Family Welfare Movement (Pembinaan Kesejahteraan Keluarga - PKK) and its achievements in national [ ] development: Indonesia * [1]

Recipient: Indonesian Family Welfare Movement (PKK) (Indonesia)

[*] Draft prepared by Dr Palitha Abeykoon Former Director, WHO South-East Asia Region 17, Horton Towers, Colombo 8, Sri Lanka 54 omen in Indonesia, whether as citizens or human Wresources for development, have the same rights, obligations and opportunities as men

Indonesia 1. Introduction

Women in Indonesia, whether as citizens or human resources for development, have the same rights, obligations and opportunities as men. This equality is obvious in all community activities and development. For these reasons, women’s status and participation in the development of the community should be accelerated and guided. Women’s participation in development enhances family prosperity. This includes development of the younger generation and youth in achieving their potential as human beings. Women’s status and participation in the Women’s participation in development has also been stated clearly in the 1988 development of the national development guidance or Garis-garis Besar Haluan Negara (GBHN). community should be The GBHN mentions the following three major areas for women’s participation: accelerated and guided. Women’s participation in 1. To participate actively in all national development according to their development enhances capabilities, skills and professions family prosperity 2. To understand family welfare in order to improve community welfare

3. To build a new generation from conception through adolescence in order to develop a better quality of Indonesian people.

These three major areas of participation are expected of all Indonesian women without exception, be they housewives, career women or professionals. Whatever their position, and whether they live in rural or urban areas, they should execute these three responsibilities for development.

2. The meaning of the Family Welfare Movement (PKK)

The Family Welfare Movement or PKK (Pembinaan Kesejahteraan Keluarga) is a development movement in the community especially for the family in order to ensure family welfare. Although it is a small component in the overall development of Indonesia, if every family looks after its own welfare, prosperous communities can hopefully be achieved.

physical and mental well-being of all families all of well-being mental and physical

of life by supporting programmes that emphasize the the emphasize that programmes supporting by life of

The general aim of PKK is to improve the family’s quality quality family’s the improve to is PKK of aim general The

WHO Photo WHO

Assembly.

cadres that encourage and show how to improve a family’s welfare. When it it When welfare. family’s a improve to how show and encourage that cadres

of the 41 the of World Health Health World

D. Ngandu-Kabeya, President President Ngandu-Kabeya, D. contributions. Women volunteers run the PKK programmes and they are the the are they and programmes PKK the run volunteers Women contributions.

Movement from Professor Professor from Movement

PKK is a movement, not an organization with paid members and membership membership and members paid with organization an not movement, a is PKK

Indonesian Family Welfare Welfare Family Indonesian

Prize on behalf of the the of behalf on Prize

the Sasakawa Health Health Sasakawa the

educating people, and by giving guidance and promoting activities. promoting and guidance giving by and people, educating

Roestam received received Roestam

Mrs Kardinah Soepardjo Soepardjo Kardinah Mrs PKK motivates the community to work for its own needs, by motivating and and motivating by needs, own its for work to community the motivates PKK

programmes that emphasize the physical and mental well-being of all families. families. all of well-being mental and physical the emphasize that programmes

The general aim of PKK is to improve the family’s quality of life by supporting supporting by life of quality family’s the improve to is PKK of aim general The

Aims and organization and Aims 2.1

illiterate and low-income families, both in rural and urban areas. urban and rural in both families, low-income and illiterate

1945 Constitution 1945

need assistance in personality and knowledge development, those who are are who those development, knowledge and personality in assistance need

and the principles of the the of principles the and

Families are the target group of the PKK programme, particularly families which which families particularly programme, PKK the of group target the are Families

based on the Pancasila Pancasila the on based

and mental prosperity prosperity mental and from its activities. its from

of physical, sociological sociological physical, of everyone is invited to participate in PKK programmes and to obtain advantages advantages obtain to and programmes PKK in participate to invited is everyone

to live peacefully in terms terms in peacefully live to individuals are family members and everyone seeks well-being. Therefore, Therefore, well-being. seeks everyone and members family are individuals

as families that are able able are that families as PKK is a movement that has universal appeal, and is based on two premises: premises: two on based is and appeal, universal has that movement a is PKK

Family welfare is defined defined is welfare Family

improvement and skills development. skills and improvement

generation, and perpetuation of a better environment through educational educational through environment better a of perpetuation and generation,

Physical or material: consisting of clothes, food, housing, health, income income health, housing, food, clothes, of consisting material: or Physical 2.

development based on the Pancasila principles, Pancasila the on based development

by God, and as citizens and community members who are useful for for useful are who members community and citizens as and God, by

Mental or spiritual: including the attitude that all human beings are created created are beings human all that attitude the including spiritual: or Mental 1.

includes the following two areas: areas: two following the includes

To achieve physical and mental well-being, the goal of family development development family of goal the well-being, mental and physical achieve To

understanding, responsibility and help. and responsibility understanding,

harmony and balance between physical and mental satisfaction with mutual mutual with satisfaction mental and physical between balance and harmony

principles of the 1945 Constitution. It is also defined as being able to create create to able being as defined also is It Constitution. 1945 the of principles

of physical, sociological and mental prosperity based on the Pancasila and the the and Pancasila the on based prosperity mental and sociological physical, of

Family welfare is defined as families that are able to live peacefully in terms terms in peacefully live to able are that families as defined is welfare Family Sasakawa Health Prize Health Sasakawa Family Welfare Movement

(Pembinaan Kesejahteraan

Keluarga - PKK) and its

achievements in national

development: Indonesia

was awarded the Sasakawa Prize, the PKK had nearly five million volunteers. Women volunteers act as advisors, facilitators and motivators. The target is

Indonesia women, because PKK recognizes the mother’s central role in the family. PKK is a movement that assists communities and the government to develop family welfare. As a movement mentioned in the Guidelines of the National Policy/ GBHN, everyone can actively participate in the PKK programme, including men as the heads of households.

The focus of PKK activities is the family. For Indonesians, family is the central social institution, the centre of personal life, not just during childhood but through adult life. Hence, all family members are encouraged to be actively involved in the movement. For Indonesians, family is the central social In terms of the organization, there are solid organizations from the national level institution, the centre down to the village/subvillage level. of personal life, not just There are two teams that support the PKK: first, the Motivating Team and during childhood but second, the Advisory or Technical Team. through adult life

The Motivating Team consists of women and men who are voluntarily interested in the family welfare of a community, with the exception of one or two paid staff who work full time. This team functions as the motivators, trainers, facilitators, supervisors and coordinators of PKK activities. The team builds bridges between the needs of the community and appropriate technologies introduced by the government or nongovernmental organizations (NGOs). It also tries to be a connector between the local community systems and the national development system. At the national level, the wife of the Minister of Home Affairs serves as the Chairperson, assisted by a Vice-chairperson and several members from various government departments.

the family welfare of a community a of welfare family the

and men who are voluntarily interested in in interested voluntarily are who men and

The Motivating Team consists of women women of consists Team Motivating The

WHO Photo WHO

her organization. her

Health Assembly on behalf of of behalf on Assembly Health

addressing the 41 the addressing World World

Sasakawa Health Prize, Prize, Health Sasakawa

Movement, winner of the the of winner Movement,

Indonesian Family Welfare Welfare Family Indonesian

Roestam, President of the the of President Roestam,

Mrs Kardinah Soepardjo Soepardjo Kardinah Mrs

spontaneous responses. spontaneous

is through simulation and games, and quizzes for for quizzes and games, and simulation through is Pancasila the of application

principles, and to obey the laws and regulations of Indonesia. The practical practical The Indonesia. of regulations and laws the obey to and principles,

over personal interests, to practise cooperation and togetherness of family family of togetherness and cooperation practise to interests, personal over

and uphold human worth, to give precedence to common national needs needs national common to precedence give to worth, human uphold and

cultural values and devotion to God in everyday life, to respect human beings beings human respect to life, everyday in God to devotion and values cultural

of the nation. This programme, therefore, is intended to perpetuate national national perpetuate to intended is therefore, programme, This nation. the of

values of the nation the of values

consists of five inseparable principles drawn from the ancient cultural values values cultural ancient the from drawn principles inseparable five of consists

the ancient cultural cultural ancient the

or the “five principles” is Indonesia’s national ideology. It It ideology. national Indonesia’s is principles” “five the or Pancasila The

principles drawn from from drawn principles

of five inseparable inseparable five of

Pancasila the of application practical and Comprehensive 1.

ideology. It consists consists It ideology.

Indonesia’s national national Indonesia’s

PKK has 10 basic programmes which are briefly described below. described briefly are which programmes basic 10 has PKK

“five principles” is is principles” “five

PKK programmes PKK 3. or the the or Pancasila The

support for the programmes carried out by the PKK. the by out carried programmes the for support

so on. This team is responsible for developing the technical guidance or or guidance technical the developing for responsible is team This on. so

information, social affairs, labour, cooperatives, small industry, religions, and and religions, industry, small cooperatives, labour, affairs, social information,

such as the departments of home affairs, agriculture, education, health, health, education, agriculture, affairs, home of departments the as such

departments that have programmes to be carried out in the community community the in out carried be to programmes have that departments

The advisory or technical team comprises representatives of government government of representatives comprises team technical or advisory The

supervisors of the Motivating Teams at the respective administrative levels. administrative respective the at Teams Motivating the of supervisors

municipality, subdistrict and the head of the village/sub-village are the the are village/sub-village the of head the and subdistrict municipality,

The Minister of Home Affairs, the Governor, the Head of the district/ the of Head the Governor, the Affairs, Home of Minister The

Group or dasawisma. or Group

sub-village level further down. It ultimately ends with the 10–20 Family Family 10–20 the with ends ultimately It down. further level sub-village

and the wife of the head of the district/municipality, subdistrict and village/ and subdistrict district/municipality, the of head the of wife the and

At the provincial level, the wife of the Governor serves as the Chairperson Chairperson the as serves Governor the of wife the level, provincial the At

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa Family Welfare Movement

(Pembinaan Kesejahteraan

Keluarga - PKK) and its

achievements in national

development: Indonesia

2. Mutual self-help or gotong-royong

Gotong means “bearing the weight of something together”, while royong Indonesia means sharing the proceeds. This phrase describes an ancient and well-defined system of cooperation and expresses the traditional feeling of familial ties, which is called kekeluargaan. Gotong-royong is integral to all Indonesian communities, be they traditional, developed or developing.

3. Food

After the poverty-stricken conditions and accompanying ignorance during colonial times, people needed to learn the importance of nutrition for the physical and mental well-being of family members. People should know that People needed healthy and nutritious menus can be cheap and within the reach of all. They to learn the should also be aware that many items on these menus are not difficult to cook. importance of Home gardens can be planted with fast-growing vegetables. Fish and small nutrition for the livestock can be kept without detriment to the environment in confined and physical and densely populated areas. Home gardens can also be used to grow traditional mental well-being herbs for medicines or jamu. of family members

4. Clothing

In the past, poverty resulted in the neglect of clothing. However, today people are aware that clean and suitable clothing is one of the basic needs of human beings. People can easily learn how to make clothing and patch-work bedspreads to meet the needs of the family.

5. Housing and home economics

Homes are the places where families improve the quality of their lives. The first requirement of comfortable housing is hygiene and a pleasant environment. In this case, people need to know how to make a simple, healthy and attractive house at a reasonable cost. People should also understand how to care for it and use the garden or yard effectively. An understanding of home economics is essential for the family’s happiness as well as for its economic well-being.

poor health and ignorance have existed for a long time long a for existed have ignorance and health poor

needs to be emphasized in communities in which poverty, poverty, which in communities in emphasized be to needs

The significant contribution of good health to well-being well-being to health good of contribution significant The

WHO Photo WHO

Sasakawa Health Prize. Health Sasakawa

giving ceremony of the the of ceremony giving

Sasakawa after the prize prize the after Sasakawa

congratulated by Mr Ryoichi Ryoichi Mr by congratulated

Welfare Movement, being being Movement, Welfare

the Indonesian Family Family Indonesian the

Roestam, President of of President Roestam,

Mrs Kardinah Soepardjo Soepardjo Kardinah Mrs

Community Health Services Post. It has five basic services: immunization, immunization, services: basic five has It Post. Services Health Community

, or Integrated Integrated or , Posyandu the called is post This month. a once meetings regular

to reach these groups, PKK has established at least one post in every village for for village every in post one least at established has PKK groups, these reach to

age, couples of childbearing age, and pregnant and lactating mothers. In order order In mothers. lactating and pregnant and age, childbearing of couples age,

Special attention is given to the health conditions of children under 5 years of of years 5 under children of conditions health the to given is attention Special

disposal of household rubbish and waste. and rubbish household of disposal

of safe drinking water and how to protect clean environments with proper proper with environments clean protect to how and water drinking safe of

are also fostered by PKK. People are shown how to obtain adequate supplies supplies adequate obtain to how shown are People PKK. by fostered also are

reasonable cost reasonable

existed for a long time. Personal hygiene habits and environmental protection protection environmental and habits hygiene Personal time. long a for existed

attractive house at a a at house attractive

emphasized in communities in which poverty, poor health and ignorance have have ignorance and health poor poverty, which in communities in emphasized

simple, healthy and and healthy simple,

families. The significant contribution of good health to well-being needs to be be to needs well-being to health good of contribution significant The families.

know how to make a a make to how know

Good health is an absolute necessity for the well-being of both individuals and and individuals both of well-being the for necessity absolute an is health Good

People need to to need People

Health 7.

and even beauty care education are given special emphasis by PKK. by emphasis special given are education care beauty even and

increase a family’s well-being and income. Programmes such as radio repairing repairing radio as such Programmes income. and well-being family’s a increase

children’s toys, knitting, crocheting, dress-making and simple carpentry can can carpentry simple and dress-making crocheting, knitting, toys, children’s

Craft skills provide a better quality of life at a low cost. Embroidery, making making Embroidery, cost. low a at life of quality better a provide skills Craft

academic or classroom education. classroom or academic

importance of “lifelong education”, which of course does not mean merely merely mean not does course of which education”, “lifelong of importance

literary primers that convey useful basic education. PKK also recognizes the the recognizes also PKK education. basic useful convey that primers literary

a “paket (package) A” has been developed, which consists of a set of of set a of consists which developed, been has A” (package) “paket a

Literacy courses are fundamental for any education programme. In response, response, In programme. education any for fundamental are courses Literacy

12 years. The PKK programme uses informal rather than formal education. education. formal than rather informal uses programme PKK The years. 12

provide “good” education for both boys and girls between the ages of 6 and and 6 of ages the between girls and boys both for education “good” provide

Since the institution of compulsory education, PKK motivates parents to to parents motivates PKK education, compulsory of institution the Since

Education and craft skills craft and Education 6.

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa Family Welfare Movement

(Pembinaan Kesejahteraan

Keluarga - PKK) and its

achievements in national

development: Indonesia

nutrition, family planning, maternal and child health, and diarrhoeal disease control Women bring their under-five children to the post for monthly monitoring

Indonesia of the children’s weight and growth, immunization against six major childhood diseases, demonstrations on nutritious feeding, and obtaining oral rehydration solutions for children with diarrhoea. Health education, family planning services and information are also provided for eligible couples. One goal is for women not to deliver a child before they are 20 years old. PKK also promotes small families – two children are enough, spaced at least three years apart. Women are also encouraged to breast-feed their children for its obvious advantages to both children and mothers. Other maternal and child health-related care is also provided in the Posyandu such as pregnancy and prenatal care, distribution of vitamin A capsules and ferrous sulphate tablets. Women volunteers act as advisors, 8. Development cooperatives facilitators and motivators Cooperatives are a basic part of Indonesia’s economic democracy. It is a form of enterprise through which a group of small businessmen can be strongly encouraged. Development of cooperatives provides communities with job opportunities, which are otherwise difficult to create.

9. Protection and conservation of the environment

This programme supports harmony between families, their neighbourhoods and their natural environment. Understanding the importance of conservation can help to reduce environmental damage, for example, from cutting firewood, or polluting rivers due to improper waste disposal.

10. Sound planning

The sound planning of family income and expenditure is very important for a poor family, particularly when there are many people working in a household. Organizing time for work and recreation, and distributing household duties among the different members of a family based on their respective capacities and interests will, hopefully lead to more orderly, effective, efficient and happier lives.

the form of materials, facilities and technical guidance technical and facilities materials, of form the

through donations. Government assistance is mainly in in mainly is assistance Government donations. through

PKK activities are funded by the local community and and community local the by funded are activities PKK

vaccines for immunization and also provides paramedical personnel for for personnel paramedical provides also and immunization for vaccines

technical guidance. For instance, the Ministry of Health supplies various various supplies Health of Ministry the instance, For guidance. technical

Government assistance is mainly in the form of materials, facilities and and facilities materials, of form the in mainly is assistance Government

PKK activities are funded by the local community and through donations. donations. through and community local the by funded are activities PKK

local departmental services at the district level. level. district the at services departmental local

bathing place, a public laundry and a lavatory facility, is provided by various various by provided is facility, lavatory a and laundry public a place, bathing

for example, how much cement will be needed to build a public or family family or public a build to needed be will cement much how example, for

their planning abilities and capabilities. Necessary technical information, information, technical Necessary capabilities. and abilities planning their

are involved in the planning process. With this involvement, villagers develop develop villagers involvement, this With process. planning the in involved are their most felt needs felt most their

groups of villagers. Through these meetings, members of the local community community local the of members meetings, these Through villagers. of groups villagers based on on based villagers

Local PKK motivating teams discuss proposed programmes and projects with with projects and programmes proposed discuss teams motivating PKK Local are determined by by determined are

implementation implementation

in which they too are active implementers. active are too they which in

programme programme

families for non-formal education/learning groups and development activities, activities, development and groups education/learning non-formal for families

Priorities for for Priorities

of under-five children immunized, and identifies illiterate members of the the of members illiterate identifies and immunized, children under-five of

of pregnant women, number of births, number of infant deaths, number number deaths, infant of number births, of number women, pregnant of

the dasawisma approach. The chairperson records and reports the number number the reports and records chairperson The approach. dasawisma the

elected among the families in this unit of households. This approach is called called is approach This households. of unit this in families the among elected

organized by PKK into units of ten under the leadership of a chairperson chairperson a of leadership the under ten of units into PKK by organized

In the PKK strategy of reaching as many families as possible, households are are households possible, as families many as reaching of strategy PKK the In

administrators and local departmental services in implementing programmes. programmes. implementing in services departmental local and administrators

PKK always has a close relationship with the various levels of local government government local of levels various the with relationship close a has always PKK

implementation.

POKJA) and the 10 programmes are divided among these four groups for for groups four these among divided are programmes 10 the and POKJA)

PKK activities are divided into four working groups (kelompok kerja or or kerja (kelompok groups working four into divided are activities PKK

implementation are determined by villagers based on their most felt needs. needs. felt most their on based villagers by determined are implementation

programmes has to be simultaneously carried out. Priorities for programme programme for Priorities out. carried simultaneously be to has programmes

While implementing PKK programmes, not every point of the 10 basic basic 10 the of point every not programmes, PKK implementing While

Programme implementation implementation Programme 4.

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa Family Welfare Movement

(Pembinaan Kesejahteraan

Keluarga - PKK) and its

achievements in national

development: Indonesia

administering them. In mass immunization campaigns conducted by PKK, it prepares the village hall, and the facilities needed for the immunization activity.

Indonesia PKK motivates mothers to bring their children for immunization.

Perhaps a group of women will decide to set aside one spoonful of rice every time they cook. These spoonfuls are accumulated in the households and collected together after a certain length of time. When there is a large enough quantity, it will be sold to provide funds to the PKK. Or perhaps people start a revolving lottery by collecting a small amount of money every month. The accumulated fund is used in turn by every member of the group by casting lots every month. Perhaps someone would buy a pair of breeding rabbits. After they multiply, some are sold and the proceeds used to buy a pair of goats. As time goes on, villagers can own The Ministry of their goats or even buffaloes by this method. Health supplies various vaccines Village roads, housing repairs and construction, digging and lining drainage or for immunization sanitary ditches, building public toilets and other similar community developments and also provides are carried out by gotong-royong activities. For example, villagers spend a few paramedical hours every week to collect stones from rivers, while others lay them on the roads personnel for converting them into facilities that improve the quality of lives of the villagers. administering them 5. Achievements

Some of the following data show in simple terms what PKK has achieved. Most of the figures given here are from the 1984–1987 period.

1. Programme for the comprehension and practical application of the national ideology Pancasila

This programme is conducted by means of simulations and games. It is a media presentation on how to apply the Pancasila in everyday life.

Members of motivation teams who have attended training courses in the propagation of the Pancasila have doubled within these three years. The number of simulation groups has increased by over 50% since 1984.

In addition, there are groups set up to help members when there are deaths in a family: 300 000 groups, and rotating lottery (arisan) groups to collect funds for community needs: 240 000 groups in 1986–87. 63

improve the quality of lives of the villagers the of lives of quality the improve

on the roads converting them into facilities that that facilities into them converting roads the on

collect stones from rivers, while others lay them them lay others while rivers, from stones collect

Villagers spend a few hours every week to to week every hours few a spend Villagers

WHO Photo WHO

41 World Health Assembly. Health World

to the special meeting of the the of meeting special the to

vaccination during his address address his during vaccination

the scars of his leprosy leprosy his of scars the 5.5 million 5.5 springs springs

Mr Ryoichi Sasakawa showing showing Sasakawa Ryoichi Mr

9.5 million 9.5 wells

water supplies: water

1.5 million 1.5 Number of families obtaining clean clean obtaining families of Number rain-water rain-water

Conservation of the environment the of Conservation (c)

injections 10% injections

condoms 3% condoms

devices (IUDs) 21% (IUDs) devices

pills 35% intrauterine intrauterine 35% pills using: acceptors of Number

roughly 20 million 20 roughly couples: eligible of Number

Family planning Family (b)

1.4 million 1.4 gardens nutrition of Number

200 000 200 posts health integrated of Number

6 million 6 lavatories family of Number

673 000 673 units lavatory and laundry bath, of Number

Health (a)

and appropriate domestic planning (1986/87) planning domestic appropriate and

Programmes for health, family planning, conservation of the environment environment the of conservation planning, family health, for Programmes 4.

touching nearly 11 million units in the four years. years. four the in units million 11 nearly touching

and the number of healthy houses in the villages increased by almost 300%, 300%, almost by increased villages the in houses healthy of number the and

number of cottage industries, businesses promoted and supervised by PKK, PKK, by supervised and promoted businesses industries, cottage of number

growing nutritious food, fruits, vegetables and small livestock was 57%. The The 57%. was livestock small and vegetables fruits, food, nutritious growing

The percentage of village families throughout Indonesia using home yards for for yards home using Indonesia throughout families village of percentage The

Programme for food, clothing and shelter (1986/87) shelter and clothing food, for Programme 3.

benefited from these programmes exceeded one million. one exceeded programmes these from benefited

Programme for education and training in skills. The numbers who have have who numbers The skills. in training and education for Programme 2.

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa Family Welfare Movement

(Pembinaan Kesejahteraan

Keluarga - PKK) and its

achievements in national

development: Indonesia

5. Cooperative programmes

PKK set up more than 230 000 small cooperative shops. Indonesia

6. Savings programmes

Number of savings accounts opened due to PKK encouragement

– Tabanas’ (national savings) 1.75 million

– Taska’ (insurance savings) 215 000

– Tapelpram (scouts and students’ savings) 611 000

6. Problems and supporting factors

Although PKK has achieved many goals and is widely acknowledged as one of the key movements in rural Indonesia, it faces many challenges such as those listed below.

1. Low level of family education

2. Inadequate incomes of some families

3. Traditional laws that sometimes act as obstacles

4. Insufficient number of skilled personnel

5. Difficulties in communication due to inadequate infrastructure facilities

) concept. ) dasawisma ( ten-household The 6.

away with polygamy. with away

The marriage law has confirmed women’s right in marriage and has done done has and marriage in right women’s confirmed has law marriage The 5.

men and women. and men

community are being replaced by laws that promote equality between between equality promote that laws by replaced being are community

The old traditions that were detrimental to women’s position in the the in position women’s to detrimental were that traditions old The 4.

concepts of development. of concepts

inherited from pre-colonial times. This is helpful when introducing new new introducing when helpful is This times. pre-colonial from inherited

Following the advice of the leaders as well as their examples is a habit habit a is examples their as well as leaders the of advice the Following 3.

The religious attitude of Indonesian communities Indonesian of attitude religious The 2.

could not be implemented quickly, if at all at if quickly, implemented be not could

Gotong-Royong or mutual help. Without this ethic, most PKK programmes programmes PKK most ethic, this Without help. mutual or Gotong-Royong 1.

There are, however, a number of opportunities that support PKK: PKK: support that opportunities of number a however, are, There

Shortage of time among PKK volunteers. PKK among time of Shortage 9.

Lack of integration in sectoral policies and rigid bureaucracies rigid and policies sectoral in integration of Lack 8.

Instability of some PKK structures and mechanisms and structures PKK some of Instability 7.

Geographical inaccessibility Geographical 6.

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa Family Welfare Movement

(Pembinaan Kesejahteraan

Keluarga - PKK) and its

achievements in national

development: Indonesia

7. Conclusion

Maximum participation by all communities is necessary for sustained national Indonesia development. Since a family is the smallest unit of society, it is very important to encourage every member of a family to play an active role in developing a happy and prosperous family. This includes mental, spiritual, material and physical well-being. Mothers hold the primary role in a family and therefore, they are central in the development of the family’s life. PKK has the duty to urge mothers to play a more active part as vanguards in achieving the goals of family welfare.

Since rural development contributes substantially to national development,

The most significant PKK has made its contributions through supporting family welfare. The most PKK programme significant PKK programme in this respect is its widespread, non-formal in this respect is its education programme covering an integrated curriculum training in literacy, widespread, non-formal primary health care and family planning, managing the Posyandu, teaching education programme civics, caring for the family and community environment, education in home gardening and cloth-making techniques, encouraging mutual help and so forth.

In general, the rural community in Indonesia is dominated by traditional conservative and paternalistic attitudes. These often conflict with the process of women’s development. PKK attempts to overcome these problems by improving social communication and convincing women of the advantages of PKK programmes and activities through dasawisma.

Since improving the quality of human development is the basic concept of PKK, its strategy is a bottom–up movement and grass-roots level approach. PKK must expose its members to the fact that development is an integrated process, in which the whole community is developed. PKK is no longer concerned only with economic progress. Therefore, development should be focused on enhancing community capacities for developing their own resources. PKK plays a very important role as a change agent. However, the changes brought about should not disrupt the cultural integrity of rural communities. Though considerable progress has been made by PKK, much remains to be done.

movement and grass-roots level approach level grass-roots and movement

basic concept of PKK, its strategy is a bottom–up bottom–up a is strategy its PKK, of concept basic

Improving the quality of human development is the the is development human of quality the Improving

Jakarta, 1987. Jakarta, Kesehatan. Pembangunan

Kecendarungan dan Faktor-faktor yang Menpengaruhi Kebijalsanaan Kebijalsanaan Menpengaruhi yang Faktor-faktor dan Kecendarungan S. Yahya

. Jakarta, 1985. Jakarta, . PKK Kegiatan Perkembangan Laporan PKK. Pusat Penggerak Tim

of Hawaii, Honolulu, 1986. Honolulu, Hawaii, of

Dissertation presented for the DrPH degree, School of Public Health, University University Health, Public of School degree, DrPH the for presented Dissertation

experience. Banjarnegara the – Indonesia rural in care health primary of

A study of selected factors influencing the development development the influencing factors selected of study A A. Suwandono

Jakarta: Family Welfare Movement (PKK), 1987. (PKK), Movement Welfare Family Jakarta:

Roestam KS. Family welfare movement in Indonesia and its achievements. achievements. its and Indonesia in movement welfare Family KS. Roestam

Jakarta: Family Welfare Movement (PKK), 1985. (PKK), Movement Welfare Family Jakarta:

Family welfare movement in Indonesia and its achievements. achievements. its and Indonesia in movement welfare Family KS. Roestam

Proceedings of the CIRDAP Workshop. Quezon City: 1985. City: Quezon Workshop. CIRDAP the of Proceedings development.

Family welfare movement, an alternative for rural women and and women rural for alternative an movement, welfare Family KS. Roestam

approach. 2nd edition. New York: The Free Press, 1971. Press, Free The York: New edition. 2nd approach.

Rogers EM, Shoemacher, FF. Communication of innovations, a cross cultural cultural cross a innovations, of Communication FF. Shoemacher, EM, Rogers

Jakarta: Ministry of Health, 1983. Health, of Ministry Jakarta:

Plan. Development Health Five-Year Fourth The Health. of Ministry Indonesia,

Jakarta: Ministry of Health, 1978. Health, of Ministry Jakarta:

The Third Five-Year Health Development Plan. Plan. Development Health Five-Year Third The Health. of Ministry Indonesia,

Japan, 1986. Japan,

Tokyo: International Medical Foundation of of Foundation Medical International Tokyo: 1986. statistics health SEAMIC

Committee on Health Statistics, Southeast Asian Medical Information Centre. Centre. Information Medical Asian Southeast Statistics, Health on Committee

Pusat Statistik, 1985. Statistik, Pusat

Jakarta: Biro Biro Jakarta: indicator. Welfare Statistics). of Bureau (Central Statistik Pusat Biro

Bibliography 8.

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa Dr B. N. Tandon, India, Chairman of the Scientific Advisory Committee of the National Institute of Nutrition, Hyderabad, one of the recipients of the 1990 Sasakawa Health Prize. WHO Photo by Tibor Farkas

69 CHAPTER 5 1990

Integrated Child Development Scheme (ICDS): India[*]

Recipient: Professor B. N. Tandon (India))

[*] Draft prepared by Dr. Palitha Abeykoon Former Director, WHO South-East Asia Region 17, Horton Towers, Colombo 8, Sri Lanka 70 he Integrated Child Development Scheme (ICDS) was started Tby the Government of India in 1975. It has been instrumental in improving the health and well-being of mothers and children

1. Summary

The Integrated Child Development Scheme (ICDS) was started by the Government of India in 1975. It has been instrumental in improving the health and well-being of mothers and children below 6 years of age by providing health and nutrition education, health services, supplementary food and preschool education. The ICDS national development programme is one of the largest in the world. It reaches more than 34 million children aged 0–6 years, In the area of child and 7 million pregnant and lactating mothers. Other programmes that impact development and on undernutrition include the National Mid-day Meal Scheme, the National nutrition, the United Rural Health Mission, and the Public Distribution System (PDS). The challenge Nations Children’s Fund for all these programmes and schemes is how to increase their efficiency, impact (UNICEF) assists the and coverage. government to further

expand and enhance the In the area of child development and nutrition, the United Nations Children’s quality of ICDS Fund (UNICEF) assists the government to further expand and enhance the quality of ICDS through the following means:

•• Improving the training of child-care workers; •• Developing innovative communication approaches with mothers; •• Improving monitoring and reporting systems; •• Providing essential supplies; •• Developing effective community-based early child-care interventions; •• Providing iron–folic acid supplementation to adolescents; •• Providing vitamin A supplementation to children; •• Increasing the use of iodized salt.

four urban slums urban four

experimental project in 29 rural and tribal blocks and and blocks tribal and rural 29 in project experimental

(ICDS) was launched in India on 2 October 1975 as an an as 1975 October 2 on India in launched was (ICDS) The Integrated Child Development Services scheme scheme Services Development Child Integrated The

health in India. The Lancet. 1981 Mar 21:317(8221): 650-3 21:317(8221): Mar 1981 Lancet. The India. in health

Integrated Child Development Service. A coordinated approach to children’s children’s to approach coordinated A Service. Development Child Integrated

[1]

workers.

for delivery of health and nutrition services in 1976–80, when the experimental experimental the when 1976–80, in services nutrition and health of delivery for supervision of the the of supervision

data have been analysed to find out the impact of the coordinated approach approach coordinated the of impact the out find to analysed been have data training and supportive supportive and training

The evaluation of the second phase of ICDS development is reported here. The The here. reported is development ICDS of phase second the of evaluation The monitoring, evaluation, evaluation, monitoring,

The first report on ICDS indicated the success of the experimental projects. experimental the of success the indicated ICDS on report first The

in four capacities – – capacities four in 2

ICDS as consultants consultants as ICDS

supportive supervision of the workers. the of supervision supportive

work for the for work

ICDS as consultants in four capacities – monitoring, evaluation, training and and training evaluation, monitoring, – capacities four in consultants as ICDS

community medicine, medicine, community

from the departments of paediatrics and community medicine, work for the the for work medicine, community and paediatrics of departments the from

of paediatrics and and paediatrics of

welfare educational services. Faculty members of medical colleges, especially especially colleges, medical of members Faculty services. educational welfare

the departments departments the

programme, and from a child development project officer and staff for social social for staff and officer project development child a from and programme,

especially from from especially

infrastructure (primary health centre) of the block for the health and nutrition nutrition and health the for block the of centre) health (primary infrastructure

medical colleges, colleges, medical

US$ 14–19). The anganwadi receives support and supervision from the health health the from supervision and support receives anganwadi The 14–19). US$

Faculty members of of members Faculty

She is an honorary worker and receives a small monthly payment (Rs 125–175; 125–175; (Rs payment monthly small a receives and worker honorary an is She

local village woman (anganwadi worker) specially trained for this programme. programme. this for trained specially worker) (anganwadi woman village local

All services are delivered at a central point in each village (anganwadi) by a a by (anganwadi) village each in point central a at delivered are services All

education, informal education for women, and health and nutrition education. education. nutrition and health and women, for education informal education,

antenatal services, postnatal care, treatment of minor illnesses, preschool preschool illnesses, minor of treatment care, postnatal services, antenatal

A), nutrition therapy for severely malnourished children, health check-ups, check-ups, health children, malnourished severely for therapy nutrition A),

supplementation (300 additional kcal, 15 g protein, iron, folic acid and vitamin vitamin and acid folic iron, protein, g 15 kcal, additional (300 supplementation

women and lactating mothers. Services include immunization, nutrition nutrition immunization, include Services mothers. lactating and women

provides a package of services for children up to six years of age, pregnant pregnant age, of years six to up children for services of package a provides

with approximate populations of 100 000 and 75 000, respectively. The ICDS ICDS The respectively. 000, 75 and 000 100 of populations approximate with

blocks and four urban slums. urban four and blocks India has a total of 5011 rural and tribal blocks blocks tribal and rural 5011 of total a has India

India on 2 October 1975 as an experimental project in 29 rural and tribal tribal and rural 29 in project experimental an as 1975 October 2 on India

The Integrated Child Development Services scheme (ICDS) was launched in in launched was (ICDS) scheme Services Development Child Integrated The

Introduction

Integrated Child Development Services Development Child Integrated 2.1

[1]

progress report after five years (1975–1980) years five after report progress

A coordinated approach to children’s health in India: India: in health children’s to approach coordinated A 2. Sasakawa Health Prize Health Sasakawa Integrated Child

Development Scheme (ICDS):

India: 1990 (India)

project changed to a national programme to cover a larger population. The rate of change due to ICDS in a year was also estimated by comparing the first and fourth years of the programme. The Government of India has declared it a programme of national importance. It will be expanded to cover 913 of the 5011 community blocks and 87 urban slum areas by 1985.

