Health for All

Overview

Health for All (HfA) is a project supported by Motorcycle Outreach providing motorcycles to support primary health delivery in Nusa Tenggara Timur (NTT) in eastern Indonesia. As of 2010 the area covered is 55 villages with a total population of 55,000.

As a clear illustration of the need for this; in one area child malnutrition dropped from 167 to 27 cases within seven months of the motorcycles being introduced.

Health for All continues to implement a program of Transport Resource Management (TRM) specifically providing zero breakdown motorcycles for rural health deliveries. This includes vaccines for children, maternal and child health care, tuberculosis, malaria and STD-HIV/AIDS treatment.

A key aspect of the Health for All work in NTT is that the motorcycles are used to reinforce and extend the effectiveness of the existing health resources provided through the national healthcare system of Indonesia. Health for All serves as a model for more widespread use of motorcycles to provide safe and effective healthcare delivery in remote areas across the country.

By working directly with existing Indonesian healthcare arrangements Health for All has a direct and sustainable impact on a wide range of related areas such as mother and child health, nutrition and health education.

Health is a human right (World Health Organisation (WHO) declaration in Alma Alta, 1978), therefore every person has the right to access health services. Health for All envisages the realisation of a healthy, vibrant and peaceful society.

Activities

To provide motorcycles for health workers, specifically midwives and nurses working in public health centres that are responsible for large areas but which have no means of transport to cover these areas. The aim is to provide easier access to health services for those in rural areas, particularly those having very limited access to transport. The use of motorcycles is monitored by Health for All and others such as community leaders, the Ministry for Health in sub-district levels, Non-Governmental Organisations and the public.
To manage and control the roadworthiness of the motorcycle fleet. This is to ensure that a Zero Breakdown principle is maintained. This is carried out by monitoring the condition of the motorcycles regularly. The health workers responsible for the motorcycles fill in a logbook and the riders themselves are regularly evaluated.
To conduct regular field monitoring to ensure the proper use of the motorcycles.
To carry out repairs whenever damage occurs.
To supply spare parts. To do this Health for All uses parts from its own tock and is refunded by the Health centre or rider.
To train health workers to ride motorcycles. This training is specifically designed to enable healthworkers to ride properly and safely in local conditions and ensures that they can maintain the Zero Breakdown programme.
To organise seminars and group discussions on health issues such as reproductive health, nutrition, STDs, HIV/AIDS, etc. Such discussions are open to the general public and aimed particuarly at women's groups.
Training on Health in the perspective of Gender and Human Rights. Health workers participate in this training with the purpose of widening their horizons with regard to the importance of looking at health in the perspective of gender and human rights.
To network and to collaborate with Government in order to work more effectvely in partnership, to ensure clear understanding of the issues and mutual support by all parties.
To network and communicate / work with NGOs, local organisations and community leaders. These groups are involved in monitoring and evaluating the programme and give feedback as to how well the programme responds to the needs of the local people.
To supply health education and information materials for distribution

Challenges

In the 2007 Indonesian Health Survey women were asked whether they have problems seeking medical advice or treatment for themselves. The most often cited problem is getting money for treatment (25 percent). Other concerns include distance to health facility (15 percent), having to take transport (13 percent), and concern that no female worker is available (11 percent).

Reliable transport enabling regular village healthcare visits helps to address each of these issues.

UNDP

The United Nations Development Program (UNDP) report on Human Development in 1999 said of Flores:

Population without access to health facilities: 29.9 %
Population without access to safe water: 54.7 %
Undernourished children under 5: 41.8 %
Households without access to sanitation: 32.5 %
Infant Mortality rate: 46 per 1,000
According to the United Nations Population Division the figures for Indonesia as a whole for 2006 were:

(United Kingdom figures provided for comparison)

Rank Country or territory Infant mortality rate
(deaths/1,000 live births) Under-five mortality rate
(deaths/1,000 live births)
87 Indonesia 26.6 31.8
174 United Kingdom 4.8 6.0

The East Nusa Tenggara Province continues to have worse figures for infant mortality and under five mortality than the rest of Indonesia. These are issues which improved basic healthcare delivery directly addresses.

UNICEF highlights East Nusa Tenggara infant mortality rate

Just an hour's flight from the tourism hub of Bali lies a string of islands known as East Nusa Tenggara (NTT). White sandy beaches, picturesque sunsets and warm, friendly people have made the tiny archipelago look like an idyllic spot.

"Behind the beauty of these islands, however, lies a serious health problem affecting nearly every family. NTT has one of the highest infant mortality rates of any Indonesian region, mainly due to poor nutrition and lack of access to skilled health workers."