Subjects and methods

The sample for the study was drawn from 56 ICDS blocks; 23 projects were established in 1975–76 and 33 in 1978–79. The criteria for selection of blocks for ICDS projects have been constant since the scheme began in October The sample for the study 1975. Rural and tribal blocks and urban slums, which are considered backward was drawn from 56 ICDS or underprivileged by the national socioeconomic criteria, are selected for blocks; 23 projects were implementation of ICDS. From the revenue records, all the selected villages established in 1975–76 have similar socioeconomic conditions, with most of the population living and 33 in 1978–79 below the poverty line; this implies a monthly income for a family of five of less than Rs 300 (US$ 30), which is too low to maintain proper health and nutrition of the family members. Children from the backward classes and with poor nutritional status are registered on a preferential basis at the village centre for ICDS services. Previous studies by the Central Committee for Nutrition and Health in ICDS3 and the Programme Evaluation Organization of the Planning Commission4 have confirmed that ICDS services primarily cover poor children from underprivileged socioeconomic groups in the villages.

The sampling methodology for the evaluation study was the same as that of the first.2 Two serial lists of anganwadis were prepared by village name, one for all anganwadis in villages of the primary health subcentre headquarters, and the other for all anganwadis about 5 km outside the villages of the subcentre headquarters.

Villages with primary healthcentre headquarters were excluded from the above lists. Random samples of the same size were drawn from the two lists. All the households in the sampled anganwadis were surveyed.

73 Sasakawa Health Prize: stories from South-East Asia

The samples studied were as follows:

a. 27,726 preschool children (16 989 rural, 5553 tribal and 5184 urban) in whom a baseline study was conducted before ICDS projects started in 1976.

b. 27,487 preschool children (10 078 rural, 8291 tribal and 9118 urban) whose baseline study was conducted before the ICDS programme started in 1979. Dr B. N. Tandon, India, receiving the 1990 Sasakawa c. 15,882 from the same blocks as sample A, but different children (9266 rural, Health Prize from Professor Plutarco Naranjo, President 3822 tribal and 2794 urban) who were surveyed in 1979–80, about three of the 43rd World Health years after the implementation of ICDS. Assembly. WHO Photo by Tibor Farkas d. 10,947 children (5291 rural, 3228 tribal and 2428 urban) from projects established in 1979 were surveyed before the projects began in 1979 and again after one year of ICDS.

e. 2532 children (1552 rural, 570 tribal and 410 urban) were selected from six ICDS projects established in 1976 and surveyed in 1979 and in 1980, i.e. three years and four years after the implementation of ICDS.

In all the populations selected for the study, acceptance was recorded of immunization for BCG, diphtheria, pertussis, tetanus (DPT; 3 doses), and poliomyelitis (3 doses); intervention with supplementary nutrition through a spot-feeding service; distribution of 200 000 IU vitamin A every six months, and health check-ups. Nutritional status was assessed by the weight-for-age method.

Results

Data for samples A and B were studied to find out the percentage of children who accepted immunization and nutrition services, and the nutritional status of the children before the introduction of ICDS programmes in these project areas in 1976 and 1979, respectively (Table 1). These children were receiving services listed separately from those provided by the Department of Health and Social Welfare (DHSW). The percentage receiving BCG immunization fell slightly from 1976 to 1979, whereas the proportion receiving DPT rose in that time (Table

Children from the backward classes and with poor nutritional status are registered on a preferential basis at the village centre for ICDS services

74 Integrated Child

Development Scheme (ICDS):

India: 1990 (India)

1). Poliomyelitis immunization is not included in the national schedule but in 1979, 9.2% of children received it through an ad-hoc programme. There was an increase in vitamin A administration between 1976 and 1979, but distribution of supplementary nutrition remained almost the same. Severe malnutrition (grades III and IV) decreased from 19.1% in 1976 to 15.1% in 1979.

We next compared data from samples B and C (both surveyed in 1979) to find out whether at that time the services received and the nutritional status of children was better in villages where ICDS had been established for more than three years (sample C) than among children receiving services from elsewhere (Table 1). Both BCG and DPT coverage were higher in three-year-old ICDS blocks (sample C) than in sample B. Health check-ups and distribution of There was an vitamin A and supplementary nutrition were significantly lower in sample B than increase in vitamin in sample C. Severe malnutrition was 10.8% in the children receiving services A administration from ICDS compared with 15.1% in the population receiving health and between 1976 and nutrition services from DHSW. 1979, but distribution of supplementary The data for samples A and C (same project blocks but different samples of nutrition remained children) were compared to assess the impact of ICDS three years after its almost the same launch. Immunization coverage with BCG and DPT increased by 108% and 622%, respectively, between 1976 (pre-ICDS, sample A) and 1979 (ICDS after three years, sample C). Health check-ups, distribution of vitamin A, and supplementary nutrition showed increases of 221%, 412% and 120%, respectively. Grades III and IV malnutrition declined by 43.5% and grade II malnutrition by 30%.

The final analysis of data from samples D and E aimed to find out whether the rate of change in the receipt of services and in the prevalence of severe malnutrition during the year 1979–80 was greatest in the first or the fourth year of an ICDS programme (Table 2). The rate of change in a year for the acceptance of all the listed services was less in the fourth year of ICDS than in the first year. However, severe malnutrition decreased by almost the same proportion in first-year and fourth-year projects.5

75 Sasakawa Health Prize: stories from South-East Asia

Table 1: Receipt of essential health services and nutritional status in samples A, B and C

______

% of children ______

Sample A (76*)Sample B (79–80$) Sample C (79–80#)

______

Immunization services from DHSW DHSW ICDS

BCG21.017.443.6

DPT4.9 14.0 35.4

PoliomyelitisNR9.2 NR

Health check-up [email protected] (57.7@)

Vitamin A10.3@ 17.7 57.1 (52.7@)

Supplementary nutrition 25.2 26.0 55.5

Nutritional status:

Normal+grade I47.256.2 62.7

Grade II 27.0 28.2 26.2

Grades III+IV19.115.110.8

NR 6.70.5 0.3 ______

*27 726 children: 23 projects (12 rural, 7 tribal, 4 urban) $ 27 487 children: 33 projects (12 rural, 12 tribal, 9 urban) # 15 882 children: same projects as sample A @ Data for four urban projects not included NR not recorded

76 Integrated Child

Development Scheme (ICDS):

India: 1990 (India)

Differences between the samples are significant (P<0.001) except those between A and B in the area of supplementary nutrition (P>0.05) and nutritional status grade II (P<0.01); and that between A and C in nutritional status grade II (P>0.05).

Fourth year projects*First year projects# ______

% of children Rate of % of children Rate of

change% change% ______

1979 1980 1979 1980 ______

Immunization: BCG50.865.228.314.826.981.8

DPT33.257.372.6 8.930.4241.6

Poliomyelitis15.619.525.05.3 17.0 220.7

Health check- up 58.7 67.7 15.3 12.1 40.9 238.0

Vitamin A63.6 70.6 11.0 13.8 42.0 204.3 Supplementary nutrition 39.0 55.4 42.0 21.2 34.3 61.8 Nutritional status:

Normal+grade I58.2 58.3 0.17 54.4 59.0 8.5 Grade II 28.2 32.3 14.5 29.0 29.0 0.0 Grades III+IV13.0 9.3 -28.5 16.1 11.8 -26.7 NR 0.2 0.1 .. 0.5 0.2 .. ______

Table 2: Rate of change in receipt of health services and nutritional status in first- and fourth-year ICDS project areas

*2532 children: 6 projects (3 rural, 2 tribal, 1 urban) # 10 947 children: 20 projects (9 rural, 7 tribal, 4 urban) NR not recorded

77 Sasakawa Health Prize: stories from South-East Asia

Discussion

The first report on ICDS (March 1981) indicated that this coordinated approach successfully delivered services and improved the nutritional status of the children.2 By March 1982, a total of 300 projects was sanctioned. The Prime Minister of India announced a 20-point programme6 on 14 January 1982: ICDS was included as one of the points and it thus became an important national programme. The government decided to expand the programme to 913 rural and tribal blocks (of 5011) and to 87 urban slum projects by the end of 1985. These would cover approximately 20% of the preschool population, and pregnant and lactating women. In fact, this would make it possible to reach 50% or more of the population groups that live below the poverty line and are in greatest need of ICDS services. Owing to financial constraints and the time required for organization, training and assembly of equipment, the ICDS approach has not yet been expanded to cover preschool children of the whole nation.

This study shows that the ICDS approach of the Government of India has continued to be successful as a national programme, with expansion to 300 projects from the original 33 projects. All the parameters for acceptance of health and nutrition services evaluated after four years in the same ICDS project areas showed a significant improvement and there was a decline in the prevalence of severe malnutrition. There was no additional income- raising activity in the villages and slums where these projects had been implemented, which could account for this improvement in the nutritional status of the children. The proportion of India’s population below the poverty line has not shown any noticeable change between 1976 and 1980, although accurate data on this point are not available. Improvement in health and nutrition in ICDS blocks therefore cannot be attributed to changes in the economic status of the families.

ICDS approach of the Government of India has continued to be successful as a national programme, with expansion to 300 projects from the original 33 projects

78 Integrated Child

Development Scheme (ICDS):

India: 1990 (India)

Acceptance of immunization and nutrition services at one point in time (1979) was better among children who had been covered by ICDS for three years (sample C) than in children receiving services independently from DHSW (sample B).

The two populations from which samples B and C were drawn are comparable in their socioeconomic status, according to the criteria laid down for selection of ICDS projects.

It is interesting to note that the non-integrated programme of the health department during 1976–79 was also fairly effective in improving the rates of DPT immunization and distribution of prophylactic vitamin A, and in

The ICDS approach is reducing the prevalence of severe malnutrition. However, these changes were a step forward towards significantly smaller than those that can be achieved through an integrated decreasing morbidity and approach to delivery of health care, nutrition and preschool education. mortality in preschool It has often been stated that the cost of the ICDS approach is high. children in India, Establishment of centres in villages, with a voluntary worker in each village, and to give them the leads to an extra cost of approximately Rs 12 (US$ 1.20) per beneficiary per opportunity for optimum year, over and above the cost of the health services infrastructure. It is difficult growth and development to calculate accurately the additional cost of the village centre for health and nutrition services only, since the centre also provides preschool education for children, and health and nutrition education and functional literacy to the women of the villages. In fact, nearly three quarters of the time of the anganwadi worker at the village centre is spent on these activities. The slight increase in the cost of health and nutrition services needed to establish the village-level centre is not only justified by the results, but seems necessary to ensure better performance of the health infrastructure established at substantial cost in India.

79 Sasakawa Health Prize: stories from South-East Asia

The ICDS approach is a step forward towards decreasing morbidity and mortality in preschool children in India, and to give them the opportunity for optimum growth and development. However, immunization coverage (which increased from 21% to 43.6% for BCG and from 4.9% to 35.4% for DPT) must be further improved, and severe malnutrition (which fell from 19.11% to 10.8%) needs to be further reduced. A proportion of children remained unimmunized and malnourished: they did not benefit through ICDS for several reasons, such as non-acceptance of immunization by the parents, lack of safe drinking water in the villages which led to frequent intestinal infections, and interruption in feeding programmes due to difficulties in transporting nutritious food to villages with poor roads. All these factors are receiving special attention, and it is hoped that the goal of Health for All by the year 2000 in India will be achieved earlier than the target date for children and mothers through ICDS.

A proportion of children remained unimmunized and malnourished: they did not benefit through ICDS for several reasons, such as non-acceptance of immunization by the parents

80 Integrated Child

Development Scheme (ICDS):

India: 1990 (India)

Dr B. N. Tandon, India, recipient of the 1990 Sasakawa Health Prize addressing the 43rd World Health Assembly. WHO Photo by Tibor Farkas

Consultants for survey teams : Dr Ashok Das, Dr V. K. Karan, Dr J. S. Anand, Dr Vijay Kumar, Dr S. C. Sood, Dr S. K. Rana, Dr M. B. Kanvi, Dr M. G. Javeli, Dr S. K. Behra, Dr K. N. Aggarwal, Dr B. K. Garg, Dr M. K. Chakraborty, Dr Y. L. Vasudeva, Dr K. Indira Bai, Dr B. N. Goswami, Dr Sunder Lal, Dr G. M. Dhar, Dr M. K. Vasundhara, Dr T. Rajagopal, Dr V. Krishnan, Dr M. Zaheer, Dr B. C. Srivastava, Dr K. C. Rajagopalan, Dr Harendra Pratap, Dr S. C. Baldev Raj, Dr Manikyaraju, Dr K. G. Kamala, Dr S. A. H. Zaidi, Dr J. K. Bhatnagar, Dr S. C. Banerjee, Dr Gopal Sharan, Dr T. B. Prasad, Dr D. S. Dave, Dr Y. Srihari Rao, Dr J. N. Khargharia, Dr A. C. Patowary, Dr H. K. Gaur, Dr S. K. Sharma, Dr G. A. Panse, Dr D. Roy, Dr Z. K. Muana, Dr B. Rath, Dr S. K. Debata, Dr R. N. Singh, Dr R. P. Bhattacharjee, Dr Y. C. Mathur, Dr D. N. Shah, Dr M. S. Dattal, Dr B. K. Mahajan, Dr B. Bhandari, Dr S. K. Sen, Dr S. K. Dixit, Dr U. J. Modi, Dr Lalita Bahl, Dr Anand Tate, Dr T. P. Jain, Dr S. Bramhanandam, Dr T. M. V. Prasad Rao, Dr H. Singh, Dr A. B. Desai, Dr V. N. Karandikar, Dr Manju Rastogi, Dr G. P. Mathur, Dr Sitesh Ray, Dr Madhuri Basu, Dr Renu B. Patel, Dr S. U. Warerkar, Dr V. Seth, Dr Jayam Subramaniam, Dr K. Haldar.

Data were analysed at the Biostatistics Division of ICDS Central Cell by Professor K. Ramachandran, Mr B. S. Parmar and Mr Ajit Sahai.

81 Sasakawa Health Prize: stories from South-East Asia

3. References

4 Integrated Child Development Service. A coordinated approach to children’s health in India. Lancet. 1981; i: 650–653. 5 Integrated Child Development Services Scheme. New Delhi: Department of Social Welfare, Government of India, 1975. 6 Tandon BN, Ramachandran K, Bhatnagar S. Integrated child development services in India: objectives, organization and baseline survey of the project population. Indian Journal of Medical Research. 1981; 73: 374–384. 7 India, Planning Commission. Evaluation report of the Integrated Child Development Scheme. New Delhi, 2009. http:// planningcommission.nic.in/reports/peoreport/peo/peo_icds.pdf - accessed 11 November 2011. 8 Tandon BN, Ramachandran K, Bhatnagar S. Integrated child development services in India: evaluation of the delivery of nutrition and health services and the effect on the nutritional status of the children. Indian Journal of Medical Research. 1981; 73: 385–394. 9 India, Ministry of Information and Broadcasting. The new 20-point programme declaration by the prime minister of India, 14 January, 1982. New Delhi: Directorate of Advertising and Visual Publicity, 1982.

82 Dr Handojo Tjandrakusuma of Indonesia, one of the winner of the 1992 Sasakawa Health Prize. WHO Photo by Tibor Farkas

83 CHAPTER 6 1992

Community-based rehabilitation: improving the quality of life of people with less ability[*]

Recipient: Dr Handojo Tjandrakusuma (Indonesia)

[*] Drafted by Dr Handojo Tjandrakusuma Former Director of the Community Based Rehabilitation Development and Training Center (CBR-DTC) PPRBM Prof.Dr.Soeharso – YPAC Nasional Jl.LU.Adi Sucipto KM-7 Colomadu-Solo 57176 Indonesia 84 r Handojo Tjandrakusuma graduated in 1965 from the Medical DFaculty of Airlangga University, Surabaya, Indonesia. Since then, he has been involved in diverse activities related to disability issues

Indonesia 1. Introduction

Dr Handojo Tjandrakusuma graduated in 1965 from the Medical Faculty of Airlangga University, Surabaya, Indonesia. Since then, he has been involved in diverse activities related to disability issues.

Dr Handojo started his career in 1966 at the Rehabilitation Centre (RC) in Surakarta, Central Java. Since 1965, Dr Handojo also held the post of Director of the Academy of Physiotherapy (Ministry of Health) in his hometown Poverty prevented Surakarta, Indonesia. In 1970, he attended the WHO Upgrading Course people in rural areas on Medical Rehabilitation in Lebanon. In 1972, under the umbrella of the from travelling to the Children’s Rehabilitation Foundation of Indonesia, Dr Handojo founded the rehabilitation centre Council for Cerebral Palsy (CP) in Indonesia and became its first Director. and institutions located mostly in big cities Dr Handojo realized that institution-based services at that time did not reach people in the rural areas for various reasons. Poverty prevented people in rural areas from travelling to the rehabilitation centre and institutions located mostly in big cities. Therefore, he started a programme to develop rehabilitation activities in rural areas, which directly involved communities. This programme was called the Village Rehabilitation Programme. The World Health Organization launched a similar concept named Community Based Rehabilitation (CBR) in 1976. Since the WHO concept of CBR was internationally accepted by governments and communities, in 1984, the Council for CP was renamed the CBR Development and Training Centre. Dr Handojo then expanded the CBR strategies to fit the social, cultural and economic situation of the society.

and reach only those who live close to the centres the to close live who those only reach and

primarily institutional in nature, located in the cities, cities, the in located nature, in institutional primarily Traditionally, rehabilitation services have been been have services rehabilitation Traditionally,

resources from IBR. IBR. from resources

one of the resources for the rehabilitation of people with less ability, as well as as well as ability, less with people of rehabilitation the for resources the of one

in the rehabilitation process itself. The CBR approach uses the community as as community the uses approach CBR The itself. process rehabilitation the in

community. There was no community participation or community involvement involvement community or participation community no was There community.

in such a scenario, rehabilitation services were only essentially delivered in the the in delivered essentially only were services rehabilitation scenario, a such in

understanding of disabled people’s needs as a part of the community. However, However, community. the of part a as needs people’s disabled of understanding

extension would allow professionals to enter the communities and increase their their increase and communities the enter to professionals allow would extension

Another approach was to extend the IBR services closer to the community. This This community. the to closer services IBR the extend to was approach Another

of help they needed. needed. they help of

know where to access these services. Third, they did not even know what kind kind what know even not did they Third, services. these access to where know

and were not aware that such services existed. Second, disabled people did not not did people disabled Second, existed. services such that aware not were and

disabled people did not understand that rehabilitation services could help them them help could services rehabilitation that understand not did people disabled

There were challenges within this model. The first challenge was that many many that was challenge first The model. this within challenges were There

such services existed services such

customers. were not aware that that aware not were

services were waiting for customers to come to them instead of reaching out to to out reaching of instead them to come to customers for waiting were services could help them and and them help could

services available, and second, be able to access these. In other words, IBR IBR words, other In these. access to able be second, and available, services rehabilitation services services rehabilitation

however, people with less ability should first be aware of the facilities and and facilities the of aware be first should ability less with people however, did not understand that that understand not did

rests with the disabled persons themselves. In order to avail of the services, services, the of avail to order In themselves. persons disabled the with rests Many disabled people people disabled Many

institution-based rehabilitation (IBR) model, the responsibility for rehabilitation rehabilitation for responsibility the model, (IBR) rehabilitation institution-based

located in the cities, and reach only those who live close to the centres. In the the In centres. the to close live who those only reach and cities, the in located

Traditionally, rehabilitation services have been primarily institutional in nature, nature, in institutional primarily been have services rehabilitation Traditionally,

disabled people. people. disabled

institution-based rehabilitation programmes did not reach a large number of of number large a reach not did programmes rehabilitation institution-based

Children’s Rehabilitation Foundation, Surakarta and a larger area. He found that that found He area. larger a and Surakarta Foundation, Rehabilitation Children’s

WHO Photo by Tibor Farkas Tibor by Photo WHO

1977, Dr Handojo mapped the houses of CP patients who sought help at the the at help sought who patients CP of houses the mapped Handojo Dr 1977,

World Health Assembly. Health World

Mr A. Al-Badi, President of the 45 the of President Al-Badi, A. Mr

667 islands with a population of 237 million; 80% lives in rural areas. In In areas. rural in lives 80% million; 237 of population a with islands 667 th

the 1992 Sasakawa Health Prize from from Prize Health Sasakawa 1992 the

rehabilitation programmes to rural communities. Indonesia consists of 17 17 of consists Indonesia communities. rural to programmes rehabilitation Dr Handojo Tjandrakusuma receiving receiving Tjandrakusuma Handojo Dr

The motivation behind the proposed strategy was the inaccessibility of current current of inaccessibility the was strategy proposed the behind motivation The

Community- and institution-based programmes institution-based and Community- 2.1

Background of the project project the of Background 2. Community-based rehabilitation: improving the quality of life of people with less ability: 1992 (Indonesia)

2.2 Defining the ideal CBR model

It was not that rehabilitation services did not exist at that time in Indonesia. In Indonesia fact, there were a number of government and nongovernment departments, agencies and organizations, as well as formal community activities in health care. This was important to consider when examining the availability of resources for the expansion of CBR activities. The Departments of Health, Social Affairs and Education had existing programmes that assisted disabled people in various ways. In addition to these government programmes, there were nongovernmental organizations (NGOs) which supplemented these services. They were responsible for running special schools and training centres for the blind, deaf and mentally challenged, rehabilitation centres specializing in A framework of the CBR orthopaedic conditions, etc. concept and strategy that was effective and easy Coverage of services for disability prevention and rehabilitation needed to be to understand would be expanded. However, an increase in only the government and nongovernment very useful as a guideline services would not be effective because the community’s awareness and for participating involvement would be minimal. Before any expansion, community sectors agencies/parties and the should first be empowered in order to “catch up” with existing disability community to coordinate prevention and rehabilitation services. Once the community had used the and implement CBR available resources to their fullest potential, all sectors could expand together. In programmes together this way, service expansion would be much more effective and efficient.

A great deal of effort was involved in changing community behaviour (attitude, knowledge and skills). These changes enabled community members to have a better understanding of disability issues (socioeconomic, sociocultural, medical, psychological, etc.), provide a positive environment (physical, psychological, sociocultural and economic) and be responsible for improving the quality of life of people with less ability. CBR was a community development programme in the field of disability prevention and rehabilitation.

Implementation of CBR required the participation of numerous sectors of society with various degrees of knowledge and experience, both professional and non-professional. It must be emphasized that the CBR model or framework should consider the multifaceted contribution of all the different participants.

87 Sasakawa Health Prize: stories from South-East Asia

As a result, the CBR model and concepts should be easily understood by all the The Departments of participants. This is the only strategy where professionals and non-professionals can Health, Social Affairs and work together in a CBR programme. A framework of the CBR concept and strategy Education had existing that was effective and easy to understand would be very useful as a guideline for programmes that assisted participating agencies/parties and the community to coordinate and implement disabled people in various CBR programmes together. ways. In addition to these government programmes, there were nongovernmental organizations (NGOs) which Case 1 supplemented these services Slamet and the homemade tofu production house In 1988, Slamet, who had a speech and hearing problem, was very happy when Mr Joko from CBR Surakarta and the village community of District Klaten found him a job as a production staff at a local homemade tofu production house.

After assessing the practical, health and safety aspects, the owner of the factory was happy to employ Slamet. However, it was not as easy as expected. The owner and colleagues had trouble in communicating information to him. Since there was no one in that village with professional experience and skills in dealing with disability, the owner then invited Mr Joko as an adviser to find a solution to the communication problem.

With time, patience and commitment, Slamet was successfully able to fit in with the factory life. He was able to complete his tasks and ineract socially with other workers. He was treated in the same manner as the other workers. After two years, Slamet was still happily working in that tofu factory and became an asset to the company.

Slamet and the owner of the tofu home industry had empowered themselves to take a decision. They did not rely on outside assistance in running their day-to-day activities. Therefore, CBR is a process by, for and with the community.

The case study above shows that a local community was able to identify the needs of a disabled person. Within a local community members should be able to discover their own method of rehabilitation. In CBR, the community should identify a disabled person’s needs by itself, and fulfil these with locally available resources.

88 Community-based rehabilitation: improving the quality of life of people with less ability: 1992 (Indonesia)

CBR is not just a way to help people with less ability. It is also a process of empowerment, which enables community members, including people with

Indonesia less ability, to cooperatively participate in their own decision-making process. The community is involved in deciding its own needs, rather than having ideas imposed on them from the outside. This feature is critical for understanding the “real” CBR. Those who wish to be implementers of CBR must only introduce the idea of CBR and then permit the villagers to determine what the idea meant to them and how best it could be used in their community. This concept is about community development in the field of disability prevention, rehabilitation and improvement in the quality of life.

3. Strategic thinking CBR is not just a way to 3.1 Behavioural change in the community help people with less ability. It is also a process The CBR model was explained to the community using the analogy of a of empowerment, which house. CBR could be conceptualized as a house with a base and three pillars enables community supporting a roof. The base consisted of the concept and philosophy of CBR. members, including The first pillar consisted of local village members, the second pillar of trained people with less ability, volunteers or CBR cadres. The third pillar consisted of professionals and to cooperatively institutions. It was important to recognize that all three pillars were necessary participate in their own within the CBR model because all these resources had important contributions decision-making process to make in the successful implementation of CBR. The community with its potential was the main agent responsible and was the main resource for programme implementation. The programme must be relevant to community needs and based on resources from within the community.

Any person or organization who wants to implement CBR is in fact a “change agent”. Behaviour change in the community only occurs when a “change agent” effectively introduces new knowledge and skills that contribute to positive changes in the community. The objective of the changes is that the community can reach a certain behaviour level that supports disability prevention and rehabilitation activities.

89 Sasakawa Health Prize: stories from South-East Asia

Case 2 below shows that CBR is a method to improve the quality of life. Mrs Dyah, a CBR cadre, realized that a disabled person had the same needs as a non- disabled person. Case 2 is about the human need to have a family. A CBR cadre Integrated programme of a community is a community member who has the right attitude towards should obtain the full disability issues and is able to change the behaviour of the local community. support and involvement of the higher levels Case 2 The change agent – quality of life of people with less ability In 1989, 27-year-old Mulyono from village Plumbon, Mojolaban, Central Java wanted to marry a woman from his village. He suffered from polio. According to Javanese culture, a man who would like to marry a woman should send his proposal to the future bride’s parents to obtain permission and fulfil the terms and conditions of the traditions.

The mother of the future bride did not accept the proposal because of his physical condition. The people from the village believed that his condition could be passed on to the next generation. Fortunately, after long counselling from Mrs Dyah, the wife of village leader and a CBR cadre from that community, she accepted the proposal. Mrs Dyah found that generally, rejection and a wrong perception of disability by the villagers was caused by the lack of knowledge of disabilities.

Mrs Dyah was a change agent within her community and successfully introduced new knowledge that resulted in community acceptance towards a disabled person. Until today, Mulyono lives happily with his wife and three healthy children.

3.2 The framework

Various disability prevention and rehabilitation activities take place in the community and they depend on the abilities and resources of those who perform them. Referring to the “house and three pillars” analogy, it is possible to consider the performance of CBR activities in three groups. Every pillar has technical and managerial aspects.

The technological activities were aimed at the grass-roots level community members who were provided with knowledge and skills that they would employ in practical ways. Early detection and early intervention for disability were examples of technical activities. In other words, CBR cadres provided the technical activities of CBR.

90 Community-based rehabilitation: improving the quality of life of people with less ability: 1992 (Indonesia)

Those in the community who were active in the local government and institutions were employed in organizational/managerial capacities. Local

Indonesia government personnel formed a “CBR coordinating team”. The purpose of this body was to manage activities such as developing and administering financial resources and organizing disability reassessment days.

The contributions to CBR made by the community, CBR cadres and professionals were all equally valuable. It could be seen that this traditional concept of rehabilitation did not fully reflect the integrated way in which the community, trained members of that community (i.e. CBR cadres) and professionals all cooperated and integrated their skills in such a way that all contributed to community-based rehabilitation. The “right way” of Various disability understanding CBR was to recognize that CBR was an open system with prevention and important contributions by diverse persons and organizations along the rehabilitation activities “professional–non-professional” continuum. take place in the community and they 3.3 Integration of CBR with available resources depend on the abilities The first strategic issue was how the new CBR programme could be specifically and resources of those incorporated into pre-existing community activities. It was too expensive who perform them and complicated to develop a separate infrastructure for community-based disability prevention and rehabilitation. The second strategic issue was to select an effective entry programme. Effective entry programmes should be easy to implement, have visible results and be easy to integrate into existing programmes. One benefit of an effective programme would be the inclusion of both technical and motivational aspects, i.e. develop community interest in disability problems. Therefore, it was suggested to develop CBR activities that could be easily integrated into the existing system. It was also beneficial to attach CBR services to programmes which had national high priority such as primary health care and nutrition programmes.

From the inception of any CBR implementation programme, its sustainability must also be considered. Too often, continuity is not considered until the very late stages (once the support and resources of the initiators are removed).

91 Sasakawa Health Prize: stories from South-East Asia

Programme maintenance must be considered right in the beginning so that every effort can be made to sustain the programme throughout the The technological implementation process. The CBR programme should include orientation of activities were aimed the community in the contingency plan so that it can have some responsibility at the grass-roots level in maintaining the programme. Otherwise, there is a real danger that CBR community members activities may fail. who were provided with knowledge and skills Several techniques for CBR maintenance were used and proposed. Because that they would employ CBR programmes had already become a part of routine community activities in practical ways and government services, a reporting and recording system was included in the existing routine. Reminder programmes were used to continue CBR presence in the villages. These reminders consisted of return visits from CBR implementers, for example, visiting guests from other CBR villages. The presence of international guests at a local village provided significant prestige to the village and motivated the members. In addition, audiovisual presentations such as slide shows and films about rehabilitation and disability were very popular. Another proposed idea was to have an annual “Cadres competition/award”.

3.4 Economy and income generation

Income generation is a strategic issue. Vocational rehabilitation was not a part of CBR. The primary reason for this was that vocational rehabilitation was too narrow in its considerations, and often did not focus sufficiently on the economic situation of the community marketplace that the disabled persons would return to.

The focus of CBR implementation should be broader than just the disabilities of a person. It should also include their capability for income generation. The focus must be broadened to include the laws of the marketplace. Without this consideration, the best efforts at vocational training would be lost. In order to survive in the current economic environment, the concept of CBR should also include “income generation”.

The Community-based rehabilitation (CBR) programme should include orientation of the community in the contingency plan so that it can have some responsibility in maintaining the programme

92 Community-based rehabilitation: improving the quality of life of people with Illustration less ability: 1992 (Indonesia) Essential factors for successful income-generating activities

A young paraplegic might have hand function, upper body coordination, as well as an interest in being a barber. He could be trained for this and return to his village to earn his living in this way. On the other hand, he Indonesia might receive this training and, on return to his village and working for some months relatively successfully, discover that other barbers have just moved into the community. If all of them cannot be supported, the one who succeeds will be the one who can compete best in economic terms. The determination to succeed does not depend upon merit or effort. The success of income-generating programmes depends on just that – generating income.

Vocational rehabilitation was too narrow in its considerations, and often did not focus sufficiently on the economic situation of the community marketplace that the disabled persons would return to PILLAR I The community members detect disability andraise funds for the necessary treatment (CBR activities done by community membersingeneral=mothers)

PILLAR II Organize training programme on early detection of disability by community members (CBR activities done by specially trained community members/cadres=women’s organization)

PILLAR III Developamanual for ED of disability, organize training for trainers,diagnosecases andprovide referral services (CBR activities done by professionals/institutions=puskesmas & posyandu)

The Illustration above indicates the other essential elements required to rehabilitate disabled people by providing them with life skills to earn in the community. Skills training that was suitable for the person’s condition was not the main success factor for generating income. More importantly, a careful assessment of the actual economic situation, and family and CBR cadre support determined success in generating income. 93 Sasakawa Health Prize: stories from South-East Asia

4. Case studies The determination to 4.1 Early Detection of Disabilities Programme in 18 villages succeed does not depend upon merit or effort. From January 1994 to December 1995, early detection (ED) programmes The success of income- were implemented in 18 villages in the districts of Surakarta, Central Java with generating programmes funding from the Sasakawa award. Initially, ED had two main sub-programmes depends on just that – – on education and practical activities. To ensure that the programme would generating income be practical and sustainable, CBR Surakarta decided to integrate ED with established government and community programmes. The most suitable programme at that time was the Posyandu (National Mother and Child Health Programme) under Puskesmas (Lower District Clinic).

Integration of the three pillars

Any integrated programme should obtain the full support and involvement of the higher levels. For instance, the Posyandu Mother and Child Programme was under Puskesmas or the Lower District Clinic, and the Lower District Clinic was under the Department of Health. From the sustainability point of view, one of the Puskesmas’ activities was to give support to the Posyandu on ED. Integration of the three pillars helped to pool resources, all of which were essential in contributing to the success of the programme.

Integration with the Posyandu

The main ED programmes were education programmes for communities and training programmes for medical staff. The education programme was informative and oriented the target audiences of women’s organizations/groups/ CBR cadres to ED in the villages. The objective of this strategy was to develop cadres who would be able to pass on this information to other women’s organizations/groups, the Posyandu and Puskesmas. Meanwhile, the objectives of training medical staff were that they had the ability to train others, and expand and conduct ED, particularly in the programme villages. Dr Handojo Tjandrakusuma A programme evaluation in November 1995 showed that six Puskesmas had of Indonesia, one of the winner of the 1992 Sasakawa implemented ED with 170 medical staff trained in ED. Although the process was Health Prize. WHO Photo by Tibor Farkas

The massive political changes and development of local autonomy rights affected many organizations in Indonesia. Development could also be seen in the areas of communication, transportation and information technology

94 Community-based rehabilitation: improving the quality of life of people with less ability: 1992 (Indonesia)

not as fast as expected, Puskesmas staff members had also started giving training and orientation to cadres at Posyandus. A posyandu in District Klaten even

Indonesia added a counter dedicated to ED and identified 25 cases of late development. As a result, more and more mothers demanded information on ED. ED projects had adopted a suitable method where tangible results could be seen in the targeted area. Knowledge on disability increased significantly in the villages.

4.2 Harelip operations project

In the rural areas, many people did not want to undergo operations because of various factors. such as finances, and a lack of education and information.

In 1995, CBR Surakarta collaborated with government and community Dr Handojo’s specific organizations on a project called “Operasi bibir sumbing” and hernia in District role in developing CBR Tegal. To give other organizations ownership of the disability projects in rural programmes led him to areas, this project involved Pusat Pengembangan dan Latihan Rehabilitasi receive the Sasakawa Para Cacat Bersumberdaya Masyarakat (PPRBM) Surakarta, Social Welfare Health Prize from Department of Tegal, Manunggal Health Organization of Slawi subdistrict Tegal, WHO in 1992. He is a Women’s Association of District Tegal, and the Micro Economy-Anniversary Team recognized speaker at of Tegal District. This project targeted 14 poor patients below 15 years of age. various seminars and workshops, both national Initially, the society of Tegal reviewed the situation and US$ 375 were raised by and international all the five organizations along with family contributions. Further, orientation to and implementation of the programmes were done by a team from the Social Welfare of Tegal, Public Hospital of Slawi, Department of Health District Tegal, subdistrict heads and subdistrict puskesmas. In 1996–1997, the collaboration of the third pillar completed the second phase of the project, in which 56 children were successfully operated. As a result, this project successfully restored self-confidence. Parents who were initially afraid of the operation spread the word about the successful operations. This encouraged other parents to have their children operated in the next year’s programme. Because of this collaboration, awareness of CBR Surakarta increased in wider areas as well as in the government and community organizations involved. These projects educated not only rural communities but also high-level organizations on their roles in disability. The collaboration of government organizations and NGOs is an example of applying the third pillar in CBR.

95 Sasakawa Health Prize: stories from South-East Asia

5. Conclusion Projects educated not In 2004, before Dr Handojo resigned from his position as Director of CBR only rural communities Surakarta, he left behind a concept in relation to community changes. Indonesia but also high-level was undergoing reformation from 1998 to 2004. The massive political changes organizations on their and development of local autonomy rights affected many organizations in roles in disability Indonesia. Development could also be seen in the areas of communication, transportation and information technology. CBR Surakarta realized that most of its strategies were no longer suitable for the community. Therefore, CBR Surakarta altered its strategy to suit the political, economic, social and cultural environment in the community.

6. Epilogue

Dr Handojo’s specific role in developing CBR programmes led him to receive the Sasakawa Health Prize from WHO in 1992. He is a recognized speaker at various seminars and workshops, both national and international. As the Director of the CBR Training Centre, with the support of Nippon Foundation and United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP), in 2000, he organized the Asia Pacific Conference on Tourism for People with Disability in Bali, and was chairperson of the conference committee. His work in welfare is well recognized in Indonesia. In 1998, he received the Ministerial Award from the Minister of Social Welfare for pioneering work and outstanding service in social welfare. In 1999, the Indonesia National Council of Welfare appreciated his dedication and work for the welfare of people with disability.

In 2004, he resigned from CBR DTC Training Centre and trained the next director to continue his mission. Dr Handojo is still very active as the chairperson of the boards of several foundations such as the Pantikosala Health Foundation Surakarta, Warga Education Foundation and National Pharmacy Foundation, as well as the main advisor to the Jakarta School of Orthotics and Prosthetics. As the founder and director of RENA Barrier Free Tourism Development Foundation in 1998, he would like to further improve the quality of life of people with disabilities through tourism.

96 Dr E. Anand, representative of the Arpana Research and Charities Trust (India), co-winner of the 1993 Sasakawa Health Prize. WHO Photo

97 CHAPTER 7 1993

Paradigm shift through development programmes in selected villages of Haryana: Arpana Research and Charities Trust–India[*]

Recipient: Arpana Research and Charities Trust (India)

[*] Draft prepared by Mrs Anne Robinson and Mrs Aruna Dayal Arpana Research & Charities Trust, Madhuban, Karnal, Haryana, India 98 rpana started in 1980. It built up a broad-based infrastructure Afor the delivery of primary health care and socioeconomic programmes in its target area of 36 villages in Haryana

1. Introduction

Haryana “Arpana” means dedication. The Arpana family is guided by Param Pujya Ma and consists of some 60 residents from different lands and faiths. They live as one family and comprise people with considerable experience from disciplines such as medicine, law, engineering, education, architecture, economics, social welfare, general management and computers. All are volunteers for life, and live and work among the needy rural people they serve.

The Arpana family is Arpana started in 1980. It built up a broad-based infrastructure for the delivery guided by Param Pujya Ma of primary health care and socioeconomic programmes in its target area of 36 and consists of some 60 villages in Haryana. Arpana provided ongoing, in-service training to primary residents from different health care workers in these 36 villages. A 75-bed hospital with five major lands and faiths disciplines provided comprehensive health care and was the training centre, referral base and permanent base of operations for the mobile units and delivery of primary health care in these villages.

Each team consisted of a trained midwife, two Integrated Child Development Scheme workers, a male village health worker (VHW) and part-time motivators. The workers also visited other rural health-care projects for new ideas, to increase their confidence and develop linkages with others in the same field.

This health training to workers spread knowledge at a minimal cost and helped to build rapport with the beneficiaries. It was a permanent investment in the future welfare of rural communities. In rural India, with limited trained medical personnel and resources, this is perhaps the most cost-effective and easily replicable method of promoting health care.

Arpana also gave the highest priority to awareness creation of basic health-care principles, preventive health initiatives and community participation to ensure a long-term solution to health and social problems, and to promote well-being in thousands of rural homes.

100

promote well-being in thousands of rural homes rural of thousands in well-being promote

long-term solution to health and social problems, and to to and problems, social and health to solution long-term

initiatives and community participation to ensure a a ensure to participation community and initiatives

creation of basic health-care principles, preventive health health preventive principles, health-care basic of creation Arpana also gave the highest priority to awareness awareness to priority highest the gave also Arpana

ever-widening target area. target ever-widening

To prevent blindness and restore sight to the blind in an an in blind the to sight restore and blindness prevent To 4.

To reduce maternal mortality and morbidity morbidity and mortality maternal reduce To 3.

six years of age of years six

To improve the nutritional and health status of children below below children of status health and nutritional the improve To 2.

To reduce infant mortality mortality infant reduce To 1.

General health objectives health General 3.1

development initiatives, especially for empowering women. empowering for especially initiatives, development

To improve health and well-being through provision of medical inputs and and inputs medical of provision through well-being and health improve To

Project goals Project 3.

laboratory facilities, and a token two-bed indoor facility. indoor two-bed token a and facilities, laboratory

services. The Medical Centre at Dalhousie was equipped with X-ray and and X-ray with equipped was Dalhousie at Centre Medical The services.

the beneficiaries the seven village centres to bring them general medical and maternal/child health health maternal/child and medical general them bring to centres village seven

to build rapport with with rapport build to Pradesh, covering some 160 villages. A mobile service conducted camps in in camps conducted service mobile A villages. 160 some covering Pradesh,

minimal cost and helps helps and cost minimal in Himachal. Arpana had a health-care service in Chamba District, Himachal Himachal District, Chamba in service health-care a had Arpana Himachal. in

knowledge at a a at knowledge Himachal Pradesh: Arpana hospital also served as a training and referral base base referral and training a as served also hospital Arpana Pradesh: Himachal

to workers spread spread workers to

50 km from Madhuban. Madhuban. from km 50 The health training training health The

and a network of VHWs. Villages covered for eye care extended up to to up extended care eye for covered Villages VHWs. of network a and

Madhuban. Intensive health care was provided through mobile services services mobile through provided was care health Intensive Madhuban.

facilities were selected and all were located within 25 km of the base in in base the of km 25 within located were all and selected were facilities

population of approximately 48 000. Villages with a scarcity of government government of scarcity a with Villages 000. 48 approximately of population

Haryana: Arpana’s target area was 36 villages in Karnal District, with a a with District, Karnal in villages 36 was area target Arpana’s Haryana:

of Karnal in the state of Haryana, and is 114 km north of Delhi. of north km 114 is and Haryana, of state the in Karnal of

The Arpana Trust complex is situated at Madhuban, 11 km outside the town town the outside km 11 Madhuban, at situated is complex Trust Arpana The

Target areas Target 2. Sasakawa Health Prize Health Sasakawa Paradigm shift through

development programmes

in selected villages of

Haryana: Arpana Research

and Charities Trust–India:

1993 (India)

3.2 General development objectives

1. To raise the standard of living and quality of life of village communities

2. To provide supplemental income for women to ensure that they had food and basics for the family Haryana 3. To provide literacy skills and create awareness among women of new and beneficial methods of action

4. To provide a safe and caring environment for preschool children while their mothers were working

5. To stimulate the overall development of children attending the day- Women are brought care centres up in an environment of neglect, and are 6. To impart knowledge, skills and training to local village midwives, considered burdens health workers and motivators because of the dowry that 7. To increase the level of social awareness, particularly among rural parents have to provide at women, and bring about community participation in self-help the time of marriage programmes.

4. Main activities

4.1 Comprehensive approach to primary health care

In rural Haryana, health is a low priority. Women are brought up in an environment of neglect, and are considered burdens because of the dowry that parents have to provide at the time of marriage. A woman is discriminated against for food, clothing and education. Married between the ages of 15 and 17 years, she is unaware of her responsibilities as a wife and mother. In her new home, she is treated with hostility or indifference unless she has a wealthy father or is able to quickly produce a son. From the day she is married, she is expected to work hard as well as give birth to children in quick succession and rear them. In fact, her role in rearing a child seems to be less important than her role in doing

101 Sasakawa Health Prize: stories from South-East Asia the many household chores, looking after the milch animals in the house and working in the fields. Children are brought up by their grandmothers or older siblings. Deliveries are carried out by traditional birth attendants (TBAs), who are uneducated and untrained.

It was in this environment that Arpana began its work. The programmes gradually evolved according to their acceptance by the community and availability of funds. The approach varied according to the need. Dr E. Anand, representative of the The low literacy rate of women made it hard for them to perceive that health Arpana Research and Charities Trust (India), co-winner of the 1993 problems stem from poor habits of nutrition and hygiene. Women and children Sasakawa Health Prize, addressing th lived on the borderline of ill health, and medical care was sought only when an the 46 World Health Assembly. WHO Photo acute health problem arose. No attempt was made to improve the underlying factors of health. The perceived health need was only for curative services. There was no perceived need for mother and child health (MCH) services, which were greatly required. Deliveries are carried To overcome these problems, the following activities were started: out by traditional birth attendants (TBAs), who •• Income generation for women: by providing handicraft work for women are uneducated and which they could do in their homes, and marketing the handicrafts untrained produced by them.

•• Health services (Arpana Rural Medical Services) at three levels: a primary level through VHWs and TBAs; a secondary level through mobile clinics and camps; and a tertiary level through a 75-bed hospital with five disciplines.

•• Education (‘Arpana Premanjali” programme): this included education for preschool children; care of children less than three years of age; provision of supplementary nutrition; non-formal education and functional literacy for adolescent girls and women; and child-to-child programmes – schoolchildren who conducted health education and health activities in their own communities.

•• Training: to produce handicrafts (women and supervisors); in health (health workers, TBAs, and community health workers).

The low literacy rate of women made it hard for them to perceive that health problems stem from poor habits of nutrition and hygiene

102 Paradigm shift through

development programmes

in selected villages of

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1993 (India)

5. Arpana Rural Medical Services (ARMS)

5.1 Methodology and design of referral system for health services

Health services were provided at three levels.

Haryana Primary level

Men and women were selected from the community and trained to conduct health-care activities in the villages. TBAs who took care of 70%–80% of childbirths in the villages were untrained. Arpana trained these women and provided them with simple materials for their work, making them a part of the health-care delivery system. Men and women are selected from the Secondary level community and trained to conduct health-care The mobile clinic team consisted of a doctor and /or auxiliary nurse midwife activities in the villages with helpers. This team covered 36 villages, providing skilled support to the primary-level workers who brought referral cases to them. It provided antenatal care, conducted well-baby clinics with immunization, growth monitoring, provided treatment for general ailments and had laboratory facilities.

Tertiary level

Arpana hospital had 75 beds and five disciplines: Medicine, Surgery, Obstetrics and Gynaecology, Ophthalmology and Dentistry. The hospital was the referral base and also where training was imparted to the different cadres of workers. Cases from the secondary level were referred to the base hospital. Serious cases identified in the field were also brought to the hospital by VHWs.

5.2 Health interventions at the primary level

1. Infectious diseases: The VHWs learnt to treat minor ailments such as boils, scabies, conjunctivitis, colds and coughs with simple remedies. If patients did not respond, they were referred to the monthly mobile clinic or the referral base hospital. Major infections such as diarrhoea and other gastrointestinal diseases, malaria, typhoid, tuberculosis and chest infections

103 Sasakawa Health Prize: stories from South-East Asia

were treated through the mobile clinics and proper medication, supervised by the VHW. Patients suffering from serious diseases were brought to the hospital for investigation and treatment.

2. Nutritional diseases: Diseases caused by nutritional deficiencies such as anaemia, night blindness (erophthalmia), iodine deficiency (goitre) and rickets (calcium deficiency) were identified by the village-level worker, and referred to the hospital for investigation, diagnosis and treatment. Continuation of treatment was supervised by the VHW.

3. Accidents: VHWs learnt how to give first aid in an emergency and then Arpana hospital has referred patients for appropriate treatment. 75 beds and five

4. Maternal and child health, and family planning: Rural women often do disciplines: Medicine, not have the health reserves required to bear the physiological strain of Surgery, Obstetrics having a baby. Haemorrhage, sepsis, pre-eclamptic toxaemia of pregnancy, and Gynaecology, obstructed labour and abortion are killers of women. Underlying anaemia Ophthalmology and compounds these problems and leads to morbidity. Hence, it is important Dentistry to recognize the factors that lead to these problems early. Arpana set up a system of checks and referrals to identify and manage such problems.

Maternal health

Pregnancy

1. Identification of anaemia: Home visits were made by the VHWs and TBAs from the third or fourth month of pregnancy. Cases of anaemia were recorded: the patient was given special care and iron and folic acid supplements. They also referred the pregnant woman to the mobile clinic for a check-up by the doctor. Haemoglobin was estimated at least twice during pregnancy. Thus, anaemic women were identified, treated and advised about their diets. Very severe cases were referred to the hospital.

2. Iron, folic acid and calcium supplements were distributed by health workers and TBAs to pregnant women for at least three months.

104 Paradigm shift through

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1993 (India)

3. Immunization with tetanus toxoid: motivated by the village workers, pregnant women took the scheduled injections of tetanus toxoid.

4. Identification of pre-eclamptic toxaemia of pregnancy: All village workers and TBAs were taught to recognize the signs and symptoms of this condition. Haryana 5. Identification of high-risk mothers: A special record was maintained of first- time pregnancies, especially among women below 18 or above 35 years of age; those in their fifth pregnancy or more; and those with a history of a previous difficult delivery, fetal loss or miscarriage. Abnormal positions and twin pregnancies were picked up by TBAs or at the antenatal clinics. TBAs were cautioned about these patients and taught how to recognize the Through home visits danger signs so that they could refer them to the hospital in time. and discussions in cluster meetings, 6. Health education: Through home visits and discussions in cluster meetings, women were made women were made aware of important health principles to follow during aware of important pregnancy and childbirth. health principles to Childbirth or the natal period follow during pregnancy

and childbirth 1. Clean methods of childbirth/prevention of sepsis: TBAs were trained to use clean methods and were given midwifery kits. Each pregnant woman and her family was taught how to prepare a clean room, clean clothes, etc. for delivery.

2. Haemorrhage: High-risk cases were carefully watched for haemorrhage. TBAs dispensed tablets to help to control cases of haemorrhage after childbirth. They were taught to massage the uterus if severe haemorrhage occurred and make swift arrangements for referral if these measures did not elicit a response.

3. Obstructed labour: Early signs of obstructed labour, especially in high-risk pregnancies, were referred to the hospital to reduce the incidence of stillbirth and neonatal death.

105 Sasakawa Health Prize: stories from South-East Asia

Postnatal (postpartum) period

TBAs paid daily visits to the women they had delivered for 10 days and VHWs visited at least once a week. During this time they performed the following tasks: weighed the baby at birth; encouraged and promoted early breast-feeding including the nutrient-rich colostrums; identified haemorrhage and referred for treatment; identified and referred women with fever and sepsis; identified anaemic women for treatment; and advised mothers on breast-feeding. They also took care of the baby’s cord, kept a record of the baby’s weight, and washed and bathed the child and mother. Mothers were Child health introduced to the concept of weaning Growth monitoring: Growth monitoring began at birth. VHWs were provided foods, which gradually weighing devices. If a baby’s weight was normal, it was weighed once a month found acceptance, during the first year. Growth charts were given to the mother, and the purpose especially in those of the charts was explained. Initially, the mothers often used the charts to start villages with a fires. Later, the mothers valued the charts and looked after them carefully. supplementary nutrition VHWs recorded the baby’s weight and other information about the child in a programme for children register. Malnourished children were identified and monitored carefully. below six years of age

Nutrition: Mothers were introduced to the concept of weaning foods, which gradually found acceptance, especially in those villages with a supplementary nutrition programme for children below six years of age. The community contributed wheat and rice at each of the two major harvests, while Arpana contributed milk, vegetables, pulses, etc. for wholesome mid-day meals. Malnourished children and infants below one year of age were given a soft meal. This proved to be a strong argument against the prevalent belief that weaning foods could not be digested by children under one year of age – a belief which resulted in deficiencies and malnourishment of infants.

Day-care centres for preschool children: Children below six years of age were extremely vulnerable, as many working parents had to abandon them to the care of aged grandparents or young brothers and sisters. With no regular attention, they suffered from deficient and irregular meals and were unable to

Children at Arpana day-care centres were provided with a warm, stimulating environment where they practised personal hygiene daily and learnt its importance

106 Paradigm shift through

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and Charities Trust–India:

1993 (India)

acquire habits of personal hygiene. Children at Arpana day-care centres were provided with a warm, stimulating environment where they practised personal hygiene daily and learnt its importance; they participated in activities which encouraged the development of their motor and cognitive skills; learnt letters and numbers; practised clay modelling and simple creative activities; and

Haryana participated in cooperative work and play. The children developed school going habits that helped them adjust to school later on. They were able to learn easily and quickly, and responded far better than other children. The drop-out rate decreased in this group of primary schoolchildren.

Creches: Arpana initially faced a great deal of mistrust in the rural community. This prevented mothers from leaving their preschool children in Arpana’s care. Arpana trained village This attitude changed over the years as the children’s changed habits proved the women to look after efficacy of the preschool methods. Soon, large numbers of Arpana preschool infants, with special centres had to respond to the demand of mothers to look after their infants. attention to their cleanliness Arpana trained village women to look after infants, with special attention to their cleanliness. A soft meal was added for infants below two-and-a-half years of age. Simple play activities stimulated their motor faculties, coordination and cognitive skills.

Immunization: Immunization was carried out against six major diseases and 85% of children below one year were completely immunized by 1992. Booster doses were given, followed by diphtheria–tetanus (DT) and tetanus toxoid (TT) immunizations for older children up to the age of 15 years. This was possible because mothers in Arpana’s villages became aware, through street meetings and discussions with Arpana workers, of the need to immunize their children.

Vitamin A: Vitamin A supplements were given every six months to children until they were five years old as a prophylactic against blindness.

Other illnesses in children: The major killers of infants and small children were diarrhoea and pneumonia. All Arpana’s village workers were given oral rehydration solution (ORS) and became adept at recognizing both dehydration and the danger signs of pneumonia in children.

107 Sasakawa Health Prize: stories from South-East Asia

Trained TBAs: TBAs were trained to encourage the village women to accept new methods of childrearing, healthy infant-feeding practices, preventive child health care, etc. This brought about a dramatic improvement in the health of rural mothers and their babies.

Family planning

Arpana instituted several programmes to improve the health of mothers and advise them on the need for family planning. The overall thrust of Arpana’s programmes was to bring about a radical change in the status of women, without which family planning efforts would not have been effective. TBAs and female community health workers advised mothers with only one or two children to use temporary methods of family planning such as the copper-T and the pill. For those with two or more children, they advised tubectomy. The success of Arpana’s family planning programme was possible only because of the infrastructure of health-care facilities that had been painstakingly built up, Mothers in Arpana’s and its trained health workers. This brought about a profound change in the villages became attitudes of the rural folk in the target villages. It took many years of hard work aware, through to inculcate a positive attitude, from the initial deep distrust of family planning. street meetings and The contraceptive measures and sterilizations performed in Arpana’s family discussions with planning programme reflected the success in changing attitudes towards the Arpana workers, of overall health-care programme at the grass-roots level. the need to immunize their children Arpana’s endeavours in family planning, in coordination with those of the State Government and the Chief Medical Officer, Karnal, contributed to the national effort in this critical area.

Arpana’s health workers and helpers were responsible for recording information, i.e. the number of couples between 15 and 45 years, the number of children per couple, immunization, antenatal and postnatal care, babies’ weight, etc. They also motivated couples for family planning through TBAs who had performed deliveries and given health care to babies. They supplied condoms and the pill to couples, as well as advice on family spacing. Education in health care and prevention was conducted from house to house and at village meetings. VHWs scripted a play on family planning and used traditional folk

Arpana’s endeavours in family planning, in coordination with those of the State Government and the Chief Medical Officer, Karnal, contributed to the national effort in this critical area

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songs to convey messages to rural audiences. Cases were referred to the mobile village clinic for fitting of copper-T, and to Arpana hospital for tubectomy or vasectomy operations.

From 1987 to 1991, 2436 operations were performed of cases referred from the primary and secondary levels. Transport for tubectomy patients was provided Haryana back to the patient’s village. VHWs followed up on a house-to-house basis.

Arpana cooperated closely with the government, which supplied contraceptive devices as well as a small incentive for sterilization cases. Where there was a village government worker, by prior arrangement, Arpana provided health care and immunization, leaving family planning to the worker. Arpana received

Arpana cooperated recognition as the best nongovernment organization (NGO) doing family planning closely with the work from the Haryana State Government for three years running. Encouragingly, government, which the Block Development Officer began referring cases to Arpana hospital. supplied contraceptive Health education devices as well as a

small incentive for Health workers were trained to motivate families to space their children. Late sterilization cases marriage of girls was encouraged, as was a delay in the birth of the first child for newly married women. In Arpana’s family planning effort, much importance was given to the education of women as well as to a reduction in neonatal and natal mortality.

Family planning camps

Arpana started a series of family planning camps at Arpana hospital, with teams of doctors from Delhi hospitals such as the All India Institute of Medical Sciences, Moolchand Hospital, Lady Hardinge Medical College, and Guru Tegh Bahadur Medical College. Laparascopic tubectomies were carried out at these camps.

109 Sasakawa Health Prize: stories from South-East Asia

5.3 Eye care

The objective of Arpana’s large rural eye relief wing was to totally eliminate preventable blindness from an ever-widening target area by identifying those in need of operations at clinics and screening camps. Arpana brought them to the hospital for operations, provided aftercare, spectacles, food, etc. and then took them back to their villages.

In 1991, 2784 operations were performed at the hospital. Glaucoma and trachoma were also tackled, both through a preventive programme, and by hospital treatment where necessary. All facilities including food were provided All facilities including free to eye patients referred from the rural camps, which especially benefited food were provided malnourished elderly patients living below the poverty line. free to eye patients referred from the rural 6. Conclusion and lessons learned camps, which especially benefited malnourished Arpana’s programmes began in 1980 in 36 illiterate, economically disadvantaged elderly patients living villages of Haryana. The primary activity of Arpana’s health programmes was below the poverty line awareness creation. With traditional, feudal mindsets, ignorance about germs and modern medicine, and old habits ingrained in all the communities, awareness needed to be generated for changes to be effected. This was carried out through VHWs who held street meetings in different neighbourhoods.

One of the most important lessons that emerged from Arpana’s village-level health programmes was that rapport between VHWs and beneficiaries is vital to the success of such a programme. Arpana selected one or two promising villagers from each of the villages and trained them as village health and development workers. Once these workers were convinced of basic health principles and the actions necessary to implement them, they could in turn convince their fellow villagers. Capacity building and communication skills were built up along with basic health information and preventive interventions. VHWs provided information, guidance and counselling on a personal level to individuals and families. As the usefulness of their advice was proven over the years, their status grew in their families, communities and villages.

Capacity building and communication skills were built up along with basic health information and preventive interventions. VHWs provided information, guidance and counselling on a personal level to individuals and families

110 Paradigm shift through

development programmes

in selected villages of

Haryana: Arpana Research

and Charities Trust–India:

1993 (India)

TBAs were also sought out by Arpana and given special training in midwifery, including hygiene and cleanliness, recognizing high-risk pregnancies and record-keeping. Continual training was provided over the years aimed at overcoming their old habits and practices, especially their mindsets, on the unimportance of their jobs and the triviality of their inputs. TBAs gave

Haryana feedback to Arpana in these sessions, which allowed changes to be made for greater effectiveness.

Arpana encouraged close cooperation between the VHWs and TBAs for the overall benefit of the villagers. Both their roles were given importance and they were encouraged to support each other. Both became links to the community, through the mobile clinics which came to their villages and to Arpana hospital, Most family women such where they were recognized by the hospital staff and were able to get easy as the mother-in-law admittance/services for their patients. This helped them earn more respect from and sister-in-law did not the village communities. know what a pregnant woman required. Even Arpana’s programme was multifaceted and intensive. Pregnant women received when informed, the information, guidance and support from VHWs and TBAs, along with check-ups, family did not consider nutrition and supplements, as well as help with explaining the importance of it necessary to send a antenatal care to their mothers-in-law. Most family women such as the mother-in- pregnant woman for law and sister-in-law did not know what a pregnant woman required. Even when check-ups, immunization informed, the family did not consider it necessary to send a pregnant woman and supplements for check-ups, immunization and supplements. Thus, infant mortality rates and women’s morbidity and mortality rates were high. VHWs and TBAs stressed the importance of check-ups, good diets, supplements and immunizations. They also brought the women to the monthly mobile clinics. They carefully recorded those at high risk, preparing them to go to the hospital for delivery. They spent hours counselling family members, especially the mother-in-law, about the necessity of antenatal care in order to have a healthy child. Marriage after 18 years of age, spacing and limiting the number of children through family planning were stressed, especially since 70% of the village women were anaemic and overworked.

111 Sasakawa Health Prize: stories from South-East Asia

Preschool children received day care in a loving ambience, and were taught through poems, stories and games. They also received nursery school education and learnt social cooperation.

Mothers participated in the mid-day meal both through donations of grain and through cooking nutritious and tasty meals.

Child health guides were schoolchildren who had attended the day-care centres. They were then trained in imparting basic health principles through skits, demonstrations of ORS (for diarrhoea), songs and rallies to build up preventive health activities in their own villages. They also participated in One of the most sanitation and cleanliness drives in their villages. Adolescent girls were involved important aspects of in literacy programmes. Arpana’s programmes was its record keeping, One of the most important aspects of Arpana’s programmes was its record- monitoring and keeping, monitoring and reporting. These were essential activities for gleaning reporting information required for checking the efficacy of inputs. Programme changes were made from the information gathered meticulously on a monthly basis. This was a dynamic programme which responded to the local needs and effected changes from within.

The changes that Arpana sought from the community were not expensive. Kitchen gardens were encouraged through discussions, information, demonstrations and packets of seeds. VHWs helped women choose small plots of land, usually just outside their kitchens, for intensive cultivation of green leafy vegetables. Courtyards and small pockets of unused land were also found. Drainage water from hand pumps was used to irrigate gardens. Over 4000 kitchen gardens were planted and tended for years, providing essential nutrients to the anaemic women and girls of the villages.

Recognizing diarrhoea as a major killer of children five years old and below (WHO estimates that 25% of India’s children in that age bracket die as a result of diarrhoea) resulted in an important initiative for diarrhoea management – home-made ORS.

Preschool children received day care in a loving ambience, and were taught through poems, stories and games. They also received nursery school education and learnt social cooperation

112 Paradigm shift through

development programmes

in selected villages of

Haryana: Arpana Research

and Charities Trust–India:

1993 (India)

Improvement in sanitation and hygiene were also among the changes Arpana effected in the target villages. These included “clean courtyards” with food kept in ventilated cupboards screened against flies and insects, clean drinking water in covered earthen pots and accessed by clean cups, and private latrines kept hygienically clean.

Haryana Thus, Arpana’s programmes effectively targeted the needs of the time, resulting in awareness creation and providing health care through a three-tier system of VHWs and TBAs, mobile clinics and a referral base hospital. As villagers became more aware, Arpana was able to move from being a provider of health services to an enabler. Women were empowered through Arpana-facilitated self-help groups (SHGs) in savings, micro-loans, entrepreneurship, civic governance and leadership. The greatest Arpana also motivated SHGs to take up health responsibilities of the community. weakness of the Now SHGs are forming their own federations for a platform from which they Arpana programme can be a more effective source of support for their member groups in monetary was its inability resources, information sharing about government programmes, and liaising with to have successful officials and agencies. programmes for men Perhaps the greatest weakness of the Arpana programme was its inability to have successful programmes for men. These programmes were started, but it was soon realized that different types of inputs would be required. The male health workers required higher salaries/incentives. Different trainings were needed and different programmes required. Due to lack of funding, these programmes were not carried out.

7. Afterword

At the time of the Sasakawa candidature, Arpana’s programmes basically provided health services and education not available to the beneficiaries by other means. This was the need of the time and Arpana did its utmost to provide these services.

However, as the government started providing more health coverage in villages, it was clear that the need for the disadvantaged was self-sufficiency in village health and greater economic security.

113 Sasakawa Health Prize: stories from South-East Asia

Thus, using the Sasakawa prize money and other resources, Arpana began a highly successful programme of women’s SHGs. For greater economic security, training was given in entrepreneurship, record-keeping, accounts, communication, leadership, local governance, legal literacy, etc.

Today, there are 373 SHGs with 5004 members; 963 members have taken business loans and set up their own businesses. Now, not only do women have more economic resources, but their status has risen in the family and community as they are able to access loans and speak out on village issues at local council meetings. Arpana development workers Arpana development workers also trained women on basic health principles, are motivated to take up which they share with their neighbours. They are motivated to take up health health responsibilities in responsibilities in their neighbourhoods and are now looking after each their neighbourhoods and pregnant woman, seeing that she receives at least three medical check-ups are now looking after each as well as the necessary immunizations and supplements. They check that pregnant woman, seeing that neighbourhood children do not get malnourished and make sure that they she receives at least three receive all their immunizations. In addition, they inform their neighbours about medical check-ups as well as the health services available to them through new government programmes. In the necessary immunizations short, they are developing self-sufficiency in health in their villages. and supplements

Arpana has facilitated two federations of 167 SHGs for women. These federations are platforms from which women’s voices are heard and, increasingly, listened to with respect. They provide larger resources for loans, more information on government schemes for the poor, forums for discussion and plans of action. The women leaders have visited district and block officers on their own and their grievances have been heard and redressed. They work together to collectively present matters for action in village councils. They are enquiring into funds and schemes received by the councils and making their village councils transparent. Arpana salutes these women, and is deeply grateful for the encouragement and support rendered by the World Health Organization through the Sasakawa Health Prize.