UNICEF March 2007

New nutrition map of Indonesia highlights widespread infant mortality, underweight children

UN World Food Program July 2006

"JAKARTA - Many people in Indonesia do not get enough to eat, significant numbers of the country's children are underweight and infant mortality continues to be a problem right across the island nation's archipelago. Those are the findings of a new study jointly conducted by the United Nations World Food Programme and Badan Pusat Statistik-Statistics Indonesia and funded in large part by the Australian government. "

Among its findings:

* People in roughly half of the sub-districts measured are consuming less than 1,700 kilocalories a day, well below the 2,100 kcal international standard considered necessary to provide the minimum energy required to adequately sustain an average adult.

* More than 30 per cent of pre-school children are underweight in 772 sub-districts, particularly in North, West and South Sumatra, Jambi, East Java, Nusa Tenggara Barat (NTB), Nusa Tenggara Timur (NTT) and West Kalimantan.

* Infant mortality rates of 55 per 1,000 live births, significantly above the national average of 43 per 1,000, are prevalent in 1,079 sub-districts stretching across the country, including Jambi, Bengkulu, West Sumatra, Banten, West and Central Java, NTB, NTT, West and South Kalimantan and Central, South and Southeast Sulawesi.

Nusa Tengara Timur

East Nusa Tenggara (Indonesian: Nusa Tenggara Timur or NTT) is a province of Indonesia, located in the eastern portion of the Lesser Sunda Islands, including West Timor. The provincial capital is Kupang, located on West Timor.

Nusa_Tenggara_TimurThe province consists of about 550 islands, but is dominated by the three main islands of Flores (The island of flowers), Sumba, and West Timor, the western half of the island of Timor. Other islands include Adonara, Alor, Komodo, Lembata, Menipo, Raijua, Rincah, Rote Island, Savu, Semau, and Solor.

Coverage

Based on a detailed prior evaluation carried out by Health For All in cooperation with the local health officials motorcycles are placed with Pusta and Pusling health service units.

Motorcycle usage is monitored through regular visits, usage reports and records kept at the service intervals. Labour charges for service and maintenance are provided by Health for All with the local administration covering the cost of replacement parts and consumables.

Red Dots show where motorcycles have been placed with local health personnel

History

Health for All was set up by Simon Milward and Willy Balawala in 2002 to bring the benefits of vehicle management systems developed in Africa to the remote region of East Flores in Indonesia.

At the time Willy Balawala, was working as Outreach Manager for Medecins Sans Frontieres (Doctors without Borders) in Indonesia. Willy was trained at the Riders for Health International Academy of Vehicle Management in Zimbabwe and took over project management of Health for All.

The project was then set up with twelve motorcycles provided for the use of Health Ministry workers.

During July 2000 Willy Balawala currently Health for All (HfA) Executive Director, conducted focus group discussions with health workers from all public health centres in East Flores District, Flores Island, Indonesia. During the course of the discussion he heard many stories about the bad health situation in the area. A great number of pregnant women in rural villages were suffering from anaemia and were sometimes dying due to severe bleeding during childbirth.

There were also many children suffering from malnutrition. In addition there were many other life-threatening illnesses such as diarrhoea, malaria and TB, that could be medically treated if those in rural areas had adequate access to healthcare.

One of the main factors which exacerbates these health problems is that people in isolated areas lack access to health facilities. People have difficulty visiting health centres due to the limited availability of public transport.

Similarly health workers do not have vehicles that can be used to reach the isolated villages within their area of responsibility. As a consequence, many people die due to the absence of health workers, or people delay referring emergency cases to health centres due to limited transport options.

There were a few motorcycles distributed by Government for operational activites but the problem was that those vehicles were not well maintained and damage was not repaired. Sometimes operational vehicles became personal property which were used for personal needs which meant that the operational expenses of the vehicles should be shouldered by the riders themselves.

There was an absence of a sustainable system that could manage transportation for Mobile Health Services.

In September 2000 Willy (at that point working with Medicins Sans Frontieres (MSF) Belgium happened to meet Simon Milward, in Kupang, West Timor, during Simon's round the world Millennium motorcycle ride.

During their brief meeting they discussed the health issues outlined above and the importance of adequate transport to improve the quality of healthcare for people in remote areas. Willy maintained contact with Simon, who later put him in contact with Riders for Health (RfH) UK.

Willy discovered that RfH had already developed a programme of transport resource management for health delivery in several countries in Africa. Expressing his intention to design a similar program in Indonesia, Simon and RfH then sponsored Willy to undergo training at the programme being implemented in Harare, Zimbabwe in February 2001.