The women leaders have visited district and block officers on their own and their grievances have been heard and redressed. They work together to collectively present matters for action in village councils

114 Dr Naila Firdous, representative of the Society for Health Education receives the 1996 Sasakawa Health Prize from the President of the 49th World Health Assembly. WHO Photo

115 CHAPTER 8 1996

Society for Health Education (SHE): Maldives[*]

Recipient: Society for Health Education (Maldives)

[*] Draft prepared by Mrs Asna Luthfee Programme Associate, Society for Health Education, Male, Maldives 116 he Society for Health Education (SHE) was established in T1988 with the objective of raising awareness on health and social issues among the people of the Maldives

Maldives 1. Introduction

The Society for Health Education (SHE) was established in 1988 with the objective of raising awareness on health and social issues among the people of the Maldives. The organization aims to foster family well-being in general and empower families and women in particular to make informed choices when seeking services from medical professionals. Awareness-raising by the organization comprises a wide range of activities, including publication and dissemination of print materials, conducting radio programmes and The organization aims to organization of public forums. At the time of establishment of the organization, foster family well-being health facilities were lacking in the majority of island communities. SHE’s in general and empower awareness-raising activities became popular among disadvantaged and families and women remote island communities. These interactions contributed to the launching in particular to make of parallel programmes on family planning, psychosocial counselling and informed choices when thalassemia prevention. At the central level, in Male’, the organization operates seeking services from a family planning clinic, a counselling unit and a laboratory specialized in medical professionals thalassemia screening.

Since its inception in 1988, SHE continues to explore options and the means to enhance the quality of life of Maldivian families. The organization reaffirms its commitment to sustaining these initiatives, and to further increasing public awareness on issues that influence family well-being. Effectiveness of health promotion initiatives are ensured by adopting suitable service delivery mechanisms, fostering improvements in reproductive health parameters, continuing thalassemia-prevention activities, promoting responsible parenthood concepts, facilitating empowerment of women and youth, supporting victims of abuse, extending counselling to adolescents and families, and encouraging community ownership of development.

117

118

of Maldivian families Maldivian of

options and the means to enhance the quality of life life of quality the enhance to means the and options Since its inception in 1988, SHE continues to explore explore to continues SHE 1988, in inception its Since

challenge that needs to be addressed effectively. addressed be to needs that challenge

nongovernmental organizations (NGOs) as intermediary interventions remains a a remains interventions intermediary as (NGOs) organizations nongovernmental

expansion of this service. In particular, public perception of services provided by by provided services of perception public particular, In service. this of expansion

and developing public administration system are not conducive to the the to conducive not are system administration public developing and

interactions with the community. However, the country’s unique geography geography unique country’s the However, community. the with interactions

for counselling, which has been confirmed by a number of assessments and and assessments of number a by confirmed been has which counselling, for

are provided for around 500 clients annually. There is a significant unmet need need unmet significant a is There annually. clients 500 around for provided are

helpline and play therapy for young children. Currently, counselling services services counselling Currently, children. young for therapy play and helpline

Counselling support services comprise face-to-face counselling, a telephone telephone a counselling, face-to-face comprise services support Counselling

most dependable and credible counselling services in the country. the in services counselling credible and dependable most

were not uncommon. This service is now popularly recognized as one of the the of one as recognized popularly now is service This uncommon. not were

introduced counselling support services in 1988, nuisance calls to its helpline helpline its to calls nuisance 1988, in services support counselling introduced

formally integrated into social services and education establishments. When SHE SHE When establishments. education and services social into integrated formally

society. Among them, counselling has gained popular acceptance and has been been has and acceptance popular gained has counselling them, Among society.

During the past 18 years, SHE has introduced a number of services to Maldivian Maldivian to services of number a introduced has SHE years, 18 past the During

Counselling and psychosocial support services support psychosocial and Counselling 2.1

communities

and remote island island remote and

Programme description Programme 2.

among disadvantaged disadvantaged among

became popular popular became other habits and practices that affect family well-being. family affect that practices and habits other

raising activities activities raising Minimize the detrimental effects of marital instability, divorce, abuse, and and abuse, divorce, instability, marital of effects detrimental the Minimize 3.

SHE’s awareness awareness SHE’s

related services. related

women, popularizing responsible parenthood concepts and strengthening strengthening and concepts parenthood responsible popularizing women,

Promote marital stability by improving the reproductive health status of of status health reproductive the improving by stability marital Promote 2.

and youth. and

rate, smoking habits, spread of drug use, large proportion of adolescents adolescents of proportion large use, drug of spread habits, smoking rate,

crucial social and health concerns including large family size, high divorce divorce high size, family large including concerns health and social crucial

Increase public awareness on the implications and consequences of of consequences and implications the on awareness public Increase 1.

Specific goals Specific 1.1 Sasakawa Health Prize Health Sasakawa Society for Health

Education (SHE):

Maldives: 1996 (Maldives)

2.2 Family planning

The Maldives experienced a population boom during the 1970s and 1980s, created by a fast-declining mortality rate and continuing high fertility levels. Maldives Even by the early 1980s, the growth rate of the Maldivian population remained above 3% and the total fertility rate (TFR) exceeded the six children level.

Family planning was rightly accorded high priority by the Society during the early years. Raising awareness on family planning was a key component of the health promotion activities of the Society. The issue was addressed through print materials and public forums. Eventually, with the support of the United Nations Population Fund (UNFPA) and the International Planned Parenthood Federation

Family planning was (IPPF), SHE established the first clinic for family planning in the Maldives called rightly accorded high the Family Planning Clinic (FPC). It remains the only clinic in the Maldives priority by the Society providing family planning services outside the government structure. during the early years. FPC currently serves more than 1300 regular customers. Services include Raising awareness on provision of pills, condoms, injectable contraceptives and intrauterine devices family planning was (IUDs). Though the clinic targets an annual service output of 600 couple-year a key component of protection rate (CYPR) , it manages to achieve a CYPR of around 400. the health promotion

activities of the Society FPC is being transformed into a centre providing ancillary services related to family planning and aims to eventually introduce most components of the reproductive health framework. Establishment of an awareness-raising service on youth, and for youth, under the banner of “Youth Kiosk” was a significant development. In the Maldives, the youth comprise more than 25% of the population and youth-related issues pose serious challenges to development planning. The Youth Kiosk provides special awareness-raising sessions for youth visiting the premises, particularly for those visiting for thalassaemia screening. These sessions provide pre-marriage counselling and information on sexual health and responsible parenthood. Around 1000 youth seek the support of the kiosk annually.

119 Sasakawa Health Prize: stories from South-East Asia

2.3 Health promotion

The themes addressed under this programme cover a wide range of issues such as family planning, nutrition, drug use, personal hygiene, thalassaemia and other genetically inherited diseases, pregnancy and responsible parenthood, environmental health and prevention of smoking.

Health promotion activities aim to provide access to beneficiaries with minimum inconvenience through various modalities. However, the effectiveness of some of the modalities gradually loses relevance with developmental progress. For example, print materials have become less effective with the expansion of radio Health promotion and television. Public forums also have become less convenient with changing activities aim to lifestyles and competing commitments. The Society endeavours to sustain its provide access health promotion activities even in a restrictive setting. to beneficiaries with minimum Under this programme, the Society publishes a monthly leaflet (Kulunu) and inconvenience through broadcasts a weekly radio programme. A wide range of topics have already various modalities been addressed through these outlets, ranging from personal hygiene to alpha- thalassaemia. Two modalities were used to extend selected services to the periphery. Initially, a mobile health team (designated as multipurpose health trip – MPHT) was fielded to targeted localities. The purpose of the field visit was to organize awareness-raising activities at the community level and extend selected medical services. The team comprised medical doctors, nurses, counsellors and health educators. The combined provision of medical services and awareness- raising activities helped to attract more people to the various programmes organized on these trips.

MPHT was highly relevant to those communities where there is no health service outlet. However, with the increasing number of health posts in the Atoll region, the relevance of the mobile team has diminished gradually. The effectiveness of these visits was sustained by increasing the number of specialists joining the team.

Another modality introduced under the health promotion programme is the organization of a community festival (Health Festival) to address continuing and emerging issues such as reproductive health, food and nutrition, smoking, drug use and youth.

Public forums have become less convenient with changing lifestyles and competing commitments. The Society endeavours to sustain its health promotion activities even in a restrictive setting

120 Society for Health

Education (SHE):

Maldives: 1996 (Maldives)

The Society organizes a special awareness-raising programme for students of secondary schools in Male’. Under this programme, students of grades 9 and 10 are given an opportunity to clarify issues that concern them. These sessions are guided by resource people and create an open environment for students to Maldives raise sensitive issues about their personal and family life, schooling, reproductive health, and nutrition and career prospects.

2.4 Facilitating people-centred development

Population and family planning issues have remained a significant component of the health promotion activities of the Society. With a contraceptive prevalence rate of 32%, SHE’s services are particularly required to desensitize family

Society organizes a planning matters among both men and women in urban and rural areas. special awareness-raising SHE also focuses on addressing matters related to mental stress and related programme for students strains associated with a rapidly modernizing society. The Society remains of secondary schools prominent in this area because of its pioneering role in introducing and in Male. Under this popularizing counselling as a viable treatment option. It provides telephone as programme, students of well as face-to-face counselling. grades 9 and 10 are given

an opportunity to clarify SHE has created innovative programmes to achieve health promotion, including issues that concern them the organization of a series of health exhibitions, which has proved to be effective in changing attitudes and promoting health-conscious lifestyles. SHE has organized seven exhibitions in three atolls. These exhibitions addressed a wide range of topics and issues. In addition to setting up informative displays, the exhibition facilitated clarification of issues directly from relevant professionals drawn from the pool of experts available in the country.

SHE is actively involved in the promotion of other issues related to health and family such as reproductive health, healthy lifestyles, nutrition and dietary habits, empowerment of women, proper utilization of medical services and participatory development. Public awareness on these issues is raised through printed materials, public meetings, and radio and TV programmes. Along with awareness raising, SHE has also taken initiatives in developing infrastructure in the atolls. Under this initiative, four community centres have been constructed in two atolls.

121 Sasakawa Health Prize: stories from South-East Asia

3. Challenges

While socioeconomic development is progressing well, certain areas of the social sector demand urgent attention. Public awareness of specific health and social issues such as nutrition and healthy dietary habits, healthy lifestyles, contraceptive acceptance, attitudinal changes to achieve better health, and mental health and related issues are areas that need to be addressed. For example, improvements in the nutritional situation fall far short of those achieved in other health-related areas. Studies undertaken in 1990 by the government and the United Nations Children’s Fund (UNICEF) reaffirmed that SHE’s services are child nutrition is a problem that has to be addressed effectively. It was found particularly required that malnutrition persists at an unacceptably high rate; about one third of to desensitize family children had stunting, 17% had wasting and 44% were malnourished. planning matters 4. Winning the Sasakawa Health Prize among both men and women in urban and Since its inception until the time of the award, SHE was a pioneer in advancing rural areas the reach of primary health care to marginalized and geographically isolated populations of the country. At that time, the primary health care system in these communities was minimal, even though there were many health posts. However, ground-breaking modalities such as the MPHT led to a notable improvement in the quality of health care available in these geographically disadvantaged communities. Along with this, the creation of innovative programmes to address emerging health issues also contributed to the effective and efficient management of health systems and policy developments. For example, the health exhibitions held in the islands was something new at that time, as SHE’s exhibitions differed from others, with live demonstrations such as showing how to prepare nutritious food.

Even though such exemplary work by SHE acted as the platform for recognition by the country’s communities and the government (such as winning the most prestigious award in the country given by the President – Public Service Award for innovative work in health care), SHE’s interaction with partners in the international arena was minimal. In order to broaden its horizon and form international alliances, the organization considered global recognition necessary

Since its inception until the time of the award, SHE was a pioneer in advancing the reach of primary health care to marginalized and geographically isolated populations of the country

122 Society for Health

Education (SHE):

Maldives: 1996 (Maldives)

to further strengthen its work and overcome challenges. International recognition such as the Sasakawa Health Prize opened up numerous opportunities to sustain SHE’s goal of providing innovative health care to the country.

Maldives 5. Post-Sasakawa Health Prize

Since the Sasakawa Health Prize in 1996, the past 15 years have seen dramatic changes in the methods of service delivery by SHE. With the worldwide social, economic, political and cultural changes, SHE once again took initiatives in adopting contemporary methods that have proven to be highly effective for service delivery.

As mentioned earlier, SHE made use of information, education and SHE made use of communication (IEC) methods in enhancing the knowledge of the public, information, education especially of marginalized communities. Though IEC leaflets and via radio and communication broadcasts had been proven effective in the Maldives in the past, these (IEC) methods methods became obsolete. As the demand for knowledge on specific health in enhancing the and social issues continued, the behavioural changes seen through IEC regarding knowledge of the such issues diminished. SHE has since then adopted behavioural change public, especially communication (BCC) methods. The BCC campaigns carried out by SHE made of marginalized use of the current technology in the country including mass media campaigns communities for identified vulnerable groups. For example, the mass media campaign under the BCC component of HIV/AIDS Global Fund Programme ensured that certain messages were instilled to effectively change behavioural patterns with regard to safe sex practices.

With economic changes throughout the world, SHE experienced financial restrictions, which greatly limited the number of health camps/festivals in the atolls. SHE thus adopted another concept – educating peers. These peers were chosen from within geographically isolated communities and trained by service providers at SHE. This proved not only cost effective in the long run, but extremely beneficial as these peer educators had as much impact in delivering services and information to their own communities as the teams from SHE. One effective example is that of peer educators trained from among migrant workers, who provide HIV/AIDS information to their people.

123 Sasakawa Health Prize: stories from South-East Asia

The past 15 years also saw in-house services get stronger as more qualified and educated staff joined the in-house reproductive health clinic, laboratory and counselling unit. A number of staff were trained in the Maldives and abroad to broaden and develop services. With the help of these trained persons, a successful community centre was developed in V. Atoll, where the locals were trained to maintain the centre.

SHE also formed alliances with both global and local partners in order to generate funds to sustain services. With these partnerships in place, the organization took initiatives to introduce more focus areas into its mandate. SHE became a member of IPPF in 1999, introducing new components such as advocacy, unsafe abortion Health promotion and AIDS to its mandate. Strategies to successfully advocate for amendment in the activities aim to restrictive rules and policies on abortion for rape and incest victims have also been provide access established through this programme and will be implemented in the near future. to beneficiaries with minimum A similar alliance was formed with the Global Fund to fight AIDS, Tuberculosis inconvenience through and Malaria (Global Fund) to combat HIV/AIDS in the country. The goal of this various modalities was to continue to maintain Maldives as a low HIV prevalence country through appropriate and curative interventions. This alliance recognizes the importance of creating a supportive environment, to ensure not only support for HIV/AIDS initiatives but also to reduce the stigma and discrimination that people with HIV/ AIDS often face. The main areas of work for SHE is community outreach, and creating a preventive and supportive environment through BCC activities.

Local partnerships were also forged with the government, which led to the recent introduction of the voluntary counselling and testing centre for HIV/AIDS in the premises of SHE. Supported by the Centre for Community Health and Disease Control (CCHDC of the government) and by the Global Fund, SHE staff were trained to handle VCT clients. SHE continues to work with civil society and community-based organizations in the new areas included in its mandate. Some of these organizations include SWAD (Society for Women Against Drugs), JOURNEY, UNDP and UNFPA. SHE has many activities in its Annual Programme Budget for 2011, which will allow NGOs in the selected islands such as Gdh. Thinadhoo, Addu Atoll to be trained, so that they could act as sub-partners, delivering services on behalf of SHE in their own island communities.

SHE continues to work with civil society and community- based organizations in the new areas included in its mandate. Some of these organizations include SWAD (Society for Women Against Drugs), JOURNEY, UNDP and UNFPA

124 Mongar Health Services Development Project win the 1997 Sasakawa Health Prize at the World Health Assembly for innovative work in health services development. Photo credit: Ministry of Health, Bhutan

125 CHAPTER 9 1997

Mongar health services development project: Bhutan[*]

Recipient: The Mongar Health Services Development Project (Bhutan)

[*] Draft prepared by Dr Sonam Ugen Community Health Department, Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Ministry of Health, Royal Government of Bhutan 126 hutan was awarded the prestigious Sasakawa Health Prize Bin 1997 for the success of the pilot project on primary health care implemented in Mongar Dzongkhag

Bhutan 1. Introduction

The 1978 Alma-Ata international conference on primary health care set in motion collaboration and partnerships with rural communities in the Kingdom of Bhutan. The background for this move was the goal of the World Health Organization (WHO) to provide “Health for All” by the year 2000. For a country with rudimentary health infrastructure compounded with problems of accessibility, logistics, and lack of skilled human resources and funding, the global call then seemed a far cry. Within a few decades of planned Within a few decades of development, the success of primary health care in Bhutan was proven planned development, beyond doubt. Bhutan’s national health system now exemplifies an ideal the success of primary model in primary health care. It is a well-thought out, well-planned system health care in Bhutan was that actually works. proven beyond doubt

Bhutan was awarded the prestigious Sasakawa Health Prize in 1997 for the success of the pilot project on primary health care implemented in Mongar Dzongkhag. Bhutan’s success story shows how the experience of one district in the mountainous Kingdom of Bhutan could lead to nationwide success in primary health care through partnerships.

2. Bhutan health services – a historical perspective

The history of planned socioeconomic development dates back to 1961, the year Bhutan embarked on its First Five-Year Plan. Before this period, health services were delivered through rudimentary facilities by a couple of doctors and a few compounders.

The difficult terrain, rough climatic conditions, scattered population, shortage of skilled human resources and scarce internal resources posed serious challenges to health-care delivery in the country. These problems were further compounded by the people’s perception of illness, which was deeply rooted in strong cultural beliefs and superstition. This situation prevailed in most parts

127

128

rudimentary health infrastructure health rudimentary

Services were largely curative and provided through a a through provided and curative largely were Services

was laid during the First Five-Year Plan period (1961–1966). (1961–1966). period Plan Five-Year First the during laid was The foundation of a modern health-care delivery system system delivery health-care modern a of foundation The

for health. Various categories of multipurpose primary health care workers workers care health primary multipurpose of categories Various health. for

in 1974 set the country on the road to self-reliance in human resources resources human in self-reliance to road the on country the set 1974 in

Institute for Health Sciences (RIHS, earlier known as the Health School) School) Health the as known earlier (RIHS, Sciences Health for Institute

basic health units (BHUs) and 22 hospitals. The establishment of the Royal Royal the of establishment The hospitals. 22 and (BHUs) units health basic

primary health care services were offered across the country through 65 65 through country the across offered were services care health primary

By the end of the Fourth Plan period (1976/77–1980/81), comprehensive comprehensive (1976/77–1980/81), period Plan Fourth the of end the By

and abroad. abroad. and

on doctors and other categories of health personnel from neighbouring India India neighbouring from personnel health of categories other and doctors on

shortage of skilled human resources for health, Bhutan was highly dependent dependent highly was Bhutan health, for resources human skilled of shortage

curative and provided through a rudimentary health infrastructure. Due to to Due infrastructure. health rudimentary a through provided and curative

First Five-Year Plan period (1961–1966). At that time, services were largely largely were services time, that At (1961–1966). period Plan Five-Year First

the world the

The foundation of a modern health-care delivery system was laid during the the during laid was system delivery health-care modern a of foundation The

among the poorest in in poorest the among

Bhutan during were were during Bhutan

Modern health services services health Modern 3.

Health indicators of of indicators Health

mortality among these groups were especially high. especially were groups these among mortality

pregnant women, lactating mothers and preschool children. Morbidity and and Morbidity children. preschool and mothers lactating women, pregnant

especially a deficiency of micronutrients, was perceived to be high among among high be to perceived was micronutrients, of deficiency a especially

due to poor nutrition and recurrent infections. The risk of malnutrition, malnutrition, of risk The infections. recurrent and nutrition poor to due

suggests that malnutrition with considerable stunting was common, mostly mostly common, was stunting considerable with malnutrition that suggests

known about the dietary habits of the people. However, available information information available However, people. the of habits dietary the about known

Specific data on the nutritional situation are not available and very little is is little very and available not are situation nutritional the on data Specific

problems of goitre and trachoma were also highly prevalent in the country. country. the in prevalent highly also were trachoma and goitre of problems

the 1960s and 1970s were tuberculosis, leprosy, malaria and smallpox. The The smallpox. and malaria leprosy, tuberculosis, were 1970s and 1960s the

infections. The major communicable diseases affecting the population in in population the affecting diseases communicable major The infections.

and largely attributable to diarrhoeal diseases, respiratory tract and parasitic parasitic and tract respiratory diseases, diarrhoeal to attributable largely and

the world. Infant and child morbidity and mortality rates were very high high very were rates mortality and morbidity child and Infant world. the

Health indicators of Bhutan during this period were among the poorest in in poorest the among were period this during Bhutan of indicators Health

as a last resort. resort. last a as

and ritual remedies and, in many instances, sought modern health care only only care health modern sought instances, many in and, remedies ritual and

of the country. For treatment, the common person looked mainly to spiritual spiritual to mainly looked person common the treatment, For country. the of Sasakawa Health Prize Health Sasakawa Mongar health services development project:

Bhutan: 1997 (Bhutan)

and nurses were trained at the RIHS. The National Health Policy aimed to provide free, integrated, equitable, cost-effective and well-balanced health services in the country. Bhutan

This unprecedented progress within a span of two decades is attributed to visionary and strong leadership, a consistent national strategy and the generous support of bilateral and multilateral partners the Government of India (GOI), WHO, UNICEF, UNFPA, UNDP and DANIDA.

3.1 Commitment to primary health care

The actual thrust to modern health development came after the Alma-Ata Declaration on primary health care in 1978. In 1979, as a signatory to the The Royal Government Declaration, Bhutan adopted the primary health care strategy to achieve the established clearly social goal of Health for All by the year 2000. The Royal Government established defined national clearly defined national objectives related to health, which reflected the nation’s objectives related to commitment to primary health care. During each successive Plan period, the health, which reflected health system was refined and streamlined to meet the essential elements of the nation’s commitment primary health care. to primary health care

Bhutan’s Fifth Five-Year Plan was geared to strengthen health infrastructure and expand coverage of essential health services. The Health Policy was aimed at attaining the highest level of health for the people of Bhutan through the primary health care approach. Accordingly, emphasis was shifted from mainly curative care to a mixture of curative, preventive, promotive and rehabilitative services. A system of integrated service delivery with a focus on expansion of the rural health services formed a component of the overall social development. The shift was aimed at eliminating disparities in health service delivery between different population groups and improving the situation in underprivileged and underserved areas.

The eight essential elements of primary health care included in the health-care package were:

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health care approach care health

of health for the people of Bhutan through the primary primary the through Bhutan of people the for health of The Health Policy was aimed at attaining the highest level level highest the attaining at aimed was Policy Health The

material etc. material

resources such as administrative set-up, human resources, construction construction resources, human set-up, administrative as such resources

the use of appropriate technology and locally available available locally and technology appropriate of use the Cost-effectiveness: 4.

capable of continuing steadily without critical dependence on external inputs. external on dependence critical without steadily continuing of capable

to ensure that the health care delivery system would be be would system delivery care health the that ensure to Sustainability: 3.

administration and other sectors during all phases. all during sectors other and administration

to garner support for the project from the district district the from project the for support garner to collaboration: Intersectoral 2.

operational phases. operational

their own health development by involving them at the formulation and and formulation the at them involving by development health own their

to ensure the participation of local people in in people local of participation the ensure to involvement: Community 1.

to peripheral health unit health peripheral to

referral from and support support and from referral

The model was based on several desirable features: features: desirable several on based was model The

participation, and improve improve and participation,

collaboration, community community collaboration,

care system. care

to strengthen intersectoral intersectoral strengthen to

supporting systems, which were major areas of weakness in the primary health health primary the in weakness of areas major were which systems, supporting

also recognized the need need the recognized also

The explicit objective was to identify appropriate strategies, technologies and and technologies strategies, appropriate identify to was objective explicit The

The Royal Government Government Royal The

participation, a model health project was developed with WHO support. support. WHO with developed was project health model a participation,

In pursuit of maximizing “Health for All by the year 2000” and community community and 2000” year the by All for “Health maximizing of pursuit In

District model health project health model District 4.

health units. units. health

community participation, and improve referral from and support to peripheral peripheral to support and from referral improve and participation, community

Government also recognized the need to strengthen intersectoral collaboration, collaboration, intersectoral strengthen to need the recognized also Government

with the aim of strengthening general service delivery at all levels. The Royal Royal The levels. all at delivery service general strengthening of aim the with

These and other key areas were addressed through a series of programmes programmes of series a through addressed were areas key other and These

• Supply of essential drugs essential of Supply •

and family planning family and

diseases, and diseases,

• Maternal and child welfare welfare child and Maternal •

• Treatment of common common of Treatment •

• Water and sanitation and Water •

disease

• • Nutrition and food supply food and Nutrition • Control of communicable communicable of Control •

• • Health education Health • Immunization •

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The district of Mongar was selected as the pilot area based on the premise that the district represented the country well in several medical and geophysical aspects. The health problems faced were typical of those in the eastern and central regions. Bhutan The developmental constraints with respect to transport and communication applied to Mongar as well as other districts.

4.1 Overview of Mongar district

Mongar district is located in the eastern region of Bhutan and encompasses 1830 sq. km of rough and mountainous terrain with swift-flowing rivers.

In 1985, the population of Mongar District was estimated at 81 834. The whole district was divided into 11 gewogs (blocks) and each gewog in turn consisted Health facilities in of 20 chiwogs (village units). Houses were scattered on the slopes of mountains Mongar were grossly and most of the gewogs were located at a walking distance of 2–5 days from the understaffed. An district centre. The majority of the population are subsistence farmers who, apart ambulance was seldom from growing vegetables and fruits, also keep some livestock. available to transport seriously ill patients The district reported a literacy rate of 10%–20% Apart from seven primary schools and one high school, there were several religious learning centres, 10 agriculture extension centres and six animal husbandry centres distributed across the district.

Health facilities in Mongar at the start of the project comprised a District-cum- Leprosy Hospital, five BHUs and three dispensaries that catered to nearby villages. These facilities provided largely curative services with little or no involvement of the community.

Like other parts of the country, the health facilities in Mongar were grossly understaffed. An ambulance was seldom available to transport seriously ill patients.

4.2 Situational analysis

Health facilities in the district lacked reliable and uniform health information. Therefore, a survey was planned to develop baseline data for the Mongar district health project. The survey was conducted by teams of health workers in 10 randomly selected villages.

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implementing schemes in the rural areas rural the in schemes implementing The health sector was seldom involved in planning and and planning in involved seldom was sector health The

the villages surveyed. Women and children were largely affected. largely were children and Women surveyed. villages the

few leafy vegetables. The incidence of anaemia and malnutrition was high in in high was malnutrition and anaemia of incidence The vegetables. leafy few

garden, the vegetables grown were limited to chillies, radish, potatoes and a a and potatoes radish, chillies, to limited were grown vegetables the garden,

Food consisted mainly of staple crops. Although most houses had a kitchen kitchen a had houses most Although crops. staple of mainly consisted Food

Nutrition

the rural areas. rural the

constructed pit latrines pit constructed

health sector was seldom involved in planning and implementing schemes in in schemes implementing and planning in involved seldom was sector health

villages; others had poorly poorly had others villages;

implemented in isolation and not introduced with health education. The The education. health with introduced not and isolation in implemented

was being used in some some in used being was

Though they were elements of health care, water supply and sanitation were were sanitation and supply water care, health of elements were they Though

open latrine system system latrine open

fields. Some form of of form Some fields.

contribution of labour. labour. of contribution

defecating in the open open the in defecating

people often refrained from requesting for the scheme to avoid compulsory compulsory avoid to scheme the for requesting from refrained often people

population were were population

in a village remained without water supply. The survey also revealed that that revealed also survey The supply. water without remained village a in

90% of the surveyed surveyed the of 90%

of the villages. Therefore, it was not surprising to note that several houses houses several that note to surprising not was it Therefore, villages. the of

were undertaken on individual request and not based on a needs assessment assessment needs a on based not and request individual on undertaken were

the 52 houses in Ganglapong village received a water supply. The schemes schemes The supply. water a received village Ganglapong in houses 52 the

surveyed had access to a piped water supply. For instance, only two out of of out two only instance, For supply. water piped a to access had surveyed

of the District Public Works Division. Only a few of the houses in the villages villages the in houses the of few a Only Division. Works Public District the of

Water supply schemes during the project period were under the jurisdiction jurisdiction the under were period project the during schemes supply Water

Water supply Water

adjacent to them. them. to adjacent

the villages in Mongar reared pigs and cattle in the ground floor of houses or or houses of floor ground the in cattle and pigs reared Mongar in villages the

had poorly constructed pit latrines. The survey also revealed that most of of most that revealed also survey The latrines. pit constructed poorly had

Some form of open latrine system was being used in some villages; others others villages; some in used being was system latrine open of form Some

that 90% of the surveyed population were defecating in the open fields. fields. open the in defecating were population surveyed the of 90% that

No sanitary activity was initiated in the villages surveyed. It was observed observed was It surveyed. villages the in initiated was activity sanitary No

Sanitary conditions Sanitary

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Health-seeking behaviour

Although predominantly a Buddhist society, the practice of rites and rituals was Bhutan not uncommon and varied from village to village. In a few villages, black magic, poisoning and traditional healers hindered acceptance of health programmes. Cultural beliefs compounded by superstition prevented local communities from seeking help from the health facilities. It was observed that people were generally cooperative and fairly open to new ideas when approached with the right attitude.

Common disease and health indicators

District health data revealed that 80% of the illnesses were communicable It was observed that in nature and directly or indirectly transmitted through human feces, largely people were generally attributed to poor sanitation and hygiene. The most common health problems cooperative and fairly reported were diarrhoea, dysentery, respiratory tract infections, worm open to new ideas when infestations and skin diseases. Malnutrition was especially common among approached with the women and children. The important health indicators reported at the outset of right attitude the project were as follows:

•• Crude death rate: 16/1000 population •• Crude birth rate: 28/1000 population •• Infant mortality rate: 118/1000 live births

Health programmes

Immunization

Immunization coverage as well as the quality of services in Mongar district was considered far from satisfactory. Due to poor accessibility, services could not be extended throughout the district. Maternal and child health (MCH) clinics were limited to BHUs, as outreach clinics had not been established then. Services were irregular and poorly organized.

Lack of an efficient distribution system for vaccines and poor logistics led to frequent shortages and disruption of services. Only two BHUs were equipped

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health development activities was a male-dominated area male-dominated a was activities development health

passive observers. Leading or initiating any community community any initiating or Leading observers. passive

meetings, their role was more or less limited to that of of that to limited less or more was role their meetings,

development activities. Although they attended public public attended they Although activities. development Women in Mongar were never directly involved in in involved directly never were Mongar in Women

hours from one village to another is not unusual. not is another to village one from hours

communication within the district very difficult. A walking distance of seven seven of distance walking A difficult. very district the within communication

the capital city and neighbouring districts, it touched very few villages making making villages few very touched it districts, neighbouring and city capital the

the national highway traversed through the district and connected Mongar to to Mongar connected and district the through traversed highway national the

poor communication and poor management of drugs and logistics. Although Although logistics. and drugs of management poor and communication poor

One of the major constraints in the district health-care delivery system was was system delivery health-care district the in constraints major the of One

Communication and logistics support system system support logistics and Communication

development activities was a male-dominated area. area. male-dominated a was activities development

women and children and women to that of passive observers. Leading or initiating any community health health community any initiating or Leading observers. passive of that to

especially common among among common especially Although they attended public meetings, their role was more or less limited limited less or more was role their meetings, public attended they Although

diseases. Malnutrition was was Malnutrition diseases. Women in Mongar were never directly involved in development activities. activities. development in involved directly never were Mongar in Women

worm infestations and skin skin and infestations worm

deliveries, giving pre- and postnatal care and advising women. advising and care postnatal and pre- giving deliveries,

respiratory tract infections, infections, tract respiratory

workers (VHWs) was limited when it came to attending attending to came it when limited was (VHWs) workers

diarrhoea, dysentery, dysentery, diarrhoea,

• Lack of female health workers: the role of male village health health village male of role the workers: health female of Lack •

problems reported were were reported problems

Women preferred to deliver at home. at deliver to preferred Women

The most common health health common most The

delivery: low antenatal and postnatal attendance in MCH clinics. clinics. MCH in attendance postnatal and antenatal low delivery:

• Low rates of skilled attendance at birth, low rates of hospital hospital of rates low birth, at attendance skilled of rates Low •

available only in Mongar block. Mongar in only available

• Limited MCH services: out of 11 blocks, MCH services were were services MCH blocks, 11 of out services: MCH Limited •

population group. population

• A high prevalence of anaemia and malnutrition among this this among malnutrition and anaemia of prevalence high A •

were probably high. This could be attributed to: attributed be could This high. probably were

Although no data are available, maternal morbidity and mortality in the district district the in mortality and morbidity maternal available, are data no Although

Maternal health Maternal

measles 50%, DPT3 and OPV 52%. OPV and DPT3 50%, measles

The immunization coverage for Mongar in 1985 was as follows: BCG 16%, 16%, BCG follows: as was 1985 in Mongar for coverage immunization The

logistic supplies from hospitals, irrespective of the distance from the hospital. hospital. the from distance the of irrespective hospitals, from supplies logistic

with refrigerators. This meant that all the other BHUs had to obtain vaccines and and vaccines obtain to had BHUs other the all that meant This refrigerators. with

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Poor communication and inefficient management and coordination hindered activities in the health units. Services were frequently disrupted due to lack of supplies of drugs and vaccines. An efficient and cost-effective mechanism Bhutan for managing communication and logistic support to facilitate the smooth and efficient delivery of health services was found to be lacking.

Referral support system

Major obstacles were encountered with patient referrals due to poor communication. Social problems such as superstition and propaganda of traditional healers further obstructed timely referral. There was no system of feedback from the hospitals to peripheral health centres.

An efficient and cost- 5. The Mongar Health Services Development Project effective mechanism for managing The Mongar Health Services Development Project was launched with WHO communication and support in 1985 and extended over a period of five years. As mentioned earlier, logistic support to this project was implemented to maximize “Health for All by the year 2000” facilitate the smooth and community participation. and efficient delivery of health services was found The main objectives were: to be lacking •• To extend primary healthcare coverage to all people in the district, promote optimum utilization of services and raise the health status of the population; •• To establish a healthcare delivery system based on total community involvement at minimum cost, i.e. through utilization of available resources and appropriate technologies; •• To identify major health problems and develop appropriate interventions to reduce morbidity and mortality rates; •• To develop an effective support system (referral, logistics, communication and information); •• To promote intersectoral coordination as an integral component of community health development; •• To promote the adoption of the project in other districts.

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care in the district the in care

harness support for developing comprehensive health health comprehensive developing for support harness Communities were involved at the planning stages to to stages planning the at involved were Communities

reorganize the supply channel for for channel supply the reorganize supply: adequate facilitate

• Strengthen the communication and logistics support system to to system support logistics and communication the Strengthen •

• at all levels. all at monitoring and supervision Strengthen •

knowledge and practice. practice. and knowledge

hazards. Develop appropriate skills to bridge gaps between between gaps bridge to skills appropriate Develop hazards.

child care, nutrition, health and hygiene, disease and health health and disease hygiene, and health nutrition, care, child

provide health education on relevant health topics such as as such topics health relevant on education health provide

• Enhance knowledge, awareness and skills of rural communities: communities: rural of skills and awareness knowledge, Enhance •

through regular training programmes. training regular through

and recruited from local communities and their capacities built built capacities their and communities local from recruited and

period of five years five of period

workers (VVHWs) and female health volunteers were selected selected were volunteers health female and (VVHWs) workers

1985 and extended over a a over extended and 1985

• volunteer village health health village volunteer health: for resources human Strengthen •

with WHO support in in support WHO with

and existing health facilities consolidated. consolidated. facilities health existing and

Project was launched launched was Project

activities, health centres relocated closer to local communities communities local to closer relocated centres health activities,

Services Development Development Services

infrastructure, sub-posts were constructed to support outreach outreach support to constructed were sub-posts infrastructure,

The Mongar Health Health Mongar The • to improve accessibility and health health and accessibility improve to coverage: Expand •

comprehensive health care in the district. district. the in care health comprehensive

at the planning stages to harness support for developing developing for support harness to stages planning the at

• communities were involved involved were communities mobilization: Community •

structures and technologies. technologies. and structures

the principle of self reliance, utilize available resources, existing existing resources, available utilize reliance, self of principle the

with well-defined roles and responsibilities. Conforming with with Conforming responsibilities. and roles well-defined with

formal coordinating bodies at various levels of the operation operation the of levels various at bodies coordinating formal

• through establishment of of establishment through coordination: intersectoral Enhance •

and curative measures was advocated. advocated. was measures curative and

health delivery system encompassing promotive, preventive preventive promotive, encompassing system delivery health

at various levels of the district. The concept of one unified unified one of concept The district. the of levels various at

commitment to support implementation of the project activities activities project the of implementation support to commitment

district health workers and community leaders to garner their their garner to leaders community and workers health district

• targeting district administrators, sectoral heads, heads, sectoral administrators, district targeting Advocacy: •

Strategies adopted adopted Strategies 5.1

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drugs, vaccines and logistics in the district, carry out a needs assessment of equipment and non-drug supplies in all district health centres, establish an efficient distribution and a buffer Bhutan stock system in the district to replenish supplies, and ensure a mechanism to redistribute short-expiry drugs to centres requiring supplies. 5.2 Activities undertaken during the project period

•• Advocacy, sensitization and education at various levels. •• Formation of organizing bodies and committees at various levels. •• Activities to improve sanitation. –– Construction of pit latrines for safe disposal of excreta. A District Health –– Shifting of pigsties and cattle sheds away from the house. Committee was –– Building of refuse pits and improving overall cleanliness established to obtain of the village. policy commitment and •• Activities to enhance community participation functional cooperation in implementing the –– Sensitization, orientation and education. project. This committee –– Selection and training of VVHWs. was entrusted with –– Selection and training of women health workers in the the responsibility of area of MCH care. deciding the feasibility •• Relocation of health centres, construction and repair of existing of activities and health facilities. coordinating assistance 5.3 Achievements and findings from other sectors

Policy commitment

A major achievement of the project was the interlinking of all levels of decision-makers in the district. A District Health Committee was established to obtain policy commitment and functional cooperation in implementing the project. This committee was entrusted with the responsibility of deciding the feasibility of activities and coordinating assistance from other sectors. A technical committee was formed to advise on matters related to the development of

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early detection of disease, its treatment and timely referral timely and treatment its disease, of detection early

facilitate health education and maximize opportunities for for opportunities maximize and education health facilitate Outreach clinics were established to increase coverage, coverage, increase to established were clinics Outreach

were being run regularly from various BHUs and Mongar hospital. Mongar and BHUs various from regularly run being were

communities. By the end of the project period, 35 permanent outreach clinics clinics outreach permanent 35 period, project the of end the By communities.

The outreach clinics helped to bring health care as close as possible to the rural rural the to possible as close as care health bring to helped clinics outreach The

opportunities for early detection of disease, its treatment and timely referral. referral. timely and treatment its disease, of detection early for opportunities

were established to increase coverage, facilitate health education and maximize maximize and education health facilitate coverage, increase to established were

The concept of outreach clinics was first tried out in Mongar. Outreach clinics clinics Outreach Mongar. in out tried first was clinics outreach of concept The

trained as VVHWs as trained

health workers, VHWs and local leaders. local and VHWs workers, health

by their communities and and communities their by

postnatal care. This high coverage was attributed to the concerted efforts of of efforts concerted the to attributed was coverage high This care. postnatal

100 farmers were elected elected were farmers 100

districts. About 210 women were given one week’s training in antenatal and and antenatal in training week’s one given were women 210 About districts.

year project period. About About period. project year

evident from the fact that there were no drop-outs, unlike the case in other other in case the unlike drop-outs, no were there that fact the from evident

covered within the five- the within covered

refresher courses every six months. Their commitment and dedication was was dedication and commitment Their months. six every courses refresher

in Mongar District was was District Mongar in

trained as VVHWs. They were initially trained for two weeks followed by by followed weeks two for trained initially were They VVHWs. as trained

The entire population population entire The

project period. About 100 farmers were elected by their communities and and communities their by elected were farmers 100 About period. project

the entire population in Mongar District was covered within the five-year five-year the within covered was District Mongar in population entire the

Primary healthcare services were expanded to all blocks of the district. Almost Almost district. the of blocks all to expanded were services healthcare Primary

Primary healthcare coverage healthcare Primary

sanitation and water supply, safe disposal of waste, health and hygiene. and health waste, of disposal safe supply, water and sanitation

MCH clinics, and increasing participation in community programmes such as as such programmes community in participation increasing and clinics, MCH

instrumental in motivating communities to attend immunization sessions in in sessions immunization attend to communities motivating in instrumental

Continuous support was forthcoming from local leaders. This support was was support This leaders. local from forthcoming was support Continuous

development committee in all other districts in 1988. 1988. in districts other all in committee development

programme. The success of this local body stimulated the formation of a village village a of formation the stimulated body local this of success The programme.

promoting active participation and developing a self-sustaining community community self-sustaining a developing and participation active promoting

decisions to implement the required activities. This local body was crucial for for crucial was body local This activities. required the implement to decisions

bodies were created to identify local problems, analyse the causes and make make and causes the analyse problems, local identify to created were bodies

project activities and facilitate urgent execution of activities. Local executive executive Local activities. of execution urgent facilitate and activities project

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Coverage of the Expanded Programme on Immunization (EPI) and growth monitoring

Bhutan During the project implementation period, almost all BHUs were equipped with refrigerators and an efficient vaccine supply system was established. This greatly reduced the costs of transportation of vaccines. Health education was made an essential component of every MCH clinic. Rural communities were actively involved in constructing permanent outreach clinic sheds, and organizing and promoting the benefits of EPI services. About 300 women health workers were trained in the district to promote EPI in their communities.

Towards the end of the project, 94% of all children in Mongar district were fully immunized before the age of one year; 85% of the interviewed mothers could Health education was show their road-to-health card. Children were weighed six times on average made an essential after birth. component of every MCH clinic. Rural Nutrition communities were actively involved in Almost all houses had kitchen gardens even before the start of the project. constructing permanent New varieties of vegetables and fruits were introduced during the project outreach clinic sheds, period. However, the lack of provision of seeds for the kitchen gardens was a and organizing and major impediment to diversification of nutritional intake after the project period promoting the benefits of had ended. EPI services Maternal health

About 70% of women received antenatal care and more than 75% of women had visited the antenatal clinic at least three to four times before delivery. About 85% of women were given two doses of tetanus toxoid (TT) and 95% received iron and folic acid. Almost half the women surveyed knew the benefits of antenatal care. However, despite the fact that 300 female health workers were trained in the district, 95% of mothers still delivered at home; 80% of these deliveries were conducted by relatives and only 20% were assisted by a trained female worker.

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and only 20% were assisted by a trained female worker female trained a by assisted were 20% only and

home; 80% of these deliveries were conducted by relatives relatives by conducted were deliveries these of 80% home;

trained in the district, 95% of mothers still delivered at at delivered still mothers of 95% district, the in trained Despite the fact that 300 female health workers were were workers health female 300 that fact the Despite

whether they had some disease. some had they whether

monitor the growth of children or that it could help to see see to help could it that or children of growth the monitor

• 75% of the mothers were aware that weighing helped to to helped weighing that aware were mothers the of 75% •

diseases prevented by immunization. by prevented diseases

• 50% of mothers could mention on an average at least three three least at average an on mention could mothers of 50% •

had used it and 19% had prepared it correctly.) it prepared had 19% and it used had

nationwide, 65% of mothers recognized an ORS packet, 59% 59% packet, ORS an recognized mothers of 65% nationwide,

diseases [CDD] revealed that the ORS access rate was 45% 45% was rate access ORS the that revealed [CDD] diseases

prepare ORS. (A nationwide review on control of diarrhoeal diarrhoeal of control on review nationwide (A ORS. prepare

packets and 80% had used them. Of these, 87% knew how to to how knew 87% these, Of them. used had 80% and packets

• 85% of mothers recognized the oral rehydration solution (ORS) (ORS) solution rehydration oral the recognized mothers of 85% •

The evaluation report revealed that: revealed report evaluation The

supply needs in the village the in needs supply

Knowledge, attitude and skills and attitude Knowledge,

assessing the rural water water rural the assessing

was made responsible for for responsible made was

to the Health Department in 1998. in Department Health the to

development community community development

essential elements of health care. Rural water supply schemes were handed over over handed were schemes supply water Rural care. health of elements essential

The respective Gewog Gewog respective The

implementing the schemes in rural areas, as water supply and sanitation were were sanitation and supply water as areas, rural in schemes the implementing

was of the view that they should be given the responsibility for planning and and planning for responsibility the given be should they that view the of was

were sought through the Gewog development committee, the health sector sector health the committee, development Gewog the through sought were

Although cooperation and coordination for the rural water supply schemes schemes supply water rural the for coordination and cooperation Although

responsible for assessing the rural water supply needs in the village. the in needs supply water rural the assessing for responsible

supply schemes. The respective Gewog development community was made made was community development Gewog respective The schemes. supply

The VVHWs were actively involved in protecting and maintaining rural water water rural maintaining and protecting in involved actively were VVHWs The

constructed after the start of the Mongar district health project. project. health district Mongar the of start the after constructed

that was used by adults and children. About two thirds of the latrines were were latrines the of thirds two About children. and adults by used was that

was found to be acceptable or good. About 94% of the houses had a latrine latrine a had houses the of 94% About good. or acceptable be to found was

the houses visited, the water supply, storage and management of waste products products waste of management and storage supply, water the visited, houses the

supply as compared to 26% of the rural population in Bhutan. In almost half of of half almost In Bhutan. in population rural the of 26% to compared as supply

Over 75% of the houses in Mongar district had access to a safe piped water water piped safe a to access had district Mongar in houses the of 75% Over

Water supply and sanitation and supply Water

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Illness episodes and health-seeking behaviour

The disease frequency reported among 42 children during a period of two Bhutan months showed that 65% of children had respiratory tract infections, 35% diarrhoea and others had skin infection, worm infestation, and diseases of the teeth and gums.

Only one quarter of these 42 children who were ill during the survey period were referred to the health facility, either by the VHW or by the health worker. Eight children were treated exclusively with home-made herbs. Seventy-five per cent of the mothers interviewed said that they first took their child to the health worker and the remaining said that they first visited a religious person.

Cultural factors Availability and accessibility of referral health services impeding the accessibility to health Considering the rough terrain and the scattered location of the households, services were reduced the project succeeded in bringing health care within an acceptable walking drastically due to distance of the villages through relocation and construction of sub-posts in increased knowledge strategic areas. Services such as EPI and MCH were delivered on a monthly and awareness basis in geographically well-distributed subunits. Cultural factors impeding the accessibility to health services were reduced drastically due to increased knowledge and awareness.

Communities organized the transport of patients on stretchers to road points. From these points, transfer of patients was coordinated with the hospital ambulance service. Over the project period, the number of referrals from the communities to the hospital tripled and that to outpatient departments quadrupled.

A referral form was introduced to refer patients from the villages to the district hospitals. This allowed feedback to basic health workers and facilitated documentation of referrals. The district hospital was well equipped with drugs, laboratory services, an X-ray unit, and surgical, physical rehabilitation and community health services.

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ambulance service ambulance

of patients was coordinated with the hospital hospital the with coordinated was patients of

stretchers to road points. From these points, transfer transfer points, these From points. road to stretchers Communities organized the transport of patients on on patients of transport the organized Communities

project or programme is to succeed. succeed. to is programme or project

district. Stakeholders must be involved during the planning stages if a a if stages planning the during involved be must Stakeholders district.

Rural development projects must involve all administrative levels of the the of levels administrative all involve must projects development Rural 5.

improve services. improve

all levels is vital. Information must be utilized at various levels to further further to levels various at utilized be must Information vital. is levels all

system. Collection, analysis and dissemination of health information at at information health of dissemination and analysis Collection, system.

term viability term

An information system is an integral part of the health-care delivery delivery health-care the of part integral an is system information An 4.

resources and ensure long- ensure and resources

mobilization of community community of mobilization

community. Candidates may be farmers, retired soldiers or lay monks. lay or soldiers retired farmers, be may Candidates community.

needs but also promote promote also but needs

chances of being accepted and becoming a catalyst for change in that that in change for catalyst a becoming and accepted being of chances

not only meet the local local the meet only not

who is responsible and well respected by the community has more more has community the by respected well and responsible is who

community participation participation community

selection of a VHW and the expected roles and responsibilities. A person person A responsibilities. and roles expected the and VHW a of selection

Activities initiated through through initiated Activities

VVHW system. Village communities must understand the criteria for for criteria the understand must communities Village system. VVHW

Selection of the right person is the single most important element in the the in element important most single the is person right the of Selection 3.

traditional values and beliefs into health-related activities. health-related into beliefs and values traditional

understanding of health and health problems. This system also integrates integrates also system This problems. health and health of understanding

system. They are a valuable resource for enhancing awareness and and awareness enhancing for resource valuable a are They system.

VVHWs are an essential link between the community and the health health the and community the between link essential an are VVHWs 2.

resources and ensure long-term viability. viability. long-term ensure and resources

not only meet the local needs but also promote mobilization of community community of mobilization promote also but needs local the meet only not

community is required. Activities initiated through community participation participation community through initiated Activities required. is community

support is withdrawn, the active participation and commitment of the the of commitment and participation active the withdrawn, is support

clinics. In order to develop a health system and sustain it after external external after it sustain and system health a develop to order In clinics.

infrastructures, appointing health workers and opening mobile outreach outreach mobile opening and workers health appointing infrastructures,

District health development entails more than building health health building than more entails development health District 1.

Lessons learned Lessons 5.4

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Prize: Health Sasakawa Mongar health services development project:

Bhutan: 1997 (Bhutan)

6. Pooling and use of common resources such as human resources for supervision, structures and transport greatly reduce the cost of services.

Bhutan 7. Support from local leaders and local bodies such as the village development committee is crucial for promoting active participation and developing a self-sustaining community programme.

6. Conclusion

Since 1961, the development of health services in Bhutan has been remarkable. The country progressed from a situation of practically no health infrastructure to a comprehensive network of services within a span of two decades. With the adoption of the primary health care system in 1979, an integrated, equitable The Royal and balanced health service consisting of a package of preventive, promotive, Government’s effort curative and rehabilitative services was established. The health status of the was recognized people has greatly improved through effective implementation of the eight internationally through essential elements of primary health care. the Sasakawa award to the Mongar Health The Royal Government’s effort was recognized internationally through the Service in 1997 Sasakawa award to the Mongar Health Service in 1997. The success of the Mongar Health Services Development Project is largely attributable to the support and commitment at the district policy level, active participation of the local communities and unstinting support of international partners, in particular, WHO. The lessons learned from the Mongar District Health Project were applied to other districts to improve the national healthcare delivery system.

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network of services within a span of two decades two of span a within services of network

of practically no health infrastructure to a comprehensive comprehensive a to infrastructure health no practically of

been remarkable. The country progressed from a situation situation a from progressed country The remarkable. been Since 1961, the development of health services in Bhutan has has Bhutan in services health of development the 1961, Since

farsighted development strategies of the past 40 years. 40 past the of strategies development farsighted

the Millennium Development Goals (MDGs). This is largely attributable to the the to attributable largely is This (MDGs). Goals Development Millennium the

518 outreach clinics outreach 518

improving the quality of services at all levels. Bhutan is well on track to achieve achieve to track on well is Bhutan levels. all at services of quality the improving

health units (BHUs) and and (BHUs) units health

The emphasis now lies on reaching the unreached population and further further and population unreached the reaching on lies now emphasis The

district hospitals, 181 basic basic 181 hospitals, district

referral hospitals, 29 29 hospitals, referral

to further develop human resources, especially at the more specialized levels. specialized more the at especially resources, human develop further to

national and two regional regional two and national

improvement in the context of Bhutan’s development. Even so, there is a need need a is there so, Even development. Bhutan’s of context the in improvement

network consisting of a a of consisting network

the ratio of doctors for every 10 000 population at 1.7, which is a significant significant a is which 1.7, at population 000 10 every for doctors of ratio the

through a four-tiered four-tiered a through

of healthcare services have been enhanced. The information available puts puts available information The enhanced. been have services healthcare of

in Bhutan is delivered delivered is Bhutan in

taken a big turn over time. As a result, the quality and efficiency of delivery delivery of efficiency and quality the result, a As time. over turn big a taken

The healthcare service service healthcare The

Along with expansion of infrastructure, human resource development has also also has development resource human infrastructure, of expansion with Along

district administration. district

training institutes and medical supplies, all hospitals are placed under the the under placed are hospitals all supplies, medical and institutes training

its programmes to the district hospitals. With the exception of referral hospitals, hospitals, referral of exception the With hospitals. district the to programmes its

community participation prompted the health sector to decentralize many of of many decentralize to sector health the prompted participation community

increasing health coverage of rural populations. The need to ensure active active ensure to need The populations. rural of coverage health increasing

1200 VHWs have been trained in the country and actively contribute to to contribute actively and country the in trained been have VHWs 1200

hospitals, 181 basic health units (BHUs) and 518 outreach clinics. More than than More clinics. outreach 518 and (BHUs) units health basic 181 hospitals,

consisting of a national and two regional referral hospitals, 29 district district 29 hospitals, referral regional two and national a of consisting

The healthcare service in Bhutan is delivered through a four-tiered network network four-tiered a through delivered is Bhutan in service healthcare The

walking distance from the nearest health facility. health nearest the from distance walking

services. About two thirds of this population now lives within three hours’ hours’ three within lives now population this of thirds two About services.

Today, over 90% of the Bhutanese population has access to primary healthcare healthcare primary to access has population Bhutanese the of 90% over Today,

Epilogue 7.

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Bhutan: 1997 (Bhutan)

8. Bibliography

1 The Fifth Plan Program for Mongar District (1981–86/87). Bhutan Thimphu: Department of Information, 1981. 2 Royal Government of Bhutan, Central Statistical Office, Planning Commission. Statistical handbook of Bhutan 1986. Thimphu. 1987. 3 de Jong JTVM. Assignment report on evaluation of Mongar project, Bhutan, 1-21 November 1988. New Delhi: WHO Regional Office for South-East Asia, 1989. http://repository. searo.who.int/handle/123456789/11893 - accessed 17 May 2012. 4 Tenzin, Sonam, Dorji Rinchen. Mongar Health Services Development Project. Thimphu: Health Division, Ministry of Health & Education, 1996. 5 Declaration of Alma-Ata International Conference on Primary Health Care. Alma-Ata, USSR, 6–12 September 1978. http:// www.who.int/hpr/NPH/docs/declaration_almaata.pdf - accessed 11 November 2011. 6 Royal Government of Bhutan. First Five-Year Plan 1961– 66. Thimphu, 1961. http://www.gnhc.gov.bt/wp-content/ uploads/2011/04/1stFYP.pdf - accessed 14 May 2012. 7 Royal Government of Bhutan. Second Five-Year Plan 1966– 1971. Thimphu, 1966. http://www.gnhc.gov.bt/wp-content/ uploads/2011/04/02fyp.pdf - accessed 14 May 2012. 8 Royal Government of Bhutan. Third Five-Year Plan 1971– 1976. Thimphu, 1971. http://www.gnhc.gov.bt/wp-content/ uploads/2011/04/03fyp.pdf - accessed 14 May 2012.

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Vol2_Web.pdf - accessed 14 May 2012. May 14 accessed - Vol2_Web.pdf

www.gnhc.gov.bt/wp-content/uploads/2011/10 plan/TenthPlan_

uploads/2011/10 plan/TenthPlan_Vol1_Web.pdf and http:// and plan/TenthPlan_Vol1_Web.pdf

Volume 2). Thimphu, 2009. http://www.gnhc.gov.bt/wp-content/ 2009. Thimphu, 2). Volume

Commission. Tenth Five-Year Plan. 2008-2013 (Volume 1 and and 1 (Volume 2008-2013 Plan. Five-Year Tenth Commission.

Royal Government of Bhutan, Gross National Happiness Happiness National Gross Bhutan, of Government Royal 16

Progress Report 2005. Thimphu: 2005. Thimphu: 2005. Report Progress

Royal Government of Bhutan. Millennium Development Goals. Goals. Development Millennium Bhutan. of Government Royal 15

Druk Medical Journal. 1986 volume 2. 2. volume 1986 Journal. Medical Druk 14

Policy, 2000. Policy,

New Delhi, WHO Department of Essential Drugs and Medicines Medicines and Drugs Essential of Department WHO Delhi, New

Stapleton M. Bhutan Essential Drugs Programme: a case history. history. case a Programme: Drugs Essential Bhutan M. Stapleton 13

Health Care Setting. Wellington, 2003. Wellington, Setting. Care Health

New Zealand, Ministry of Health. Public Health in a Primary Primary a in Health Public Health. of Ministry Zealand, New 12

review, Bhutan. Thimphu, Ministry of Health, February 2007. February Health, of Ministry Thimphu, Bhutan. review,

Royal Government of Bhutan, Ministry of Health. Health sector sector Health Health. of Ministry Bhutan, of Government Royal 11

- accessed 14 May 2012. May 14 accessed - uploads/2011/04/05fyp.pdf

http://www.gnhc.gov.bt/wp-content/ 1982. Thimphu, 87.

Royal Government of Bhutan. Fifth Five-Year Plan, 1981– Plan, Five-Year Fifth Bhutan. of Government Royal 10

to 30.9.77. Thimphu, 1977. 1977. Thimphu, 30.9.77. to

Year Plan: half yearly progress report for the period from 1.4.77 1.4.77 from period the for report progress yearly half Plan: Year

Royal Government of Bhutan, Planning Commission. Fourth Five- Fourth Commission. Planning Bhutan, of Government Royal 9

E - S A ast outh from stories sia

Prize: Health Sasakawa Major Shirley de Silva, President of the Family Planning Association of Sri Lanka (far right), winner of the Sasakawa Health Prize receiving the 2004 Sasakawa Health Prize from Mr M.N Khan of Pakistan, president of the 57th World Health Assembly. Photo credit: WHO/Pierre Virot

147 CHAPTER 10 2004

The triumphant journey of FPA Sri Lanka: Sasakawa and beyond[*]

Recipient: The Family Planning Association of Sri Lanka (Sri Lanka)

[*] Draft prepared by Mrs Sabina Omar Family Planning Association of Sri Lanka, Bullers Lane, Colombo 7, Sri Lanka 148 he Family Planning Association of Sri Lanka (FPA) is a pioneering Torganization that has defined the landscape of family planning and sexual and reproductive health (SRH) in Sri Lanka

1. Introduction

The Family Planning Association of Sri Lanka (FPA) is a pioneering organization that has defined the landscape of family planning and sexual and reproductive Sri Lanka health (SRH) in Sri Lanka. From its inception, the organization has experienced a journey of challenges and achievements; above all, the organization has witnessed a shift in perceptions.

After four centuries of colonial rule, Sri Lanka gained independence in 1948. During the post- Many sexual health and social issues needed to be addressed. Poverty, nutrition, Independence era, and access to health services were intrinsically linked issues affecting the well- family planning issues being of the population. During this post-Independence era, family planning did not feature on the issues did not feature on the government’s “to do” list. The population had government’s “to do” doubled between 1900 and 1948. The numbers of infant and maternal deaths list. The population were high. An increase in the population at a macro level and families affected had doubled between by infant/maternal mortality at the micro level existed side by side. 1900 and 1948 Prior to the 1950s, family planning and reproductive health were seldom discussed by the government or in the public sphere. The multireligious social make-up of the country also contributed to diverse views on family planning and sexuality. Further, family planning did not feature in the government health plans of the time. The FPA has been at the forefront of family planning services, support and education, introducing new and innovative concepts relating to SRH in Sri Lanka. Reaching out to people in need of support and gaining their trust has been essential in the journey of the FPA in order to bring family planning to the fore as a lifestyle choice. The concept had to be liberated from the many taboos associated with family planning and sexual relationships.

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Family Planning Association of Sri Lanka in 1974 in Lanka Sri of Association Planning Family

Sri Lanka, and the organization changed its name to the the to name its changed organization the and Lanka, Sri

Constitution in 1972, the country was christened christened was country the 1972, in Constitution With the introduction of the country’s first Republican Republican first country’s the of introduction the With

improved nutrition, care, education, and a better quality of life for parents and and parents for life of quality better a and education, care, nutrition, improved

choices relating to sexuality, one’s body and the size of one’s family translated to to translated family one’s of size the and body one’s sexuality, to relating choices

choices and provide the best for their children and families. The ability to make make to ability The families. and children their for best the provide and choices

was to create awareness and educate young men and women about individual individual about women and men young educate and awareness create to was

popular contraceptives. Starting at the grass-roots level, the need of the moment moment the of need the level, grass-roots the at Starting contraceptives. popular

In the early days of the FPA, the task at hand was not merely handing out out handing merely not was hand at task the FPA, the of days early the In

gained prominence and acceptance as FPA Sri Lanka (FPA). Lanka Sri FPA as acceptance and prominence gained

1974. Today, although still incorporated under this name, the organization has has organization the name, this under incorporated still although Today, 1974.

organization changed its name to the Family Planning Association of Sri Lanka in in Lanka Sri of Association Planning Family the to name its changed organization

Constitution in 1972, the country was christened Sri Lanka, and the the and Lanka, Sri christened was country the 1972, in Constitution

lifestyle choice lifestyle

Association of Ceylon. With the introduction of the country’s first Republican Republican first country’s the of introduction the With Ceylon. of Association

planning to the fore as a a as fore the to planning

In 1970, the organization was formally incorporated as the Family Planning Planning Family the as incorporated formally was organization the 1970, In

in order to bring family family bring to order in

young women of reproductive age, was a cause espoused by the organization. organization. the by espoused cause a was age, reproductive of women young

in the journey of the FPA FPA the of journey the in

the sexual revolution of the 1960s, the need for SRH services, especially for for especially services, SRH for need the 1960s, the of revolution sexual the

their trust has been essential essential been has trust their

pioneering steps impacted the demographic course of Sri Lanka. Even before before Even Lanka. Sri of course demographic the impacted steps pioneering

need of support and gaining gaining and support of need

equipment and contraceptive support to expand its service base. These These base. service its expand to support contraceptive and equipment

Reaching out to people in in people to out Reaching

also received funds from the Swedish government to acquire the necessary necessary the acquire to government Swedish the from funds received also

of the International Planned Parenthood Federation (IPPF). The association association The (IPPF). Federation Parenthood Planned International the of

New life was injected into the Association in 1954 when it became an affiliate affiliate an became it when 1954 in Association the into injected was life New

lack of funds limited the number of clinics. clinics. of number the limited funds of lack

planning service delivery centres or clinics in different parts of the country. The The country. the of parts different in clinics or centres delivery service planning

year. The primary objective of the association at the time was to establish family family establish to was time the at association the of objective primary The year.

for all the activities of the association. Staff support was enlisted only in the fifth fifth the in only enlisted was support Staff association. the of activities the all for

FPA was held on 15 January 1953. At the outset, volunteers were responsible responsible were volunteers outset, the At 1953. January 15 on held was FPA

WHO/Pierre Virot WHO/Pierre

was then known. Following informal discussions, an inaugural meeting of the the of meeting inaugural an discussions, informal Following known. then was

Photo credit: credit: Photo

the feasibility of starting a family planning association in Ceylon – as Sri Lanka Lanka Sri as – Ceylon in association planning family a starting of feasibility the

57 World Health Assembly. Health World

Sri Lanka addressing the the addressing Lanka Sri and acquaintances consisting of professionals and social workers, who discussed discussed who workers, social and professionals of consisting acquaintances and

Planning Association of of Association Planning

The journey of the FPA began with the small steps taken by a group of friends friends of group a by taken steps small the with began FPA the of journey The

President of the Family Family the of President

Major Shirley de Silva, Silva, de Shirley Major

The concept of family planning and pioneering steps pioneering and planning family of concept The 2. The triumphant journey

of FPA Sri Lanka:

Sasakawa and beyond:

2004 (Sri Lanka)

children alike. The mental anguish of a family caused by infant and maternal mortality could be reduced. More importantly, the physical and psychological trauma experienced by women who have multiple births could be minimized. The services provided by the FPA gave people the tools to improve their quality of life. The FPA’s message was focused on an improved sense of well-being for families. Through its ground-breaking first steps, the FPA laid the foundation for policy decisions by the Government of Sri Lanka (GOSL) relating to fertility, thereby reducing the high rates of maternal and infant mortality, and improving Sri Lanka the health and nutrition of mothers and children. Today, these efforts have paid rich dividends.

3. A demographic shift through family planning Over the past 57 Over the past 57 years, the country has experienced a demographic shift. The years, the country growth rates during the first half of the twentieth century saw the population has experienced a heading towards dangerously unsustainable numbers. However, due to the demographic shift. The efforts of the FPA and support by the GOSL, the country sees stabilization in growth rates during population growth. Although population stabilization was not on the agenda the first half of the of the FPA, the work done with the community in relation to family planning twentieth century saw and sexual health has indirectly contributed to this demographic shift. Within the population heading one year, the GOSL recognized the untiring initial steps of the FPA to improve towards dangerously the quality of life through family planning. The advantages of moving towards a unsustainable numbers sustainable and stable population as a developing nation were also recognized. Provision was made for an annual grant of Rs 2500 to the FPA in the 1954/55 government budget.