Indonesia's Healthcare Delivery System

The organization of the Health Care system in Indonesia is as follows:

At the city level, there is a City Health Office that is headed by a Medical Professional appointed by and responsible to the Mayor for administrative and operational matters in health policy and medical procedures and which is also responsible to the Department of Health at the national level.

At the community level the Puskesmas (Community Health Center) provides comprehensive health services. The area of the Puskesmas is a subdistrict or a part of the subdistrict. The area covered is determined by the density of population, geographical nature of the area and the state of transport infrastructure. Typically a Puskesmas serves 30,000 people.

In implementing the health program, the Puskesmas is supported by a network including Pustu (Assistant Puskesmas), Pusling (Mobile Puskesmas), and Village Midwives Clinic (BDD).

A Pustu is a simple health service unit under the Puskesmas that covers two to three villages (approx 2000 to 3000 people). A Pustu is an integral part of the Puskesmas.

A Pusling is a mobile health services unit that is equipped with a motorcycle, car or boat, healthcare and communication equipment. In remote areas that can not be reached by the formal health services, a Pusling replaces the function of a Puskesmas or Pustu.

A Village Midwives Clinic (BDD) serves one or more villages which do not have other health services. The midwife is provided with a building with obstetric facilities where she lives and works.

[caption id="attachment_382" align="aligncenter" width="640"]Baniona Puskesmas (Community Health Center)

Motorcycles

After research into the most suitable motorcycle type taking into account criteria such as economy, reliability, ease of use, spare parts supply, dealer support and import regulations as well as local road conditions, Health for All selected the Yamaha YT115 model. Thanks to Yamaha these vehicles were provided at a very competitive rate.

The YT115 motorcycles are capable of economically and reliably carrying a rider and their equipment while also being straightforward to maintain. When needed it is also possible to carry a passenger.

Health for All’s experience with these motorcycles has been very good. The YT 115 is a variant of the popular RX 115. The nearest equivalent model in Europe is the RXS100.

Motorcycle enthusiasts may wonder why agricultural models like the Yamaha AG 100 or the larger AG 200 were not used instead. The reason for choosing a model already available in Indonesia is to take advantage of the existing parts supply network and expertise as well as to avoid expensive and lengthy (occasionally even impossible) import procedures. Some of the adaptations used on the agricultural models are also available locally for use on the YT115 models.

For scooters the emphasis will be on reliability, large wheels for rough road usage, adequate suspension and four-stroke engines to pre-comply with emerging emissions regulations in Indonesia.

Scooters

sidesaddleAlthough it may be surprising to westerners more accustomed to litre capacity displacements, Indonesian culture actually sees the Yamaha YT115 models used by Health for All as big bikes. Costs and import restrictions limit the number of larger motorcycles in use.

Also part of local culture is the fact that these big motorcycles are not seen as appropriate for women to ride.

As passengers, women in Indonesia unfortunately very often ride side-saddle. As riders women usually choose step-through scooters.

P20060612_082518Health For All is currently evaluating suitably robust and locally available scooter models for addition to the existing fleet. These would be used in areas with suitable road networks for scooter use. This will increase mobility among female healthcare workers.

Results

Training at the international Academy for Transport Resource Management in Harare, Zimbabwe facilitate by Riders for Health UK
Exposure to the programme being implemented in Harare
Purchase of 12 Yamaha YT115 motorcycles which are used to deliver health services to more than 50,000 people in four sub-districts
13 Healthcare workers trained to ride motorcycles and in basic motorcycle maintenance.
Health deliver riders accustomed to implementing the Zero Breakdown system.
During the successful National Immunisation Week in four sub-districts, the utilisation of motorcycles was managed by Health for All.
The decline in malnutrition cases in children under five years old.
An increase in the number of healthcare worker visits to rural areas to deliver health services such as vaccinations for children and education in good nutrition, health and hygience for mothers and children.
Intensive monitoring of the Zero Breakdown programme and regular servicing of the motorcycles to ensure the success of the programme.
An increase in the monitoring of sanitation facilities.
The ability to respond quickly and more easily to emergency cases.
Training given to 60 Healthcare workers in Health Services in the Perspectives of Gender and Human Rights
Dissemination of health information material on subjects such as Nutrition, Maternal and Child Health, STDs and HIV/AIDS.

People

Left to right: David (Motorcycle Outreach), Bass (HfA Mechanic), Mans (HfA Field Coordinator), Eman (HfA Assistant Coordinator), Willy (Health for All Manager) at the Larantuka Field Office (June 2006)

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