During the early years, the FPA established family planning clinics around the country served by trained doctors, nurses and midwives. They also visited government medical institutions to initiate clinical services. The FPA won the support of medical staff, who voluntarily provided their services. Going beyond providing clinical services, the FPA worked to gain the trust of the people through discussions, education and interaction with the public. The initiatives of the FPA prompted the GOSL to integrate family planning into the Health Ministry’s Maternal and Child Health Programme in 1965. Subsequently, the

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space for dialogue on a platform of mutual understanding mutual of platform a on dialogue for space

ethnic and multi-religious society. The FPA had to create create to had FPA The society. multi-religious and ethnic Family planning is a culturally sensitive subject in a multi- a in subject sensitive culturally a is planning Family

the 1960s, together with the IUD. IUD. the with together 1960s, the

unprecedented manner. The pill proved to be the most popular contraceptive in in contraceptive popular most the be to proved pill The manner. unprecedented

1960 followed by clinical trials transformed the lives of women and men in an an in men and women of lives the transformed trials clinical by followed 1960

initiatives. However, the introduction of the oral contraceptive pill (the pill) in in pill) (the pill contraceptive oral the of introduction the However, initiatives.

about the right to choose and access contraception were all ground-breaking ground-breaking all were contraception access and choose to right the about

The introduction of each method of contraception and creating awareness awareness creating and contraception of method each of introduction The

sterilization in the form of vasectomies and tubectomies, if desired by the client. client. the by desired if tubectomies, and vasectomies of form the in sterilization

1968, the three-monthly injection Depo Provera. The FPA also provided provided also FPA The Provera. Depo injection three-monthly the 1968,

In 1963, the intrauterine device (IUD) was introduced by the FPA and, in in and, FPA the by introduced was (IUD) device intrauterine the 1963, In

methods (condom and diaphragm); spermicides were introduced soon after. after. soon introduced were spermicides diaphragm); and (condom methods

In the 1950s, the only methods of contraception available were the barrier barrier the were available contraception of methods only the 1950s, the In

ground-breaking initiatives ground-breaking Breaking new ground in the area of contraceptives of area the in ground new Breaking 4.

contraception were all all were contraception

global trends and Sri Lankan goals in reproductive health care. care. health reproductive in goals Lankan Sri and trends global to choose and access access and choose to

Policy. Though started as a family planning organization, the FPA adapted to the the to adapted FPA the organization, planning family a as started Though Policy. awareness about the right right the about awareness

by way of a second policy in 1998 – the Population and Reproductive Health Health Reproductive and Population the – 1998 in policy second a of way by contraception and creating creating and contraception

GOSL adopted a National Population Policy in 1989/90, which was redefined redefined was which 1989/90, in Policy Population National a adopted GOSL of each method of of method each of

access to SRH by 2015 was a part of the Millennium Development Goals. The The Goals. Development Millennium the of part a was 2015 by SRH to access the client. The introduction introduction The client. the

the world over. Access to SRH was recognized as a right, and ensuring universal universal ensuring and right, a as recognized was SRH to Access over. world the tubectomies, if desired by by desired if tubectomies,

1994) changed the paradigm of family planning with the focus shifting to SRH SRH to shifting focus the with planning family of paradigm the changed 1994) of vasectomies and and vasectomies of

The International Conference on Population and Development (held in Cairo in in Cairo in (held Development and Population on Conference International The sterilization in the form form the in sterilization

The FPA also provided provided also FPA The

the average Sri Lankan. Sri average the

gathered momentum as a positive force, gradually gaining wider acceptance by by acceptance wider gaining gradually force, positive a as momentum gathered

SRH services and support. Easing itself into the psyche of the people, the FPA FPA the people, the of psyche the into itself Easing support. and services SRH

of mutual understanding. The FPA first reached out to those in dire need of of need dire in those to out reached first FPA The understanding. mutual of

multireligious society. The FPA had to create space for dialogue on a platform platform a on dialogue for space create to had FPA The society. multireligious

Family planning is a culturally sensitive subject in a multi-ethnic and and multi-ethnic a in subject sensitive culturally a is planning Family

mainstream health services of the country. the of services health mainstream

This was a definitive step, whereby fertility and family planning entered the the entered planning family and fertility whereby step, definitive a was This

GOSL stepped in and acquired the majority of clinics operated by the FPA. FPA. the by operated clinics of majority the acquired and in stepped GOSL

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2004 (Sri Lanka)

The FPA worked to move contraceptives from under the shroud of suspicion and taboo through provision of much-needed information, education and communication. Contraceptives have empowered women in Sri Lanka from all ethnic and religious backgrounds to plan their own lives and that of their children. This has provided more women in Sri Lanka the opportunity for stable employment, education and the ability to focus on the health, nutrition, education and well-being of their children and families. The availability of contraceptives has also resulted in women delaying childbirth. The increase Sri Lanka in the number of women giving birth above the age of 30 years is evidence of this. While the pill has impacted women on a personal level, it has also shaped the way the country has moved forward, with more women empowered to contribute to the economy and the next generation, whether as a part of the Contraceptives have workforce or as caregivers equipped to provide the best support to their families. empowered women in Sri Lanka from all The FPA took the unprecedented step of introducing the emergency ethnic and religious contraceptive pill – Postinor 2 – to the Sri Lankan public. The project was funded backgrounds to plan by The Consortium for Emergency Contraception and was launched in 1997. their own lives and that The goal was to introduce a branded, dedicated emergency contraceptive pill of their children (ECP) to the local market. The FPA conducted aggressive educational campaigns and created awareness among health workers and the public. All SRH training seminars as well as the mainstream media provided information about the ECP. The manner in which the ECP works was communicated and the FPA took steps to ensure that the message was clear: the ECP, if administered properly, would not amount to an abortion, the side-effects were minimal and it was not a method of contraception. At the outset, Postinor 2 was available only through private medical practitioners. The FPA facilitated the opening of several thousands of Postinor 2 sales outlets throughout the country. The product was made available through the pharmaceutical network in the country as part of the project. The creation of awareness and increased accessibility delivered results, as sales reached an average of 18 000 packets per month by the end of 2002. By 2003, over 3000 pharmacies were purchasing the product from FPA marketing officers and it was clear that the product had gained popularity as a brand and as a reliable emergency contraceptive.

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of the most effective tools of communication of tools effective most the of

through a “hotline” in October 1997, which proved to be one one be to proved which 1997, October in “hotline” a through

public, the FPA created a safe and reliable space for discussion discussion for space reliable and safe a created FPA the public, As the use of the ECP was a relatively new concept for the the for concept new relatively a was ECP the of use the As

family planning and reproductive health information produced by a South South a by produced information health reproductive and planning family

non-Sinhala speaking cinemagoers. This was the first commercial film with with film commercial first the was This cinemagoers. speaking non-Sinhala

till then. The film was shown with English subtitles in some cinemas to attract attract to cinemas some in subtitles English with shown was film The then. till

the film continuously for 92 days, breaking their highest collection record up up record collection highest their breaking days, 92 for continuously film the

across all 13 cinemas in the country. The Regal Cinema in Colombo showed showed Colombo in Cinema Regal The country. the in cinemas 13 all across

The film saw full houses at each of the three showings during the first few weeks weeks few first the during showings three the of each at houses full saw film The

length film entitled Yuvathipathi (man and wife), which premiered in July 1994. 1994. July in premiered which wife), and (man Yuvathipathi entitled film length

The search for new methods to communicate led the FPA to produce a full- a produce to FPA the led communicate to methods new for search The

reach out to the public. public. the to out reach

interviews, which gave the FPA publicity, and a face and voice though which to to which though voice and face a and publicity, FPA the gave which interviews,

the doctors of the FPA were featured on radio and TV programmes and gave gave and programmes TV and radio on featured were FPA the of doctors the

published in popular newspapers and journals on SRH issues. In addition, addition, In issues. SRH on journals and newspapers popular in published

(STIs) and AIDS. Following this programme, a large number of articles were were articles of number large a programme, this Following AIDS. and (STIs)

workers and the public the and workers

sexuality, reproductive health, family planning, sexually transmitted infections infections transmitted sexually planning, family health, reproductive sexuality,

awareness among health health among awareness

participated in the programme, which featured lectures and films on human human on films and lectures featured which programme, the in participated

campaigns and created created and campaigns

for media personnel in 1998. Members of the print and electronic media media electronic and print the of Members 1998. in personnel media for

aggressive educational educational aggressive

issues among the public. The FPA conducted a two-day residential workshop workshop residential two-day a conducted FPA The public. the among issues

The FPA conducted conducted FPA The

The media is a powerful tool for creating awareness on health and reproductive reproductive and health on awareness creating for tool powerful a is media The

Sensitizing the media the Sensitizing 5.

anonymity of the hotline ensured privacy. privacy. ensured hotline the of anonymity

ECP but also included topics such as sexual health and family planning. The The planning. family and health sexual as such topics included also but ECP

serve them. It was also evident that the advice sought was not limited to the the to limited not was sought advice the that evident also was It them. serve

callers, the FPA gleaned information on the target groups and how to better better to how and groups target the on information gleaned FPA the callers,

per day from people in all parts of Sri Lanka. From the nature of the calls and and calls the of nature the From Lanka. Sri of parts all in people from day per

unparalleled success. At the time, on average, the hotline received 30 calls calls 30 received hotline the average, on time, the At success. unparalleled

was operative from 8 am to 5 pm on all working days of the week. It was an an was It week. the of days working all on pm 5 to am 8 from operative was

The hotline was promoted through advertising campaigns for Postinor 2 and and 2 Postinor for campaigns advertising through promoted was hotline The

1997, which proved to be one of the most effective tools of communication. communication. of tools effective most the of one be to proved which 1997,

created a safe and reliable space for discussion through a “hotline” in October October in “hotline” a through discussion for space reliable and safe a created

As the use of the ECP was a relatively new concept for the public, the FPA FPA the public, the for concept new relatively a was ECP the of use the As

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa The triumphant journey

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2004 (Sri Lanka)

Asian country. Appreciated by both critics and the audience, the film grossed the second-highest collection for films shown in the year 1995. The National Film Corporation forwarded the film to film festivals in India and China. It was also nominated for prestigious film awards in Sri Lanka and reached a wider audience in a manner that was well received by the target groups.

6. Taking proactive steps

Sri Lanka 6.1 Ensuring the accessibility of contraceptives

Even after the introduction of contraceptive methods such as the pill. the challenge of accessibility remained. The innovative Contraceptive Retail Sales marketing programme of the FPA, introduced during the latter part of the The FPA provided 1970s, played a pivotal role in making contraceptives available from trustworthy training for salespeople and reliable sources at affordable prices. The FPA promoted the availability of and distributors on a choice of condoms and contraceptive pills. A condom by the brand name SRH issues to ensure “Preethi” (meaning joy or happiness) and an oral contraceptive pill named that the retailers would “Mithuri” (female friend) are two trusted brands used by many women and understand the needs of men in the country today due to market penetration, affordability and visibility. their customers The FPA worked to create a successful sales network through retailers and pharmacies throughout the country. The FPA provided training for salespeople and distributors on SRH issues to ensure that the retailers would understand the needs of their customers. They would also communicate these details to the FPA, thereby assisting the FPA to improve the programme and the contraceptive sales services offered. For example, what should be done if a 12-year-old boy wished to purchase a condom? Could the retail salesperson refuse to sell? The FPA created awareness among the retailers of the consequences of not using a condom, which could result in tragedy for the boy and his young partner.

Advertising campaigns including billboards in prominent locations and panels placed in shop fronts were used to create visibility for brands such as Preethi and Mithuri. This programme supplemented the GOSL’s efforts to distribute contraceptives through clinics and midwives during home visits. While this provided an essential service, it also resulted in revenue generation for the organization. Today, the contraceptive pill and condoms are freely available in supermarkets and pharmacies around the country and the pill is available to women without a prescription. 155

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was to achieve replacement-level fertility by the year 2000 year the by fertility replacement-level achieve to was

Project was launched in 1990. The main aim of the project project the of aim main The 1990. in launched was Project

and Reproductive Health Education and Motivational Motivational and Education Health Reproductive and The Praja Shanthi (Bliss to the community) Family Planning Planning Family community) the to (Bliss Shanthi Praja The

of the project, and its penetration and acceptance within communities. within acceptance and penetration its and project, the of

These volunteers undertook 100 700 home visits. This highlights the reach reach the highlights This visits. home 700 100 undertook volunteers These

The average contraceptive prevalence rates increased from 48% to 79%. 79%. to 48% from increased rates prevalence contraceptive average The

trained grass-roots level volunteers reached a population of over 120 000. 000. 120 over of population a reached volunteers level grass-roots trained

was implemented in 40 midwife areas in four districts of the country; 518 518 country; the of districts four in areas midwife 40 in implemented was

FPA annual report of 1998–1999, for the year under review, the project project the review, under year the for 1998–1999, of report annual FPA

to meet its objectives by project completion in 1999. As recorded in the the in recorded As 1999. in completion project by objectives its meet to

contraceptive prevalence rates in the project areas and the FPA was able able was FPA the and areas project the in rates prevalence contraceptive

Shanthi activities within communities. The project resulted in improved improved in resulted project The communities. within activities Shanthi

people of their community their of people

areas of the country and trained new volunteers to spearhead Praja Praja spearhead to volunteers new trained and country the of areas

the numerous benefits to the the to benefits numerous the

the people of their community. Each year, the project worked in different different in worked project the year, Each community. their of people the

leaders as they recognized recognized they as leaders

commitment of village leaders as they recognized the numerous benefits to to benefits numerous the recognized they as leaders village of commitment

the commitment of village village of commitment the

volunteerism and the energy and dedication of the youth. It attracted the the attracted It youth. the of dedication and energy the and volunteerism

of the youth. It attracted attracted It youth. the of

FPA volunteers and the community. This project thrived on the spirit of of spirit the on thrived project This community. the and volunteers FPA

the energy and dedication dedication and energy the

areas. Working from within the community created a rapport between the the between rapport a created community the within from Working areas.

spirit of volunteerism and and volunteerism of spirit

and also addressed the general health status of the people in the project project the in people the of status health general the addressed also and

This project thrived on the the on thrived project This

among youth, an increase in the use of contraceptives by married couples, couples, married by contraceptives of use the in increase an youth, among

Shanthi had a direct impact on the increase in the levels of SRH awareness awareness SRH of levels the in increase the on impact direct a had Shanthi

and contraceptives, and awareness programmes for the youth. Praja Praja youth. the for programmes awareness and contraceptives, and

provided on family planning, health, gender issues, women’s empowerment, empowerment, women’s issues, gender health, planning, family on provided

trained to take on leadership at the community level. Education was was Education level. community the at leadership on take to trained

SRH educational activities including through home visits. Leaders were were Leaders visits. home through including activities educational SRH

of six other NGOS and mobilized grass-roots level volunteers to spearhead spearhead to volunteers level grass-roots mobilized and NGOS other six of

areas. The project was implemented around the country with the support support the with country the around implemented was project The areas.

a sustainable manner while promoting reproductive health in underserved underserved in health reproductive promoting while manner sustainable a

fertility by the year 2000. This project contributed toward a national goal in in goal national a toward contributed project This 2000. year the by fertility

in 1990. The main aim of the project was to achieve replacement-level replacement-level achieve to was project the of aim main The 1990. in

Reproductive Health Education and Motivational Project was launched launched was Project Motivational and Education Health Reproductive

The Praja Shanthi (Bliss to the community) Family Planning and and Planning Family community) the to (Bliss Shanthi Praja The

Increasing the use of contraceptives of use the Increasing 6.2

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6.3 Women’s health

The FPA recognized the need to start a Well Woman Clinic to encourage women to have routine health checks as, after childbirth, the average woman neglected her health. This service is conducted daily at the FPA headquarters in Colombo. The clinic is conducted by a team of lady doctors. Through this programme, which was initiated in 1997, women are given a complete physical and gynaecological examination in addition to blood and urine examinations Sri Lanka and a Pap smear test. Clients are provided with the test results and reports and, where required, referred to consultants for special investigations. In 2002, 18 609 clients were seen at the clinic. This clinic also offers much-needed counselling services for clients with sexual problems such as impotence, The FPA has conducted non-consummation of marriage, frigidity, lack of sexual desire, etc. Another advocacy programmes area where counselling is required is where newly-wed couples – especially in an effort to educate women – have to prove their virginity at the time of marriage. The FPA has the public and abolish conducted advocacy programmes in an effort to educate the public and abolish the traditional “virginity the traditional “virginity test”, which has to be humiliatingly endured by a new test”, which has to be bride. The negative impact of such a traumatic experience on women, virginity humiliatingly endured and the sexual rights of women are included in all FPA reproductive health by a new bride education programmes. Proactive action is necessary to create a change in traditional perceptions that degrade women and their sexual rights.

The FPA has from its inception worked with couples on subfertility issues. At the FPA’s Subfertility Clinic, couples can discuss fertility issues, seek guidance while the FPA conducts investigations and suggests solutions and treatment for subfertility. In 2002, 625 couples registered for these services and 77 previously subfertile women conceived and delivered during the year.

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their sexual rights sexual their

traditional perceptions that degrade women and and women degrade that perceptions traditional Proactive action is necessary to create a change in in change a create to necessary is action Proactive

and AIDS. and

virility and libido, and sexual health issues such as testicular cancer, sterilization sterilization cancer, testicular as such issues health sexual and libido, and virility

up and voice their concerns, especially in relation to issues such as impotence, impotence, as such issues to relation in especially concerns, their voice and up

suffered from SRH issues. Men have also been given the opportunity to speak speak to opportunity the given been also have Men issues. SRH from suffered

consultant doctor was available to provide advice and treatment to men who who men to treatment and advice provide to available was doctor consultant

service was introduced by the FPA in 1998. During this special weekly clinic, a a clinic, weekly special this During 1998. in FPA the by introduced was service

Aware of its responsibility to uphold gender equity, a male reproductive health health reproductive male a equity, gender uphold to responsibility its of Aware

programme was a good “eye-opener” for them. them. for “eye-opener” good a was programme

Shanthi programmes agreed that women have equal rights and that the the that and rights equal have women that agreed programmes Shanthi

giving them the power of choice. Many males who participated in the Mahila Mahila the in participated who males Many choice. of power the them giving

make their voices heard. This project opened a window for many women, women, many for window a opened project This heard. voices their make

they are not empowered to speak for themselves and assert their rights and and rights their assert and themselves for speak to empowered not are they

home makers who are subject to violence and abuse within the home when when home the within abuse and violence to subject are who makers home

in each of these roles these of each in

grip. Stereotypical gender roles see women as passive, tolerant, non-aggressive non-aggressive tolerant, passive, as women see roles gender Stereotypical grip.

employees, and their rights rights their and employees,

affect the next generation: an endless vicious cycle that has many women in its its in women many has that cycle vicious endless an generation: next the affect

daughters, sisters and and sisters daughters,

of nutrition would lead to future health and reproductive complications that that complications reproductive and health future to lead would nutrition of

by them as mothers, wives, wives, mothers, as them by

or lactating woman at a higher health risk. Similarly, depriving the girl child child girl the depriving Similarly, risk. health higher a at woman lactating or

of the different roles played played roles different the of

male members of the family. This places the already undernourished pregnant pregnant undernourished already the places This family. the of members male

Women were made aware aware made were Women

where women are traditionally expected to partake of their meal after the the after meal their of partake to expected traditionally are women where

rights in each of these roles. This initiative was necessary in a social context context social a in necessary was initiative This roles. these of each in rights

played by them as mothers, wives, daughters, sisters and employees, and their their and employees, and sisters daughters, wives, mothers, as them by played

in a sociocultural context. Women were made aware of the different roles roles different the of aware made were Women context. sociocultural a in

rights and responsibilities, while aiming at attitudinal changes that are crucial crucial are that changes attitudinal at aiming while responsibilities, and rights

the target groups. The focus of the programme was to sensitize women to their their to women sensitize to was programme the of focus The groups. target the

respected members of the community at the village level and also directly to to directly also and level village the at community the of members respected

for a better tomorrow”. The project was delivered through influential and and influential through delivered was project The tomorrow”. better a for

Gender Equity and Empowerment Project – in 1997 to “empower women women “empower to 1997 in – Project Empowerment and Equity Gender

education and new perspectives, the FPA launched the Mahila Shanthi – – Shanthi Mahila the launched FPA the perspectives, new and education

lives. With a view to creating this awareness and empowering women through through women empowering and awareness this creating to view a With lives.

aware of their rights and their ability to make decisions that impact their daily daily their impact that decisions make to ability their and rights their of aware

The services provided by the FPA would be immaterial if women were not not were women if immaterial be would FPA the by provided services The

Empowering women Empowering 6.4

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7. Reaching out to neglected populations

Throughout its journey, the FPA has reached out to social groups on the fringes of society and brought to light the issues faced by these diverse social groups. A few examples of the extensive work carried out by the FPA are given below.

7.1 The youth

Sri Lanka At the beginning of the FPA’s work, it was evident that discussion of sexual health and related issues was limited. Young people would be exposed to information that was inaccurate, derogatory of women and sexual relations, and they continued to be in the dark regarding contraception and prevention of communicable diseases. The organization took an innovative step in The FPA recognized the importance of counselling on sexual health and engaging the youth in reproduction – this was necessary to create increased awareness and provide counselling programmes a safe space for dialogue on issues faced by adolescents and young adults. as far back as 30 years The organization took an innovative step in engaging the youth in counselling ago – when counselling programmes as far back as 30 years ago – when counselling itself was an itself was an unknown unknown concept for the average Sri Lankan. The counselling initiatives of the concept for the average FPA took on greater significance because of the perception of youth during Sri Lankan the early 1970s. The country had seen a youth insurgency in 1971 and there was much stigma and negative attitudes associated with any youth movement and activity. The FPA established what was known as the Tharuna Janagahana Kamituwa (Youth Division) in 1975 with the objective of creating awareness. These youth discussed SRH issues and carried out peer counselling.

Projects were crafted to disseminate information on various aspects of population, sexuality and reproduction among the youth of Sri Lanka, and to inculcate the idea that planned parenthood was important for a happy life. The FPA arranged for training and orientation for the members of the youth group in subjects such as population, family health and nutrition, communication, family planning, human reproduction, youth needs and aspirations, and planning and implementation of programmes. With the

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planned parenthood was important for a happy life happy a for important was parenthood planned

the youth of Sri Lanka, and to inculcate the idea that that idea the inculcate to and Lanka, Sri of youth the

aspects of population, sexuality and reproduction among among reproduction and sexuality population, of aspects Projects were crafted to disseminate information on various various on information disseminate to crafted were Projects

of participating schools have acknowledged the positive influence of the the of influence positive the acknowledged have schools participating of

discussions with peers and counsellors. Parents, teachers and the principals principals the and teachers Parents, counsellors. and peers with discussions

encouraged students to post questions and issues that could be addressed via via addressed be could that issues and questions post to students encouraged

and decision-making skills. A question box placed within the club premises premises club the within placed box question A skills. decision-making and

were appointed and provided with comprehensive training in leadership leadership in training comprehensive with provided and appointed were

patron of the club. Office bearers such as the president, secretary, etc. etc. secretary, president, the as such bearers Office club. the of patron

would facilitate learning. The principal of each school was appointed the the appointed was school each of principal The learning. facilitate would

would carry posters with SRH information and audiovisual equipment that that equipment audiovisual and information SRH with posters carry would

set up in a classroom specially dedicated to the cause, and the club premises premises club the and cause, the to dedicated specially classroom a in up set

support and the creation of awareness among students. Each Youth Club was was Club Youth Each students. among awareness of creation the and support

Youth Clubs were another method used to create a platform for dialogue, dialogue, for platform a create to used method another were Clubs Youth

students

awareness among among awareness

SRH issues. issues. SRH

and the creation of of creation the and

information on the level of knowledge among adolescent schoolchildren on on schoolchildren adolescent among knowledge of level the on information

for dialogue, support support dialogue, for

schoolchildren, a baseline survey was conducted in 40 schools to obtain obtain to schools 40 in conducted was survey baseline a schoolchildren,

to create a platform platform a create to

services. In 2001, with a view to improving knowledge on SRH issues among among issues SRH on knowledge improving to view a with 2001, In services.

another method used used method another

approach in schools, focusing on education, counselling and provision of of provision and counselling education, on focusing schools, in approach

Youth Clubs were were Clubs Youth

and education on SRH issues was required. The FPA adopted a three-pronged three-pronged a adopted FPA The required. was issues SRH on education and

The overwhelming response to the hotline made it clear that more awareness awareness more that clear it made hotline the to response overwhelming The

The FPA also established a hotline to answer any questions on SRH issues. issues. SRH on questions any answer to hotline a established also FPA The

and popularize the two-child family norm. norm. family two-child the popularize and

cards were also designed by two members of the Youth Division to raise funds funds raise to Division Youth the of members two by designed also were cards

of overpopulation and raise funds for future youth-focused activities. Greeting Greeting activities. youth-focused future for funds raise and overpopulation of

called “Prashna” (Problem) was staged to create awareness about the problems problems the about awareness create to staged was (Problem) “Prashna” called

of rural areas was one of the aims of the Youth Division. In 1976, a drama drama a 1976, In Division. Youth the of aims the of one was areas rural of

of schools in rural areas. This was a great achievement as educating the youth youth the educating as achievement great a was This areas. rural in schools of

initiatives of the Youth Division and its Youth Committees had gained the trust trust the gained had Committees Youth its and Division Youth the of initiatives

1976. Over 75% of the entries had come from rural areas; thus, the awareness awareness the thus, areas; rural from come had entries the of 75% Over 1976.

country was sought through campaigns such as a poster competition held in in held competition poster a as such campaigns through sought was country

programmes around the country. Active participation of the youth around the the around youth the of participation Active country. the around programmes

support of the FPA, the Youth Division worked on educational seminars and and seminars educational on worked Division Youth the FPA, the of support

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availability of information and counselling services. The creation of health awareness, and moving SRH beyond the realms of the taboo have resulted in teachers, who were previously reluctant to teach SRH in school for various reasons, gaining the confidence to teach the subject and discuss issues and questions posed by students in a comfortable environment. An annual interschool debate competition was another way in which young people were encouraged to engage in SRH issues.

Sri Lanka The Youth Caravan project focused on SRH awareness and education for adolescents by young people known as Youth Volunteer Members. This project was launched during the latter half of 1999 under the name “Youwana Yathra” (Youth Caravan). The main objective was the provision of knowledge on SRH issues to 15 000 youth with a view to encouraging them to be more An annual interschool responsible for their own SRH behaviour. Young people in the 16–25 years’ debate competition was age group volunteered their time and efforts, and received extensive training another way in which in leadership, counselling and communication skills. Based in Colombo and young people were in other towns and cities around the country, the project worked towards encouraged to engage maximum outreach. The project focused on five areas of SRH – STIs, AIDS in SRH issues and safe sex, unwanted pregnancies and abortion, sexual abuse and gender equality. The activities included seminars using audiovisual aids and interactive methods such as role-plays and discussions for youth who had completed their secondary education. Competitions and special activities such as dramas on days such as World AIDS Day, Population Day and even Valentine’s Day were designed to create interest among the target groups.

The Reproductive Health Education Programme for Adolescents in Sri Lanka was first initiated by the FPA in 1982. This began with a programme called “Facts of Life” designed specifically for adolescents and implemented by Dr Sriani Basnayake, the Medicinal Director of the FPA. It proved to be extremely popular with parents who were looking for ways to provide guidance on the subject to their children. In 1984, the FPA began a wider programme on reproductive health in schools with the approval of the Minister of Education. Although reproductive health is a part of the school curriculum in the higher grades, the transfer of knowledge is not always successful as

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education on SRH issues was required was issues SRH on education

to the hotline made it clear that more awareness and and awareness more that clear it made hotline the to

questions on SRH issues. The overwhelming response response overwhelming The issues. SRH on questions The FPA also established a hotline to answer any any answer to hotline a established also FPA The

the early 1960s. Estates were visited in order to educate the labour force and and force labour the educate to order in visited were Estates 1960s. early the

order to improve their well-being, health and lifestyle. This work was started in in started was work This lifestyle. and health well-being, their improve to order

recognized that plantation workers were in need of assistance and support in in support and assistance of need in were workers plantation that recognized

live in this limited space, giving rise to a host of socioeconomic issues. The FPA FPA The issues. socioeconomic of host a to rise giving space, limited this in live

for each family are small and as families grow, even extended families tend to to tend families extended even grow, families as and small are family each for

to them, including education and health services. The “line room” dwellings dwellings room” “line The services. health and education including them, to

been improvements in their living conditions, rights and the services available available services the and rights conditions, living their in improvements been

services. As opposed to the plight of these people 50 years ago, there have have there ago, years 50 people these of plight the to opposed As services.

of labourers tend to skirt the fringes of mainstream Sri Lankan society and and society Lankan Sri mainstream of fringes the skirt to tend labourers of

to Sri Lanka by the British specifically to work the tea plantations. These groups groups These plantations. tea the work to specifically British the by Lanka Sri to

workers on the tea plantations are of Indian Tamil origin having been brought brought been having origin Tamil Indian of are plantations tea the on workers

rubber production rubber

rooms” and the residents of these dwellings form a small community. Most Most community. small a form dwellings these of residents the and rooms”

as is the case with with case the is as

by the management of the estate. Each estate may have one or more “line “line more or one have may estate Each estate. the of management the by

labour-intensive process process labour-intensive

plantations reside in basic dwellings popularly known as “line rooms” provided provided rooms” “line as known popularly dwellings basic in reside plantations

in Sri Lanka is still a a still is Lanka Sri in

with rubber production. The workforce providing labour on tea and rubber rubber and tea on labour providing workforce The production. rubber with

The production of tea tea of production The

production of tea in Sri Lanka is still a labour-intensive process as is the case case the is as process labour-intensive a still is Lanka Sri in tea of production

economy of Sri Lanka. Lanka. Sri of economy

Tea plays an important role in the identity and economy of Sri Lanka. The The Lanka. Sri of economy and identity the in role important an plays Tea

role in the identity and and identity the in role

Tea plays an important important an plays Tea

Tea plantation and other workers other and plantation Tea 7.2

to young people. people. young to

technology in an effort to make the subject matter more tangible and less alien alien less and tangible more matter subject the make to effort an in technology

posters and brochures and provided audiovisual information using modern modern using information audiovisual provided and brochures and posters

organizations engaged in youth educational activities. The FPA moved beyond beyond moved FPA The activities. educational youth in engaged organizations

to educate teachers and students. It is also a training facility for other other for facility training a also is It students. and teachers educate to

at the FPA and serves as a resource for school and educational authorities authorities educational and school for resource a as serves and FPA the at

The centre helped to strengthen peer educational activities on SRH issues issues SRH on activities educational peer strengthen to helped centre The

centre is open to schoolchildren and young people from all over the country. country. the over all from people young and schoolchildren to open is centre

or embarrassment. A group of 10 young persons were trained as guides. This This guides. as trained were persons young 10 of group A embarrassment. or

to bridge this gap and create a space for young people to learn without fear fear without learn to people young for space a create and gap this bridge to

Centre to provide SRH knowledge to youth was set up at the FPA headquarters headquarters FPA the at up set was youth to knowledge SRH provide to Centre

subject. In 2002, a permanent Sexual and Reproductive Health Resource Resource Health Reproductive and Sexual permanent a 2002, In subject.

teachers do not have adequate knowledge or skills required to teach the the teach to required skills or knowledge adequate have not do teachers

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supervisory staff through lectures and film shows on family planning and how it can improve the quality of life. Training courses were also conducted for estate medical officers and midwives who worked on these estates. As hospitals were sometimes many miles away from the estate, midwives delivered babies. With the introduction of these programmes, the FPA witnessed an increased demand by estate populations for contraceptives. In addition to the services provided with the cooperation of the GOSL, a mobile clinic programme was launched in 1971. The mobile clinic could move from estate to estate Sri Lanka providing much-needed family planning and support services to pregnant women at their door-step.

Programmes were also conducted for the industrial sector covering men and

Training courses were women employed in factories, and for the various trade unions within the conducted for estate industrial sector. Seminars were conducted with the assistance of the Labour medical officers and Department and International Labour Organization (ILO). These seminars led midwives who worked to the trade unions considering family planning as an individual right instead on these estates. As of an imposition. Each of these sessions would consist of three talks covering hospitals were sometimes the concept of family planning, the population problem and family planning many miles away from methods. Short films and slides were also shown on these topics. the estate, midwives 7.3 Internally displaced people delivered babies

In January 2000, the FPA successfully completed an 18-month project to improve the general health and reproductive health status of internally displaced people (IDPs). Funding support for the project was obtained from the IPPF’s Netherlands Trust Fund. The displacement of vast numbers of people during the long-drawn-out ethnic conflict in the island led to an unprecedented influx of refugees into makeshift welfare centres in the north- central parts of the country. The IDPs are a vulnerable group who exist on the margins of society with minimal access to basic survival needs and even less by way of SRH facilities. This project was implemented in three north-central districts of the country – Anuradhapura, Polonnaruwa and Puttalam – which had a high concentration of IDPs. At the time of the project, 24 clusters of camps provided shelter for 13 600 families amounting to a refugee population

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moulavis of the mosques the of moulavis

rehabilitation officers and religious leaders such as the the as such leaders religious and officers rehabilitation The FPA worked through the government agents, agents, government the through worked FPA The

camps were in dire need of improved standards of hygiene and cleanliness. cleanliness. and hygiene of standards improved of need dire in were camps

few months, the FPA concentrated on general health and sanitation as the the as sanitation and health general on concentrated FPA the months, few

was introduced as a high-profile health awareness campaign. During the first first the During campaign. awareness health high-profile a as introduced was

violence and displacement, and fraught with distrust and anxiety. The project project The anxiety. and distrust with fraught and displacement, and violence

was necessary, as this was a group of people who had been traumatized by by traumatized been had who people of group a was this as necessary, was

and ownership of the project was imparted to the community, whose buy-in buy-in whose community, the to imparted was project the of ownership and

religious leaders such as the moulavis of the mosques. A sense of responsibility responsibility of sense A mosques. the of moulavis the as such leaders religious

The FPA worked through the government agents, rehabilitation officers and and officers rehabilitation agents, government the through worked FPA The

Maximum community participation ensured the success of this project. project. this of success the ensured participation community Maximum

and to educate and sensitize the camp community on gender issues. issues. gender on community camp the sensitize and educate to and

Organization (ILO) Organization

youth through 48 trained, part-time counsellors, to provide first aid services, services, aid first provide to counsellors, part-time trained, 48 through youth

and International Labour Labour International and

community, to provide SRH information and counselling to adolescents and and adolescents to counselling and information SRH provide to community,

the Labour Department Department Labour the

leaders, to facilitate government health-care services to reach the camp camp the reach to services health-care government facilitate to leaders,

with the assistance of of assistance the with

health/RH awareness creation through trained volunteers and community community and volunteers trained through creation awareness health/RH

Seminars were conducted conducted were Seminars

levels of family planning by one third, to ensure community participation in in participation community ensure to third, one by planning family of levels

the industrial sector. sector. industrial the

access to quality health/SRH services to the camp community, to improve improve to community, camp the to services health/SRH quality to access

various trade unions within within unions trade various

national average. The seven specific objectives of the project were: to provide provide to were: project the of objectives specific seven The average. national

in factories, and for the the for and factories, in

health status of the target population and to bring it on a par with that of the the of that with par a on it bring to and population target the of status health

men and women employed employed women and men

shorter period from August 1999. The primary objective was to improve the the improve to was objective primary The 1999. August from period shorter

industrial sector covering covering sector industrial

period of 12 months commencing from April 1998 and the second was for a a for was second the and 1998 April from commencing months 12 of period

conducted for the the for conducted

of the IDPs. The project was implemented in two stages. The first covered a a covered first The stages. two in implemented was project The IDPs. the of

Programmes were were Programmes

The FPA implemented a project targeting the SRH and basic health needs needs health basic and SRH the targeting project a implemented FPA The

in the camps was also minimal. minimal. also was camps the in

group susceptible to communicable diseases. Family planning among couples couples among planning Family diseases. communicable to susceptible group

the health of the IDPs deteriorated rapidly and they proved to be a high-risk high-risk a be to proved they and rapidly deteriorated IDPs the of health the

care system did not reach the camps regularly or adequately. In this situation, situation, this In adequately. or regularly camps the reach not did system care

levels. However, health care remained underserved. The government health- government The underserved. remained care health However, levels.

bare essentials such as food, clothing and shelter were provided at minimal minimal at provided were shelter and clothing food, as such essentials bare

by the GOSL with assistance from international and local donor agencies. The The agencies. donor local and international from assistance with GOSL the by

of around 69 000. The health and welfare work in each camp was handled handled was camp each in work welfare and health The 000. 69 around of

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Sasakawa and beyond:

2004 (Sri Lanka)

The major problem encountered was language. Most governmental health service providers spoke only Sinhalese and 90% of the IDPs were Muslims and Tamil people who were Tamil speaking. To move beyond the obstacles faced due to language, local doctors, midwives and IDPs were brought together through FPA polyclinics conducted at camp level. Seven different services were delivered simultaneously by the health staff – mother and child health care including contraceptive services, health and education, child dental care, treatment for worms, malaria treatment, general health consultations as well Sri Lanka as a pharmaceutical dispensary. The polyclinics proved to be popular and were always well attended. Health-care services to reduce and minimize the prevalence of diseases neglected by the system were offered through 117 polyclinics that served over 34 000 patients. The polyclinics proved to be popular and were The project used highly participatory methods to mobilize the camp always well attended. communities by training 240 young health volunteers – both men and women Health-care services to – living in the camps. During the project they were provided with training, reduce and minimize attended seminars and lectures, qualified in first aid (through the offices of the the prevalence of Sri Lanka Red Cross), took part in all the camp’s health drives and provided diseases neglected advice on sanitation and hygiene. Intensive awareness drives on HIV/AIDS were by the system were carried out by the volunteers. The idea was to create a sense of healing and offered through 117 well-being from within the community, and establish and provide camp-level polyclinics that served health committees to provide leadership to the volunteers in carrying out the over 34 000 patients work. Active volunteers were trained as peer educators to run SRH sessions with young people. They were also encouraged to direct those requiring counselling to the 24 FPA-trained counsellors at the camps. The commitment, enthusiasm and energy of these young volunteers attracted the energy of the media and they were featured on national television and in the print media.

Another challenge was the resistance faced by the predominantly Muslim IDP community. Realizing the patriarchal nature of the community, the FPA reached out to the men of the community through male volunteers to make them understand that contraception meant improved health of the mother and child. Over time, they understood and began to accept the message. For the women in the camps, the project was an eye-opener. Misconceptions were also rife as a

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phones, SMS and e-mail and SMS phones,

that is available including the world wide web, mobile mobile web, wide world the including available is that

online to provide support using the latest technology technology latest the using support provide to online Today with the Happy Life Project, the organization is is organization the Project, Life Happy the with Today

SMS and e-mail. e-mail. and SMS

technology that is available including the world wide web, mobile phones, phones, mobile web, wide world the including available is that technology

Life Project, the organization is online to provide support using the latest latest the using support provide to online is organization the Project, Life

centre carried posters to create awareness. However, today with the Happy Happy the with today However, awareness. create to posters carried centre

to handling SRH issues. During the 1960s to the 1990s, the FPA resource resource FPA the 1990s, the to 1960s the During issues. SRH handling to

of the ICT arm of the GOSL has brought about this innovative approach approach innovative this about brought has GOSL the of arm ICT the of

The award-winning Happy Life Project made possible with the support support the with possible made Project Life Happy award-winning The

ensures privacy, confidentiality and information from a trusted source. source. trusted a from information and confidentiality privacy, ensures

provided and reach out to those in need of support in a manner that that manner a in support of need in those to out reach and provided

the internet, the FPA has tapped into cyberspace to extend the services services the extend to cyberspace into tapped has FPA the internet, the

and poster campaigns carried out previously. In the fast-paced age of of age fast-paced the In previously. out carried campaigns poster and

has added CDs and DVDs with information on SRH issues to the booklets booklets the to issues SRH on information with DVDs and CDs added has

at the camps the at For sustainability, the FPA maintains an identity that is contemporary. It It contemporary. is that identity an maintains FPA the sustainability, For

FPA-trained counsellors counsellors FPA-trained

Going online Going 8. counselling to the 24 24 the to counselling

direct those requiring requiring those direct

model for cooperation between and among diverse humanitarian agencies. agencies. humanitarian diverse among and between cooperation for model

also encouraged to to encouraged also

completion of the project. The partnership has been cited as an excellent excellent an as cited been has partnership The project. the of completion

people. They were were They people.

the GOSL personnel and the FPA was productive and resulted in fruitful fruitful in resulted and productive was FPA the and personnel GOSL the

sessions with young young with sessions

health-care personnel and the close cooperation and coordination between between coordination and cooperation close the and personnel health-care

educators to run SRH SRH run to educators

the camp community. The service support received from the government government the from received support service The community. camp the

were trained as peer peer as trained were

for health-care services. The project received the support of the leaders in in leaders the of support the received project The services. health-care for

Active volunteers volunteers Active

work in the camps. The IDPs also started to visit the government facilities facilities government the visit to started also IDPs The camps. the in work

and, with the assistance of volunteers, found it easier to carry out their their out carry to easier it found volunteers, of assistance the with and,

the camps. Public health inspectors started serving the camp communities communities camp the serving started inspectors health Public camps. the

As a result of this initiative, the government health services began reaching reaching began services health government the initiative, this of result a As

discuss their issues with volunteers from among their community. community. their among from volunteers with issues their discuss

using modern methods. The project gave them the voice to speak up and and up speak to voice the them gave project The methods. modern using

camps were practising some form of contraception, but only 33% were were 33% only but contraception, of form some practising were camps

of the project in April 1998 showed that 40.6% of the couples within the the within couples the of 40.6% that showed 1998 April in project the of

result of cultural practices and beliefs. A survey conducted at the beginning beginning the at conducted survey A beliefs. and practices cultural of result

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa The triumphant journey

of FPA Sri Lanka:

Sasakawa and beyond:

2004 (Sri Lanka)

9. Using volunteers

Volunteerism has been a part of the organization. This continues till date and the focus is for family planning to be voluntarily accepted by people. On an organizational level, the governance of the FPA is carried out by volunteers who are professionals working towards the empowerment of individuals through the creation of SRH awareness and support systems. From the 1970s, the FPA worked through a system of volunteer committees who would run Sri Lanka family planning community projects. Training for volunteers started in areas where family planning community projects were already under way. Volunteers were trained from all over the country including estate medical assistants and midwives. To meet these new training needs, a comprehensive curriculum Volunteerism has was drawn up by the FPA based on the early training programmes and the been a part of the requirements of the volunteers. Local government officers, officers of government organization. This departments and officers of the armed forces were trained as peer educators. continues till date Voluntary service organizations such as the Rotary Clubs were also trained to and the focus is for conduct family planning programmes for their members. Thus, training activities family planning to be were broad-based and covered categories such as grass-roots level volunteers, voluntarily accepted members of community-based organizations, medical personnel, officers by people belonging to state institutions and members of staff of the FPA.

10. The Sasakawa Award and beyond

Winning the Sasakawa Award in 2004 is testament to the pioneering spirit and commitment of the FPA. In the post-Sasakawa Award era, the FPA has continued to provide the services and support that it is now known and trusted for in Sri Lanka. In order for the work of the FPA to be carried out, it is vital that the organization looks at its survival and sustenance. With a view to ensuring the continuity of the FPA, the organization under its current leadership is working to diversify its donor base and build new partnerships that are mutually beneficial to donor and donee. It is important that future projects undertaken by the FPA be sustainable for the community and the organization.

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women entering their confinement their entering women

distribution of hygienic packs and pregnancy kits for for kits pregnancy and packs hygienic of distribution

Fund (UNFPA) set up mobile clinics, organized the the organized clinics, mobile up set (UNFPA) Fund The FPA in partnership with the United Nations Population Population Nations United the with partnership in FPA The

workplace and sexual harassment. harassment. sexual and workplace

leadership would bring to the fore gender issues such as discrimination in the the in discrimination as such issues gender fore the to bring would leadership

lifestyles and needs. More women in the workforce, in places of power and and power of places in workforce, the in women More needs. and lifestyles

their bodies, they can plan their careers, finances and families to suit their their suit to families and finances careers, their plan can they bodies, their

women. As women become more aware of a sense of autonomy relating to to relating autonomy of sense a of aware more become women As women.

today have seen an increase in life expectancy among Sri Lankans, especially especially Lankans, Sri among expectancy life in increase an seen have today

due to the stabilized population growth. The lifestyle changes and choices of of choices and changes lifestyle The growth. population stabilized the to due

One third of the current population of 22 million belongs to the workforce workforce the to belongs million 22 of population current the of third One

for their members their for

planning programmes programmes planning

Demographic bonus and increased life expectancy life increased and bonus Demographic 10.1

to conduct family family conduct to

were also trained trained also were

of the humanitarian assistance provided to IDPs. IDPs. to provided assistance humanitarian the of

as the Rotary Clubs Clubs Rotary the as

medical and health services, and reproductive health services became a part part a became services health reproductive and services, health and medical

organizations such such organizations

that provided new opportunities to reach out to groups of society in need of of need in society of groups to out reach to opportunities new provided that

Voluntary service service Voluntary

concerns of women. Although this was a new role for the FPA, it was one one was it FPA, the for role new a was this Although women. of concerns

The FPA also trained individuals as “be-frienders” to focus on listening to the the to listening on focus to “be-frienders” as individuals trained also FPA The

of hygienic packs and pregnancy kits for women entering their confinement. confinement. their entering women for kits pregnancy and packs hygienic of

Population Fund (UNFPA) set up mobile clinics, organized the distribution distribution the organized clinics, mobile up set (UNFPA) Fund Population

eastern parts of the island. The FPA in partnership with the United Nations Nations United the with partnership in FPA The island. the of parts eastern

provide the humanitarian support required by the IDPs in the northern and and northern the in IDPs the by required support humanitarian the provide

the final 12 months of the ethnic conflict in Sri Lanka, the FPA was ready to to ready was FPA the Lanka, Sri in conflict ethnic the of months 12 final the

the thinking of the organization in dealing with a humanitarian crisis. During During crisis. humanitarian a with dealing in organization the of thinking the

as a result was reactive. The lessons learned from this experience shaped shaped experience this from learned lessons The reactive. was result a as

was not equipped to deal with a natural disaster of this proportion. All action action All proportion. this of disaster natural a with deal to equipped not was

support. When the devastating tsunami of 2004 struck Sri Lanka, the FPA FPA the Lanka, Sri struck 2004 of tsunami devastating the When support.

the FPA works to expand its horizons to include humanitarian services and and services humanitarian include to horizons its expand to works FPA the

action is a fundamental element of how the FPA provides its services. Today, Today, services. its provides FPA the how of element fundamental a is action

thinking and action beyond the sphere of SRH has become clear. Proactive Proactive clear. become has SRH of sphere the beyond action and thinking

During the post-Sasakawa Award period, the importance of proactive proactive of importance the period, Award post-Sasakawa the During

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa The triumphant journey

of FPA Sri Lanka:

Sasakawa and beyond:

2004 (Sri Lanka)

10.2 Meeting the Millennium Development Goals (MDGs)

In keeping with MDG 5 of universal access to SRH by 2015, the FPA works to recognize excluded populations such as those of different sexual orientations. Through its work in SRH care, education, support and counselling, the FPA directly contributes to Universal Access covered by Section 5b of the MDG, and has a major impact on maternal mortality, poverty and AIDS covered under Section 5a of the MDG. Success in this area has been achieved due to the close Sri Lanka working relations between the FPA and the Ministry of Health, and relevant departments such as the Family Health Bureau, Health Education Bureau and the National STD/AIDS Control Programme. The FPA works in collaboration with the GOSL at the national, provincial and district levels. Instead of resting on its laurels, the organization 10.3 Moving into the future firmly believes that with Although the sociocultural climate has changed from 1953 to 2010, the spirit each accomplishment, of FPA Sri Lanka stays the same as they work to build trust, break new ground, there are new challenges reach out, encourage volunteerism and ensure sustainability for SRH support and goals to work towards systems and the organization itself. The story of the FPA is one of “mission accomplished”. However, instead of resting on its laurels, the organization firmly believes that with each accomplishment, there are new challenges and goals to work towards. Today, the FPA is of the view that it does not have the luxury of time and the mantra of the organization is to “adapt fast and proactively serve; innovation being the key to survival”.

169 170

, Colombo. , http://www.fpasrilanka.org at Available years).

Family Planning Association of Sri Lanka. Annual report (various (various report Annual Lanka. Sri of Association Planning Family 5

Family Planning Association of Sri Lanka. Sri of Association Planning Family 4

Colombo: Family Planning Association, 2003. Association, Planning Family Colombo:

Weerakoon Bradman. Golden jubilee souvenir, 1953–2003. 1953–2003. souvenir, jubilee Golden Bradman. Weerakoon 3

Institute for Health Policy, 2007. Policy, Health for Institute

millennium 2001–2101: trends and implications. Colombo: Colombo: implications. and trends 2001–2101: millennium

De Silva WI. A population projection of Sri Lanka, for the new new the for Lanka, Sri of projection population A WI. Silva De 2

- accessed 15 May 2012. May 15 accessed - statistics.gov.lk/home.asp

http://www. Lanka. Sri Statistics, and Census of Department 1

Bibliography 11.

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa Dr Sharad D. Gokhale from the International Leprosy Union (ILU) of India, one of the winner of the 2006 Sasakawa Health Prize

171 CHAPTER 11 2006

International Leprosy Union (India): “Life is beautiful”[*]

Recipient: International Leprosy Union (India)

[*] Initial draft prepared by Dr S.D. Gokhale International Leprosy Union-Health Alliance, 1779/84, Gurutrayee, Near Bharat Scout Ground, Sadashiv Peth, Pune-411030, India 172 LU was formed with the aim of involving the community in Itackling the issue of stigma, social isolation and dehabitation. ILU is an association of Indian nongovernmental organizations (NGOs) with partnership open to NGOs working in other endemic countries

1. Background

Freedom is a natural and basic human aspiration. For centuries, a unique disease called leprosy has succeeded in taking it away from people. People suffering from leprosy have to fight not only against the bacillus Mycobacterium leprae but also against stigma and discrimination, and in gaining dignity as individuals in the community.

The International Leprosy Union (ILU) has taken a position that leprosy is more People suffering from of a social disease than a medical one. During the late fifties, the development leprosy have to fight not of drugs to treat leprosy was a major achievement in the evolution of this age- only against the bacillus old disease. The discovery of multidrug therapy (MDT) in 1981 made it possible Mycobacterium leprae for leprosy patients to be cured. At the same time, it became possible to reduce but also against stigma the duration of treatment drastically for some patients – from lifelong treatment and discrimination, and in to a maximum of two years. As a result, people became less fearful of leprosy gaining dignity as individuals and, along with this, the stigma associated with the disease also declined. in the community In spite of this success in the field of medicine, however, stigma associated with the disease persists and the rights of persons affected by leprosy are still denied in many communities. ILU was formed with the aim of involving the community in tackling the issue of stigma, social isolation and dehabitation. ILU is an association of Indian nongovernmental organizations (NGOs) with partnership open to NGOs working in other endemic countries.

2. The needs of leprosy-affected persons

Leprosy is caused by Mycobacterium leprae, which is a bacillus that attacks the skin and peripheral nerves, and affects parts of the body such as the feet, hands, face and earlobes. Because of the damage to the nerves, the affected person, if left untreated, ultimately develops deformities in the hands, feet and face.

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evolution of this age old disease old age this of evolution

drugs to treat leprosy was a major achievement in the the in achievement major a was leprosy treat to drugs

medical one. During the late fifties, the development of of development the fifties, late the During one. medical

position that leprosy is more of a social disease than a a than disease social a of more is leprosy that position The International Leprosy Union (ILU) has taken a a taken has (ILU) Union Leprosy International The

• Networking with other organizations organizations other with Networking •

• Media and advocacy and Media •

wrong with the person the with wrong

• Research and documentation on human rights issues rights human on documentation and Research •

told that there is nothing nothing is there that told

• Recognition, felicitation and awards and felicitation Recognition, •

The family needs to be be to needs family The

• Field work Field •

through counselling. counselling. through

• Forum on social issues issues social on Forum • needs psychological help help psychological needs

aid, the affected person person affected the aid,

are as follows: as are

Apart from physical physical from Apart

of persons affected by leprosy in their own countries. The main activities of ILU ILU of activities main The countries. own their in leprosy by affected persons of

form an NGO to deal with issues related to the social and rehabilitation needs needs rehabilitation and social the to related issues with deal to NGO an form

by leprosy into the general society. This led NGOs from developing countries to to countries developing from NGOs led This society. general the into leprosy by

needs efforts from the society to demolish stigma and integrate those affected affected those integrate and stigma demolish to society the from efforts needs

situation where only help in cash or kind can achieve total rehabilitation. It It rehabilitation. total achieve can kind or cash in help only where situation

understanding that leprosy cannot be treated as a medical condition or as a a as or condition medical a as treated be cannot leprosy that understanding

conference on rehabilitation held in Mumbai in 1986. It began with the the with began It 1986. in Mumbai in held rehabilitation on conference

The International Leprosy Union (ILU) was launched at the regional disability disability regional the at launched was (ILU) Union Leprosy International The

International Leprosy Union Leprosy International 3.

WHO/Peter Williams WHO/Peter

Photo credit: Photo

happily occupying respectable positions at work and within their communities. communities. their within and work at positions respectable occupying happily

World Health Assembly. Health World

thousands in India who are completely cured and back with their families, families, their with back and cured completely are who India in thousands

(ILU) of India addressing the 59 the addressing India of (ILU)

International Leprosy Union Union Leprosy International person. There should be no fear after the person is cured. Today, there are are there Today, cured. is person the after fear no be should There person.

Dr Sharad D. Gokhale from the the from Gokhale D. Sharad Dr

counselling. The family needs to be told that there is nothing wrong with the the with wrong nothing is there that told be to needs family The counselling.

Apart from physical aid, the affected person needs psychological help through through help psychological needs person affected the aid, physical from Apart

hands and feet. feet. and hands

assistive devices. Some of them will require corrective surgery to protect their their protect to surgery corrective require will them of Some devices. assistive

individual and the health services. Such individuals need support aids and and aids support need individuals Such services. health the and individual

care of the damaged eyes, hands and feet becomes an important task for the the for task important an becomes feet and hands eyes, damaged the of care

difficult to reverse these consequences of the disease. For such individuals, individuals, such For disease. the of consequences these reverse to difficult

impairment and disfigurement of the hands, feet and face, it becomes very very becomes it face, and feet hands, the of disfigurement and impairment

of utmost importance. Unfortunately, for those who are diagnosed late, with with late, diagnosed are who those for Unfortunately, importance. utmost of Once leprosy is contracted, immediate treatment with a full course of MDT is is MDT of course full a with treatment immediate contracted, is leprosy Once International Leprosy

Union (India): “Life is beautiful”: 2006 (India)

3.1 Forum on social issues

Stigma: ILU approaches the Indian Parliament

Advocacy has been an important issue for ILU. At the International Workshop held at Wardha, India in 1986 by the Gandhi Memorial Leprosy Foundation (GMLF) and ILU, stigma was defined as “a continuum of society’s response from total rejection to total acceptance”.

ILU joins hands with other organizations on human rights issues associated with leprosy and supports efforts in rectifying existing laws that discriminate against persons affected by leprosy. For example, certain laws in India actually fuel the creation of this stigma. The Indian Lepers Act, 1898 prevented ILU joins hands with leprosy-affected individuals from travelling on trains, going to public places, other organizations on etc. A long and arduous battle that lasted for 20 years has helped to remove human rights issues this law from the statute book. However, dozens of other pieces of legislation associated with leprosy exist, which attempt to segregate persons affected by leprosy from mainstream and supports efforts society. Consider, for instance, the Juvenile Justice Act, 1986, which states that in rectifying existing if a child is suffering from leprosy one must segregate and put the child into a laws that discriminate leprosy home. Another case is the Prevention of Begging Act, 1959. There are against persons 16 such laws that create stigmatization. This is grossly wrong and is currently affected by leprosy seen to be unnecessary.

There is a dire need to change these laws and modify government policies because they effectively take away the basic human rights of affected persons. The Prevention of Begging Act, 1959 in Bombay mentions that a leprosy- affected person has to be committed to a leprosy institution indefinitely till death. The point is: do we have the right to infringe upon the liberty of a person in such a manner? Also, the Hindu Marriage Act, 1955 and the Muslim Marriage Act, 1955 need to be amended, as they allow divorce on the grounds of leprosy.

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committed to a leprosy institution indefinitely till death till indefinitely institution leprosy a to committed

mentions that a leprosy affected person has to be be to has person affected leprosy a that mentions

The Prevention of Begging Act, 1959 in Bombay Bombay in 1959 Act, Begging of Prevention The

WHO/Peter Williams WHO/Peter

Photo credit: Photo

of India (far right). (far India of

International Leprosy Union Union Leprosy International

D. Gokhale from the the from Gokhale D.

Group photo - Dr Sharad Sharad Dr - photo Group

of the community and that of the media, as it reaches the community at large. large. at community the reaches it as media, the of that and community the of

their families and rejected by their village folk. ILU’s task is to change the psyche psyche the change to is task ILU’s folk. village their by rejected and families their

who have been cured are not accepted back in society. They are abandoned by by abandoned are They society. in back accepted not are cured been have who

As far as patients are concerned, those who are under treatment or even those those even or treatment under are who those concerned, are patients as far As

From rejection to self-care self-care to rejection From

Field work work Field 3.2

all over the world. the over all

annually to outstanding workers and organizations in the field of leprosy from from leprosy of field the in organizations and workers outstanding to annually

the selection process for the International Gandhi Award that is given given is that Award Gandhi International the for process selection the

discriminate against persons affected by leprosy. It provides help in conducting conducting in help provides It leprosy. by affected persons against discriminate

works jointly with the GMLF in advocating for changes in the existing laws that that laws existing the in changes for advocating in GMLF the with jointly works

ILU collaborates closely with the GMLF in organizing meetings and seminars. It It seminars. and meetings organizing in GMLF the with closely collaborates ILU

Collaboration with the Gandhi Memorial Leprosy Foundation Leprosy Memorial Gandhi the with Collaboration

HIV/AIDS”.

“Issues surrounding families and children living in the shadow of leprosy and and leprosy of shadow the in living children and families surrounding “Issues

A workshop was also jointly organized with WHO in May 2005 in Pune on on Pune in 2005 May in WHO with organized jointly also was workshop A

Workshop

May 2005; and Ranchi, Jharkand State in November 2005. November in State Jharkand Ranchi, and 2005; May

Lucknow, Uttar Pradesh State in December 2004; Kolkata, West Bengal State in in State Bengal West Kolkata, 2004; December in State Pradesh Uttar Lucknow,

the community at large at community the

Bihar State in August 2004; Bhubaneshwar, Orissa State in December 2004; 2004; December in State Orissa Bhubaneshwar, 2004; August in State Bihar

the media, as it reaches reaches it as media, the

consultations were also held in Pune, Maharashtra State in June 2004; Patna, Patna, 2004; June in State Maharashtra Pune, in held also were consultations

community and that of of that and community

in elimination of leprosy in high-endemic states”. State- and district-level district-level and State- states”. high-endemic in leprosy of elimination in

the psyche of the the of psyche the

New Delhi in June 2004 on “Advocacy strategies and the role of the media media the of role the and strategies “Advocacy on 2004 June in Delhi New

ILU’s task is to change change to is task ILU’s

Consultations were held in Raipur, Chattisgarh in January 2004 and in in and 2004 January in Chattisgarh Raipur, in held were Consultations

National consultations National

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa International Leprosy

Union (India): “Life is beautiful”: 2006 (India)

ILU started developing programmes that begin with self-care. Self-care implies teaching a patient how to take care of their feet and hands. By supporting such initiatives, persons affected by leprosy are able to prevent new disabilities from developing or existing ones from getting worse. It also helps persons affected by leprosy to obtain certain appliances such as proper footwear, wheelchairs and crutches, which allow them to lead a productive life in society.

Looking after children and family members

ILU sponsors children and family members who have to live under the shadow of leprosy and HIV/AIDS. Support for education is provided to children on a yearly basis. The core belief of ILU is that sponsoring children of persons

ILU started affected by leprosy will allow them to live with their own families rather than in developing institutions. This effort has been successful since 1995. It also provides the next programmes that generation with developmental opportunities that will help them improve their begin with self-care. lives in future. Self-care implies True rehabilitation: factory run by persons affected by leprosy in Pune teaching a patient how to take care of With support from industrialists, ILU was able to set up a machine shop to their feet and hands produce automobile parts for Tata Engineering and Locomotive Company (TELCO). The TELCO trucks have a locking system that is fairly complicated. It is now made in the workshop staffed by persons affected by leprosy. The factory is unique in the sense that it is a cooperative run by persons affected by leprosy. These individuals take all the decisions with regard to production, financial policies, employment, or sharing profits among themselves. This initiative has been internationally recognized and has received the ILU award.

Providing small loans

Small loans are provided to persons affected by leprosy so that they are able to become productive members of society as well as their families. This allows them to be independent and empowers them to make decisions with regard to their daily lives and interaction with members of the community.

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reduce the stigma that has been prevalent for ages for prevalent been has that stigma the reduce

positive coverage in the mainstream media will help help will media mainstream the in coverage positive The struggle of persons affected by leprosy and its its and leprosy by affected persons of struggle The

response in an inclusive and non-stigmatizing way. non-stigmatizing and inclusive an in response

Society will have to listen to the changes occurring in leprosy and rectify its its rectify and leprosy in occurring changes the to listen to have will Society

mainstream media will help reduce the stigma that has been prevalent for ages. ages. for prevalent been has that stigma the reduce help will media mainstream

The struggle of persons affected by leprosy and its positive coverage in the the in coverage positive its and leprosy by affected persons of struggle The

nothing wrong with us.” with wrong nothing

society does not come to you, let us go to the society and tell them that there is is there that them tell and society the to go us let you, to come not does society

during the felicitation ceremony, one of the Lokdoots said, “My friends, if if friends, “My said, Lokdoots the of one ceremony, felicitation the during

journey back to the society where they once belonged. As a part of his speech speech his of part a As belonged. once they where society the to back journey

recognition provided them with confidence and supported them in their their in them supported and confidence with them provided recognition

Venkatraman and the WHO Goodwill Ambassador, Yohei Sasakawa. This This Sasakawa. Yohei Ambassador, Goodwill WHO the and Venkatraman

individuals were publicly felicitated by the former President of India, Sri R. R. Sri India, of President former the by felicitated publicly were individuals

ILU has been following this pattern, which started when a number of cured cured of number a when started which pattern, this following been has ILU

of stigma and aid in rehabilitating persons affected by leprosy into society. society. into leprosy by affected persons rehabilitating in aid and stigma of

messengers) to generate awareness about leprosy, work towards the elimination elimination the towards work leprosy, about awareness generate to messengers)

print and online media have agreed to become Madhyamdoots (media (media Madhyamdoots become to agreed have media online and print

as volunteers in this field. A large number of mediapersons from the electronic, electronic, the from mediapersons of number large A field. this in volunteers as

In addition, there are thousands of Boy Scouts and Girl Guides who are working working are who Guides Girl and Scouts Boy of thousands are there addition, In

registers persons who have been cured of leprosy as volunteers. volunteers. as leprosy of cured been have who persons registers

elimination and prevention of stigma. In the endemic states of India, ILU ILU India, of states endemic the In stigma. of prevention and elimination

Lokdoots, meaning peoples’ messengers), to spread awareness about leprosy leprosy about awareness spread to messengers), peoples’ meaning Lokdoots,

and have a family.” ILU has been supporting persons affected by leprosy (called (called leprosy by affected persons supporting been has ILU family.” a have and

“Look, I had leprosy, but I am happy, I am cured. I am working; I am married married am I working; am I cured. am I happy, am I but leprosy, had I “Look,

A man who has suffered can tell his tale with great confidence. When he says, says, he When confidence. great with tale his tell can suffered has who man A

and HIV/AIDS and

experience sharing is certainly more credible than any other form of advocacy. advocacy. of form other any than credible more certainly is sharing experience

the shadow of leprosy leprosy of shadow the

cured on a public platform so that they can tell their stories. This “first person” person” “first This stories. their tell can they that so platform public a on cured

who have to live under under live to have who

Apart from the mainstream media, it is vital to get individuals who have been been have who individuals get to vital is it media, mainstream the from Apart

and family members members family and

ILU sponsors children children sponsors ILU

Lokdoots and Madhyamdoots: the historic concepts historic the Madhyamdoots: and Lokdoots

Recognition, felicitation and awards and felicitation Recognition, 3.3

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Union (India): “Life is beautiful”: 2006 (India)

Award for outstanding work in leprosy

Each year, ILU gives an award to outstanding individuals and organizations for the work done in uplifting the lives of persons affected by leprosy.

3.4 Media and advocacy

Fighting the stigma: media fellowships (Madhyamdoot)

The next significant question that arises in this battle is: how do we change the mindset of society and use the media in this process? ILU has started a fellowship programme for media people to fund their visits to the homes of leprosy-affected persons who have been cured. They Each year, ILU gives an can talk to the family members and write about their experiences. With award to outstanding awareness generated on the issue, it will be easier for the community to individuals and accept such persons. In the battle against the stigma attached to leprosy, organizations for the ILU organized media partnership workshops in eight cities of India in late work done in uplifting 2005, reaching out to around 250 development and health journalists the lives of persons across all major media houses in the country. affected by leprosy Apart from the media fellowship programme, ILU’s aim is to counsel families living under the shadow of leprosy. Rehabilitation means making a leprosy-affected person economically self-sufficient, socially accepted and psychologically confident. Rehabilitation International and WHO convened a workshop in Geneva where a representative of ILU was invited. At this meeting, a standard definition was evolved.

Media workshops

A media workshop was held in New Delhi in January 2005 in collaboration with the Centre for Media Research. Eight media partnership workshops were also held to sensitize over 300 media personnel across India to seek their support in getting across the right message about leprosy in their coverage.

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discrimination in India and Nepal and India in discrimination

Trust to produce a film on reducing stigma and and stigma reducing on film a produce to Trust

ILU also collaborated with the BBC World World BBC the with collaborated also ILU psychologically confident psychologically

socially accepted and and accepted socially

self-sufficient, self-sufficient, out surveys to collect such data. data. such collect to surveys out

person economically economically person human rights. The Indian Human Rights Commission also requested ILU to carry carry to ILU requested also Commission Rights Human Indian The rights. human

making a leprosy-affected leprosy-affected a making requested to conduct a survey and collect data on the subject of stigma and and stigma of subject the on data collect and survey a conduct to requested

Rehabilitation means means Rehabilitation 2005. ILU helped in organizing a workshop on human rights. ILU was also also was ILU rights. human on workshop a organizing in helped ILU 2005.

the shadow of leprosy. leprosy. of shadow the subcommission on this subject, which made a trip to Pune, India in March March in India Pune, to trip a made which subject, this on subcommission

families living under under living families The United Nations Human Rights Commission has established a a established has Commission Rights Human Nations United The

ILU’s aim is to counsel counsel to is aim ILU’s

Research and documentation on human right issues right human on documentation and Research 3.5

below, it stated, “We were all leprosy patients.” patients.” leprosy all were “We stated, it below,

the poster was, “There is one thing common amongst us” and in very fine print print fine very in and us” amongst common thing one is “There was, poster the

work – one was a manager, the other a nurse and another a doctor. The title of of title The doctor. a another and nurse a other the manager, a was one – work

Posters were designed with photographs of individuals from various fields of of fields various from individuals of photographs with designed were Posters

for their successful treatment and being able to lead a normal life in society. society. in life normal a lead to able being and treatment successful their for

A campaign was started in 2005 by congratulating persons affected by leprosy leprosy by affected persons congratulating by 2005 in started was campaign A

India and Nepal. Nepal. and India

the BBC World Trust to produce a film on reducing stigma and discrimination in in discrimination and stigma reducing on film a produce to Trust World BBC the

people) was produced and screened in January 2005. ILU also collaborated with with collaborated also ILU 2005. January in screened and produced was people)

A film titled “Chalo Lokdoot Bane” (let us become the messengers of the the of messengers the become us (let Bane” Lokdoot “Chalo titled film A

Somaiya Publications Somaiya

• , 1984, published by by published 1984, , programmes and policies Rehabilitation •

Somaiya Publications, and Publications, Somaiya

• , 1993, published by by published 1993, , strategies intervention Dehabilitation •

• , 1998, published by Ameya Prakashan Ameya by published 1998, , leprosy of face Human •

• , 2005, published by Icons media Icons by published 2005, , regained Dignity •

published the following books: following the published

Lokdoots and honours the efforts they make at the community level. ILU has has ILU level. community the at make they efforts the honours and Lokdoots

published every quarter. The newsletter covers the outstanding work of the the of work outstanding the covers newsletter The quarter. every published

A quarterly newsletter called the Last Mile was started in January 2005 and is is and 2005 January in started was Mile Last the called newsletter quarterly A

Production of educational materials materials educational of Production

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Union (India): “Life is beautiful”: 2006 (India)

ILU took the initiative to develop a grievance redress cell. It collects complaints on breaches of human rights. ILU examines them and forwards them to the State and National Human Rights Commission, which examine the complaints and re-establish the rights.

3.6 Networking with other organizations

ILU has been successful in networking with the International Leprosy Association (ILA) and International Association for Integration, Dignity and Economic Advancement (IDEA) in promoting the rights of persons affected by leprosy, by participating in the various meetings and forums held by them. It continues to also network with various media organizations throughout India to get support

The discovery of from the media in sending out positive information about the disease as well as multidrug therapy about the rights of persons affected by leprosy. (MDT) in 1981 made it possible for leprosy patients to be cured

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leprosy-free country. leprosy-free

of history and that India will achieve Mahatma Gandhi’s dream of becoming a a becoming of dream Gandhi’s Mahatma achieve will India that and history of

rehabilitation. Through these efforts, it hopes that the disease will become part part become will disease the that hopes it efforts, these Through rehabilitation.

care along with the provision of development opportunities for economic economic for opportunities development of provision the with along care

persons affected by leprosy. It also hopes to generate awareness of self- of awareness generate to hopes also It leprosy. by affected persons

Through its programmes, ILU hopes to instil self-confidence and empower empower and self-confidence instil to hopes ILU programmes, its Through

Conclusion 4.

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Mrs Dian Syarief, chairperson of Syamsi Dhuha Foundation (SDF), winner of the Sasakawa Health Prize, addressing the 65th World Health Assembly on behalf of her foundation

183 CHAPTER 12 2012

Never give up[*]

Recipient: Syamsi Dhuha Foundation (Indonesia)

[*] Syamsi Dhuha Foudation (SDF) Jl. Ir. H. Juanda 369 Komp. DDK No. 1 Bandung 40135 – Indonesia 184 yamsi Dhuha, which means morning light, was born out of Sgratitude for God's unfathomable love and grace, which shines through a “disaster” of an ailment

1. Introduction Indonesia The Syamsi Dhuha Foundation (SDF) is located in Bandung, Indonesia. Syamsi Dhuha, which means morning light, was born out of gratitude for God's unfathomable love and grace, which shines through a “disaster” of an ailment. An ailment is often perceived as a tragedy, but it can also morph into an extraordinary expression of God's love and grace.

Few people know about the disease named lupus, or systemic lupus erythematosus (SLE), which is a chronic autoimmune disease. It is also known as the “great imitator”, as it can mimic the symptoms of Few people know various other diseases, causing difficulty in diagnosis. Its cause and cure about the disease are unknown. If it is not detected early and treated appropriately, its named lupus, or consequences can be as fatal as those of cancer. It can attack various bodily systemic lupus systems and organs. The symptoms range from mild to serious, and could erythematosus (SLE), be even life-threatening. Some factors suspected of triggering lupus include which is a chronic genetic predisposition, hormones and the environment (medicine, poison, autoimmune disease food and sunlight). Lupus patients undergo a dramatic change in their personal and family lives, which is occasionally very hard to cope with. To some, their direct involvement with this ailment, either as a patient or supporter, has been an experience that should be patients, doctors, nurses, hospitals and a wider public.

2. The beginning

SDF began by realizing the value of this experience. Initially SDF, through one of its programmes, “Care for lupus”, sought to encourage the friends of odapus (people living with lupus) and their families, through various activities that benefit communities beyond the lupus circle. In line with its mission (“as an avenue of charity to attain joy in this world and beyond the earthly life”), SDF aspires to involve everyone, not just odapus, in many activities that can benefit individuals and others.

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cost of medication of cost

financial difficulties due to the relatively high high relatively the to due difficulties financial

in Indonesia is the fact that many of them have have them of many that fact the is Indonesia in One of major challenges facing lupus patients patients lupus facing challenges major of One

lupus patients are assisted to strengthen their faith by cultivating a belief belief a cultivating by faith their strengthen to assisted are patients lupus

spiritual aspects of patients. In a support session called Contemplation, Contemplation, called session support a In patients. of aspects spiritual

publicity about the disease. A unique approach is to strengthen the the strengthen to is approach unique A disease. the about publicity

and public education through seminars and talk shows to generate generate to shows talk and seminars through education public and

SDF lobbies with the media and others to support awareness campaigns campaigns awareness support to others and media the with lobbies SDF

cost or free drugs for lupus patients, as provided for AIDS patients. patients. AIDS for provided as patients, lupus for drugs free or cost

Association (IRA), SDF approached the Ministry of Health to provide low- provide to Health of Ministry the approached SDF (IRA), Association

discounts for lupus patients. Supported by the Indonesian Rheumatism Rheumatism Indonesian the by Supported patients. lupus for discounts

building networks with clinical laboratories and pharmacists to provide provide to pharmacists and laboratories clinical with networks building

This directed SDF’s priority objective of lessening the financial burden by by burden financial the lessening of objective priority SDF’s directed This

medication, and most of them are not covered by private health insurance. insurance. health private by covered not are them of most and medication,

many of them have financial difficulties due to the relatively high cost of of cost high relatively the to due difficulties financial have them of many

individuals and others and individuals

One of major challenges facing lupus patients in Indonesia is the fact that that fact the is Indonesia in patients lupus facing challenges major of One

activities that can benefit benefit can that activities

odapus, in many many in odapus, theses on lupus. on theses

everyone, not just just not everyone, SDF encourages university students from several disciplines to undertake undertake to disciplines several from students university encourages SDF

SDF aspires to involve involve to aspires SDF identifying what needs to be done to support them. Through this database, database, this Through them. support to done be to needs what identifying

of patients. The database, though a modest is the primary source of of source primary the is modest a though database, The patients. of

a database that would help create a better picture of the demography demography the of picture better a create help would that database a

first step taken by the Foundation was to collect information to establish establish to information collect to was Foundation the by taken step first

SDF’s membership has grown to almost 600 members currently. The The currently. members 600 almost to grown has membership SDF’s

public awareness about lupus since 2004. Starting with just 10 members, members, 10 just with Starting 2004. since lupus about awareness public

began conducting activities to help and support lupus patients and build build and patients lupus support and help to activities conducting began

Learning from how peer groups operate in other countries, SDF has been been has SDF countries, other in operate groups peer how from Learning

Lupus Foundation). Foundation). Lupus

and the other is the Jakarta-based Yayasan Lupus Indonesia (Indonesian (Indonesian Indonesia Lupus Yayasan Jakarta-based the is other the and

Currently, there are very few peer groups in Indonesia; one of them is SDF SDF is them of one Indonesia; in groups peer few very are there Currently,

are also required to find ways to lessen the financial and mental burden. burden. mental and financial the lessen to ways find to required also are

to not only provide education and advocacy to help lupus patients, but but patients, lupus help to advocacy and education provide only not to

country’s total population, Indonesian lupus peer groups are expected expected are groups peer lupus Indonesian population, total country’s

With approximately 200 000 people living with lupus or 0.1% of the the of 0.1% or lupus with living people 000 200 approximately With

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Foundation, Indonesia

that suffering from a sickness is not the end of the world. In other words, no matter how bad the physical condition, the soul and mind need to

Indonesia be peaceful and healthy. Making friends with lupus instead of fighting against it is a unique approach introduced by SDF to cope with lupus. An article on this subject was written by Ms Dian Syarief, the founder and chairperson of SDF and herself a victim of lupus, and published in the local newspaper, Jakarta Post.

Despite very limited resources, including finances, human capital, technology and public support, SDF continues working with many parties, striving to face the challenges and hoping to be a role model for other peer groups in Indonesia. The Foundation focuses on education 3. Activities at the Syamsi Dhuha Foundation and socialization The Foundation focuses on three major activities under the “Care for lupus programme, and the and care for low vision” programme. These aim to improve the quality Care for lupus of life of people living with lupus and low vision. They include a support group programme, an education and socialization programme, and the Care for lupus SDF awards.

3.1 Support group programme

Under the support group programme, which is supported by many volunteers including doctors, SDF provides information to patients and their families about lupus and low vision by answering questions raised by them. Text (sms), e-mail, phone and other communication channels, including the social media, are used to communicate with members and the public at large. Under this programme, some regular activities are also carried out, such as sharing sessions and contemplation, sports and recreational activities, and an English conversation club. Besides lupus, the Foundation also has an empowering programme to help improve the quality of life of people with low vision. Some programmes that have been conducted include the Shiatsu Massage Training and Certification Programme, Computer Training and Certification Programme for low vision and blind people, and writing skills for low vision and blind people.

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and internationally. Three abstracts and poster presentations were submitted to the the to submitted were presentations poster and abstracts Three internationally. and

increased awareness of lupus and the existence of the Foundation, both locally locally both Foundation, the of existence the and lupus of awareness increased

Shanghai, China in 2007 and in Vancouver, Canada in 2010. This effort has has effort This 2010. in Canada Vancouver, in and 2007 in China Shanghai,

submitted a poster presentation to the International Congress on Lupus, in in Lupus, on Congress International the to presentation poster a submitted

“Luppy”. In addition to books, SDF has published articles in the media, and and media, the in articles published has SDF books, to addition In “Luppy”.

To make it easier to explain lupus, SDF created an animated character named named character animated an created SDF lupus, explain to easier it make To

• • Luppy’s note, the medical diary (2012) diary medical the note, Luppy’s

• • The cheeky Luppy is here again (questions and answers on lupus, 2011) lupus, on answers and (questions again here is Luppy cheeky The

and the media the and

• •

Luppy my cheeky friend (animation book and DVD about lupus, 2010) lupus, about DVD and book (animation friend cheeky my Luppy also medical doctors doctors medical also

their families, but but families, their • • Care for lupus (music album, 2009) album, (music lupus for Care

only patients and and patients only

• • Love enables me to raise up (2009) up raise to me enables Love

programme are not not are programme

• • Miracle of love, journeying with lupus towards God (2008) God towards lupus with journeying love, of Miracle

and socialization socialization and

for this education education this for

and one music album: album: music one and

The target audiences audiences target The

Under the education and socialization programme, SDF has published some books books some published has SDF programme, socialization and education the Under

media plays an important role in bringing awareness of lupus to the public at large. large. at public the to lupus of awareness bringing in role important an plays media

and medical professionals, SDF held lupus training for the media in 2011, as the the as 2011, in media the for training lupus held SDF professionals, medical and

were attended by more than 200 participants. Besides providing training to patients patients to training providing Besides participants. 200 than more by attended were

two training sessions for primary care doctors in rural areas have been held, and and held, been have areas rural in doctors care primary for sessions training two

perform their tasks in rural areas. With the cooperation of the local government, government, local the of cooperation the With areas. rural in tasks their perform

Therefore, the Foundation has initiated training for medical doctors to help them them help to doctors medical for training initiated has Foundation the Therefore,

to be aware of the symptoms and know how to arrive at a diagnosis of lupus. lupus. of diagnosis a at arrive to how know and symptoms the of aware be to

doctors and the media. Primary care doctors, as first-line health providers, have have providers, health first-line as doctors, care Primary media. the and doctors

socialization programme are not only patients and their families, but also medical medical also but families, their and patients only not are programme socialization

aspect of the Foundation’s activities. The target audiences for this education and and education this for audiences target The activities. Foundation’s the of aspect

have in diagnosing it, the education and socialization programme is an important important an is programme socialization and education the it, diagnosing in have

Realizing that lupus is still a relatively unknown disease and the difficulties doctors doctors difficulties the and disease unknown relatively a still is lupus that Realizing

3.2 Education and socialization programme socialization and Education 3.2

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Foundation, Indonesia

Award winners and representatives of the foundations presenting awards are applauded by assembled delegates

Indonesia 8th and 9th International Congress on SLE in Shanghai and Vancouver, respectively:

•• Strengthening the faith – a spiritual healing for lupus patients •• Challenges for Indonesian’s lupus peer group •• How to make friends with lupus During the 9th International Congress on SLE in Vancouver, SDF was invited as one of the four panelists to speak at the Global Voluntary Initiative Discussion, together with representatives from the Lupus As part of the global Foundation of Canada, Lupus Europe and Lupus Foundation of America. lupus community, SDF was among the 29 recipients of the “International Lifetime SDF actively promotes Achievement Award” from the Committee of the Congress. awareness of lupus As part of the global lupus community, SDF actively promotes awareness of lupus. It is increasingly drawing the government’s attention to the disease by conducting an annual event to commemorate World Lupus Day (WLD). The WLD annual gathering is one example of promoting awareness, educating patients and the public, as well as creating an understanding of what lupus is and how to live with it. This WLD annual event has become a forum for almost all stakeholders: doctors, nurses, patients, hospitals, pharmaceutical companies, government officers, universities, students, volunteers and the media. The agenda includes free consultation for lupus patients and the public with many specialist doctors, Walk for Lupus, volunteers on the street, lupus talk show and seminar, bazaar and exhibition, and an art and music performance. This event has proven successful in raising the motivation of those with lupus and serves as an excellent media event to raise awareness, caring and cooperation among stakeholders.

As a result of the initial WLD gatherings in 2004 and 2006, SDF realized the difficulties of many poor people in accessing major lupus drugs. After a discussion with and support from the Indonesian Association of

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cost of medication of cost

financial difficulties due to the relatively high high relatively the to due difficulties financial

in Indonesia is the fact that many of them have have them of many that fact the is Indonesia in One of major challenges facing lupus patients patients lupus facing challenges major of One

universities in Indonesia. Indonesia. in universities

proposals were submitted (increased from 15 in 2011) from several several from 2011) in 15 from (increased submitted were proposals

the quality of life of people living with lupus. Thirty-five research research Thirty-five lupus. with living people of life of quality the

one category of research was added, i.e. “All about lupus” to improve improve to lupus” about “All i.e. added, was research of category one

In 2012, in addition to the research sponsorship for herbal supplements, supplements, herbal for sponsorship research the to addition in 2012, In

treat, and/or prevent SLE and its consequences. its and SLE prevent and/or treat,

example or act have advanced local efforts to understand, understand, to efforts local advanced have act or example

patients and the public at large who by word, deed, deed, word, by who large at public the and patients

• To appreciate local institutions, health professionals, professionals, health institutions, local appreciate To •

with lupus with

distribution of lupus drugs lupus of distribution

• To increase national awareness of and caring for people people for caring and of awareness national increase To •

imbalance and inequity in in inequity and imbalance

for lupus for

Health to overcome the the overcome to Health

supplementary therapies and herbal-based medicines medicines herbal-based and therapies supplementary

to the Ministry of of Ministry the to

• To encourage and support research on finding finding on research support and encourage To •

lupus drugs distribution" distribution" drugs lupus

parties in Indonesia for the control of lupus lupus of control the for Indonesia in parties

"Special channel for for channel "Special

• To strengthen and enhance cooperation among relevant relevant among cooperation enhance and strengthen To •

a programme called called programme a

proposed initiating initiating proposed

programme are: programme

The foundation also also foundation The

to hold this programme on an annual basis. The objectives of this this of objectives The basis. annual an on programme this hold to

writing competition award and lifetime achievement award. SDF strives strives SDF award. achievement lifetime and award competition writing

categories of awards were created – research sponsorships award, award, sponsorships research – created were awards of categories

In 2011, SDF initiated the “Care for lupus SDF awards”. Three Three awards”. SDF lupus for “Care the initiated SDF 2011, In

3.3 Care for lupus SDF awards SDF lupus for Care 3.3

drugs, especially to the villages, and rural and remote areas. remote and rural and villages, the to especially drugs,

Health to overcome the imbalance and inequity in distribution of lupus lupus of distribution in inequity and imbalance the overcome to Health

called "Special channel for lupus drugs distribution" to the Ministry of of Ministry the to distribution" drugs lupus for channel "Special called

Health. In 2012, the foundation also proposed initiating a programme programme a initiating proposed also foundation the 2012, In Health.

a petition signed by 1500 people was delivered to the Ministry of of Ministry the to delivered was people 1500 by signed petition a

insurance programme for poor people (jamkesnas). During the meeting, meeting, the During (jamkesnas). people poor for programme insurance

include lupus drugs in the eligible drugs list within the national health health national the within list drugs eligible the in drugs lupus include

2006 to advocate for the distribution of low-cost lupus drugs and to to and drugs lupus low-cost of distribution the for advocate to 2006

Rheumatology, SDF initiated a meeting with the Minister of Health in in Health of Minister the with meeting a initiated SDF Rheumatology,

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The judges consisted of professors, lecturers and medical doctors from Indonesia the School of Pharmacy, Institute of Technology, Bandung and Faculty of Medicine, Padjadjaran University. They selected three winners from among 26 proposals for herbal supplements, and two winners from among nine proposals for “All about lupus”. The award, IDR 30 million (US$ 3100), was granted to the respective winners to defray research expenses. The natural resources being studied are jackfruit seed, sweet potato and Kalanchoe pinnata.

Ten articles on the topic of lupus published in the media were

SDF aims to have a submitted for the writing competition this year and three of them were comprehensive lupus selected as winners. clinic, where various In the lifetime achievement category, the committee selected 10 specialist doctors will individuals, doctors and institutions for their work in supporting people attend, and diagnostics with lupus and their families, promoting public education and awareness and rehabilitation are about lupus, and striving for a call to action by the government to increase integrated in one place financial support for lupus research, awareness and patient services.

In the long run, SDF aims to have a comprehensive lupus clinic, where various specialist doctors will attend, and diagnostics and rehabilitation are integrated in one place.

4. Conclusion

During the introductory speech before the Award presentation, Mr Yohei Sasakawa of the Sasakawa Memorial Health Foundation stated that besides the innovative work done by the Foundation, what was even more interesting was that the work was initiated and led by a lupus patient with low vision. Ms Dian Syarief, chairperson of SDF, was diagnosed with lupus in 1999. She had to undergo several major surgeries: six craniotomies due to brain abscess, gallbladder removal, uterus removal, among others. She also suffers from low vision, as she had lost 95% of her eyesight due to brain abscess. Despite struggling with her own illness, her desire to

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shoulder-to-shoulder with SDF SDF with shoulder-to-shoulder

it was shared with everyone who had worked hard hard worked had who everyone with shared was it

gratitude at having received the award and said that that said and award the received having at gratitude Mr Eko Pratomo, the founder of SDF, expressed his his expressed SDF, of founder the Pratomo, Eko Mr

international forum. international

have helped Indonesia's humanitarian diplomatic initiatives in an an in initiatives diplomatic humanitarian Indonesia's helped have

The honourable achievements of Dian and Eko through their Foundation Foundation their through Eko and Dian of achievements honourable The

eight years ago. years eight

quality of life for lupus and low vision patients ever since SDF was born born was SDF since ever patients vision low and lupus for life of quality

education, socialization, support and research programmes to improve the the improve to programmes research and support socialization, education,

had worked hard shoulder-to-shoulder with SDF in running various various running in SDF with shoulder-to-shoulder hard worked had

received the award and said that it was shared with everyone who who everyone with shared was it that said and award the received

Mr Eko Pratomo, the founder of SDF, expressed his gratitude at having having at gratitude his expressed SDF, of founder the Pratomo, Eko Mr

lupus in Indonesia in lupus

of the management of of management the of

their appreciation of the efforts conducted in Indonesia. Indonesia. in conducted efforts the of appreciation their

community's awareness awareness community's

her address, Ms Syarief thanked the Sasakawa Foundation and WHO for for WHO and Foundation Sasakawa the thanked Syarief Ms address, her

the government’s and and government’s the

Foundation, Ms Dian Syarief, made an acceptance speech in English. In In English. in speech acceptance an made Syarief, Dian Ms Foundation,

that have increased increased have that

award ceremony were moved when the Founder and Chairperson of the the of Chairperson and Founder the when moved were ceremony award

innovations and activities activities and innovations

lupus in Indonesia. Delegates from WHO Member States attending the the attending States Member WHO from Delegates Indonesia. in lupus

commitment to various various to commitment

the government’s and community's awareness of the management of of management the of awareness community's and government’s the

award for its ongoing ongoing its for award

commitment to various innovations and activities that have increased increased have that activities and innovations various to commitment

The SDF received the the received SDF The

Sasakawa were also present. The SDF received the award for its ongoing ongoing its for award the received SDF The present. also were Sasakawa

the World Health Organization (WHO) Dr Margaret Chan and Mr Yohei Yohei Mr and Chan Margaret Dr (WHO) Organization Health World the

Health Assembly, Professor Therese N’Dri Yoman. The Director-General of of Director-General The Yoman. N’Dri Therese Professor Assembly, Health

the Sasakawa Health Prize 2012 by the President of the Sixty-fifth World World Sixty-fifth the of President the by 2012 Prize Health Sasakawa the

24 May 2012 when the Syamsi Dhuha Foundation (SDF) was awarded awarded was (SDF) Foundation Dhuha Syamsi the when 2012 May 24

Goodwill for Indonesia was evident at the Palais de Nations in Geneva on on Geneva in Nations de Palais the at evident was Indonesia for Goodwill

Epilogue 5.

motivating her lupus and low vision friends and others. others. and friends vision low and lupus her motivating

and “NEVER GIVE UP!” are the three messages she always conveys in in conveys always she messages three the are UP!” GIVE “NEVER and

“Care for lupus, your caring save lives”; “Low vision, care and share” share” and care vision, “Low lives”; save caring your lupus, for “Care

her to run the Foundation. Foundation. the run to her

motivating and mobilizing others to get involved and work together with with together work and involved get to others mobilizing and motivating

spread awareness about the disease and help others was instrumental in in instrumental was others help and disease the about awareness spread

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Foundation, Indonesia

th Indonesia Ms Dian Syarief’s acceptance speech at the 65 World Health Assembly, 2012

Distinguished Delegates, Ladies and Gentlemen,

We thank the Sasakawa Foundation and the World Health Organization for their appreciation of our endeavour in Indonesia.

For us, being part of millions of people worldwide who have lost their prime health and eyesight, life has taught us amazing lessons. Indeed, having good health and being able to see are two indispensable, invaluable Limitations are a part aspects of life. They cannot be substituted with anything else. We didn't of life, and they exist realize this truth when we still had them and took them for granted. in every country in the world. What we can Limitations are a part of life, and they exist in every country in the world. do is to keep alive our What we can do is to keep alive our zeal to survive and to thrive, and zeal to survive and to our effort to reach the goals. Even if we have to lose to a disease, we shall thrive, and our effort concede defeat with honour because we will have done our best with all to reach the goals of our strength.

As Hilary Rodham Clinton said once: "I can accept losing. I cannot accept quitting."

Every gesture, every action of care from one person to another will be a source of encouragement and power to survive together in doing our best.

Never give up! Care for lupus; your caring saves lives.

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Prize as the WHO Director-General, Dr Margaret Chan, applauds Chan, Margaret Dr Director-General, WHO the as Prize

presents Mrs Dian Syarief and Mr Eko Pratomo with the 2012 Sasakawa Health Health Sasakawa 2012 the with Pratomo Eko Mr and Syarief Dian Mrs presents

World Health Assembly, Assembly, Health World 65 the of President N’Dri-Yoman, Thérèse Professor

E - S A ast outh from stories sia Sasakawa Health Prize: Prize: Health Sasakawa Annex 1

Statutes of the Sasakawa Health Prize (as amended in January 1998)

Article 1 Establishment

Under the title of the “Sasakawa Health Prize”, a Prize is established within the framework of the World Health Organization, which shall be governed by the following provisions.

Article 2 The Founder

The Prize is established upon the initiative of and with funds provided by Mr Ryoichi Sasakawa, Chairman of the Japan Shipbuilding Industry Foundation and President of the Sasakawa Memorial Health Foundation.

Article 3 Capital

The Founder endows the Prize with an initial capital in Japan of US$ 1 million. The capital of the Prize may be increased by income from its undistributed reserves or by gifts and bequests. The Founder shall designate the Sasakawa Memorial Health Foundation to be responsible for investment of the capital and any undistributed reserves.

Article 4 Prize

The Sasakawa Health Prize shall consist of a statuette and a sum of money of the order of US$ 100 000 to be given to a person or persons, an institution or institutions, or a nongovernmental organization or organizations having accomplished outstanding innovative work in health development, such as the promotion of given health programmes or notable advances in primary health care, in order to encourage the further development of such work. Current and former staff members of the World Health Organization, and current members of the Executive Board, shall be ineligible to receive the Prize. The sum of money, derived from the income and/or the undistributed reserves, shall be determined by the Prize Selection Panel. The Prize shall be presented during a meeting of the World Health Assembly to the recipient(s) or to a person(s) representing the recipient(s).

195 Sasakawa Health Prize: stories from South-East Asia

Article 5 Prize Selection Panel

The Selection Panel entitled the “Sasakawa Health Prize Selection Panel” shall be composed of: the Chairman of the Executive Board, a member elected by the Executive Board from among its members for a period that may not exceed the duration of his or her terms of office on the Executive Board, and a representative appointed by the Founder.

Article 6 Proposal and selection of candidates for the Prize

Any national health administration as well as any former recipient of the Prize may put forward the name of a candidate for the Prize. Proposals shall be made to the Administrator who will submit them to the Prize Selection Panel together with his technical comments. The Selection Panel will decide in private meeting, by a majority of its members, on the recommendation to be made to the Executive Board of the World Health Organization, whose decision shall be final.

Article 7 Administrator

The Prize shall be administered by its Administrator, namely the Director-General of the World Health Organization, who shall act as Secretary of the Prize Selection Panel.

The Administrator shall be responsible:

1. For the execution of the decisions taken by the Prize Selection Panel within the limits of its powers as defined in these Statutes; and

2. For the observance of the present Statutes and generally for the administration of the Sasakawa Health Prize in accordance with these Statutes.

Article 8 Accountability

Reports on work carried out by recipients of the Prize shall, where appropriate, be submitted annually to the Administrator, who shall be accountable to the World Health Assembly for operations effected by virtue of these Statutes.

Article 9 Revision of the Statutes

On the motion of one of its members, the Prize Selection Panel may propose revision of the present Statutes. Any such motion, if endorsed by a majority of the members of the Selection Panel, shall be submitted to the Executive Board for its approval. Any revision shall be reported for information to the next session of the World Health Assembly.

196 Annex 2

Sasakawa Health Prize Guidelines (as amended in January 1998)

(1) The Sasakawa Health Prize consisting of a statuette and a sum of money of the order of US$100000, will be awarded for outstanding innovative work in health development.

(2) The Prize will be given to a person or persons, an institution or institutions, or a nongovernmental organization or organizations having accomplished notable advances in the health field in recent years, particularly since the promotion of the strategy for achieving health for all by the year 2000.

(3) The Prize aims at encouraging the further development of outstanding innovative work in health development that has already been accomplished and extends far beyond the call of normal duties; it is not intended as a reward for excellent performance by a candidate of duties normally expected of an official occupying a government position or of a governmental or intergovernmental institution.

(4) The following criteria will be applied in the assessment of the work done by the candidate/candidates:

(a) Contribution to the successful formulation and implementation of the national policy and strategy for health for all by the year 2000;

(b) Promotion of and substantial achievement in advancing given health programmes which have resulted in increasing primary health care coverage, and/or improving the quality of health care to the population, and a notable reduction of given health problems;

(c) Contribution to increased efficiency and management of health systems; policy development, health legislation and ethics, within the framework of primary health care;

(d) Innovative programmes to reach socially and geographically disadvantaged population groups;

(e) Innovative efforts in training and education of health workers in primary health care;

197 Sasakawa Health Prize: stories from South-East Asia

(f) Successful and effective efforts in involving communities in planning, management and evaluation of primary health care programmes;

(g) Development and successful application of health systems research for the advancement of primary health care.

(5) The candidate/candidates nominated for the Prize must be intimately and directly connected with the efforts and achievements in a given area and must have the possibility of remaining involved in the further development of this work.

(6) As one of the main objectives of the Prize is to encourage the further development of such work, the candidate/candidates will be requested to indicate how the award funds would be used for this purpose. The recipient/recipients of the award will, where appropriate, be required to submit annually a report on work carried out to the Administrator of the Prize.

(7) To facilitate the assessment of the work done and the accomplishments, the most recent and pertinent documentation directly related to the work should be submitted along with the nomination. Such materials should illustrate clearly the nature of work carried out, the results achieved, the difficulties and obstacles encountered, and the solutions proposed and implemented; they need not necessarily have been published in a scientific or other journal. Inadequate or inappropriate documentary evidence of the work carried out will greatly handicap the Prize Selection Panel in the assessment of the candidature.

(8) To further support the documentary evidence, if necessary, the Administrator, on behalf of the Prize Selection Panel, reserves the right to examine the work done by the candidate/candidates.

(9) Current and former staff members of the World Health Organization, and current members of the Executive Board, shall be ineligible to receive the Prize.

(10) If more than one candidate is considered eligible by the Prize Selection Panel and selected to receive the Prize, the sum will be proportionately distributed between them.

(11) These guidelines will be reviewed and updated periodically as considered appropriate.

198 Annex 3

Recipients of the Sasakawa Health Prize

2012 Syamsi Dhuha Foundation (Indonesia) 2011 Dr Eva Siracká (Slovakia) Pequeña Familia de María/Albergue Maria Association (Panama)

2010 Dr Xueping Du (China)

2009

Dr Amal Abdurrahman Al Jowder (Bahrain)

2008 Movement for Reintegration of People Affected by Hansen’s Disease (MORHAN) (Brazil)

2007 Dr Jose Antonio Socrates (Philippines)

2006 International Leprosy Union (India) Agape Rural Health Program - Holistic Community Based Health Development Program (Puerto Princesa City, Palawan, Philippines)

2005 Centre for Training and Education in Ecology and Health for Peasants (Mexico)

2004 The Family Planning Association of Sri Lanka (Sri Lanka)

2003 Department of Health Center for Health Development - Eastern Visayas (Philippines) Yemen Leprosy Elimination Society (Republic of Yemen)

199 Sasakawa Health Prize: stories from South-East Asia

2002 Programa Nacional de Atención Odontológica Integral para Mujeres Travbajadoras de Escasos Recursos (Chile)

2001 Dr João Aprigio Guerra de Almeida (Brazil)

2000 Dr Yoav Horn (Israel) Dr Oviemo Otu Ovadje (Nigeria) Family Planning Association (PLAFAM) (Venezuela)

1999 Dr J.G. Ortiz Guier (Costa Rica) Institute of Urban Primary Health Care (South Africa)

1998 Ms Roselyn Mokgantsho Mazibuko (South Africa) Dr Ahmed Abdul Qadr Al Ghassani (Oman) Gondar College of Medical Sciences (Ethiopia)

1997 The Mongar Health Services Development Project (Bhutan)

1996 Father A. Gherardi (Chad) Society for Health Education (Maldives)

1995 Dr J. Torres Goitia Torres (Bolivia) Professor Le Kinh Due (Viet Nam)

1994 Dr Mo-Im Kim (Republic of Korea)

1993 Professor Oladapo Alabi Ladipo and Mrs Grace Ebun Delano (Nigeria) Arpana Research and Charities Trust (India)

200 1992 Dr Handojo Tjandrakusuma (Indonesia) Mme Brigitte Girault et M. Badara Samb (Senegal) Canadian Public Health Association (Canada)

1991 Dr Hector Martinez Gomez and Dr Edgar Rey Sanabria (Colombia) The Regional Centre for Development and Health/Primary Health Care (Benin) The Vulowai Health Committee (Fiji)

1990 Monsignor Fiorenzo Angelini (Holy See) Professor B. N. Tandon (India) Biankouri Health Centre (Togo)

1989 Dr Niu Dongping (China)

1988 Dr Christian Aurenche (France/Cameroon) Indonesian Family Welfare Movement (PKK) (Indonesia)

1987 Sister Marie Joan Winch (Australia)

1986 Ayadaw Township People’s Health Plan Committee (Myanmar) Dr Lucille Teasdale Corti and Dr Pietro Corti (Uganda) Dr Amorn Nondasuta (Thailand)

1985 Dr Jesus C. Azurin (Philippines) Dr David Bersh Escobar (Colombia) SEWA-RURAL (Society for Education, Welfare and Action - Rural) (India)

201

Mr Yohei Sasakawa, WHO Goodwill Ambassador for Leprosy Elimination and on behalf of the Sasakawa Memorial Health Foundation, addresses the delegates before presenting the 2012 Sasakawa Health Prize. This prize is awarded for outstanding and innovative work in health development.

The Alma-Ata Conference on Primary Health Care in 1978 mobilized a "primary health care (PHC) movement that undertook to tackle the "politically, socially and economically unacceptable health inequalities In all countries. The Declaration of Alma-Ata was clear about the values to be strengthened - social justice, equity and the right to better health for all. Most countries of the South-East Asia Region undertook a variety of initiatives to translate these values into tangible reforms, and many achieved commendable success. One long-term Impact has been that, today, health equity enjoys Increased prominence and acceptance In the discourse of political leaders and ministries of health.

This book is an attempt to capture some of the PHC-related success stories In the South-East Asia Region, the benchmark for the choice being that all of these efforts earned global recognition by being awarded the prestigious Sasakawa Health Prize of the World Health Organization.

Apart from being interesting case studies they hold many valuable lessons for health development today, to "put people at the centre of health care.

ISBN 978 92 9022 411 2

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