B4559

Glimpses of Innovations in Primary Health Care in South-East Asia
August 2010
WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia. Glimpses of innovations in primary health care in South-East Asia. 1. Primary Health Care. 2. Health Care Reform. 3. Community Health Centers. 4. Community Health Aides. 5. Medicine, Traditional. 6. Delivery of Health Care. 7. South-East Asia. ISBN 978-92-9022-386-3 (NLM classification: W 84.6)
World Health Organization 2010 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution can be obtained from Publishing and Sales, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publications@searo.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization.
Printed in India 2
Contents
Foreword Introduction Bangladesh
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Demand Side Financing for Maternal Health : (DSF) Community Health Clinics 24
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Bhutan
Integrating Traditional Medicine in Primary Health Care
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DPR Korea
Universal Free Medical Care System
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India
ASHA - Accredited Social Health Activist Project Arunoday 72
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Indonesia
Village Midwives Programme Health Insurance for the Poor
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Contents
Maldives Myanmar
Healthy Villingili Island Programme 104
Healthy Mother Project
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Nepal
Female Community Health Volunteers
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Sri Lanka Thailand
National Health Development Network 134
Universal Coverage Scheme Strategic Route Map (SRM)
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Timor-leste
SISCa (Integrated Community Health Services)
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Foreword
For over three decades, primary health care (PHC) has been the main strategy for attainment of health for all the level of health that permits all people to lead a socially and economically productive and satisfied life. It has been the key approach to equity and social justice in health. Although today we are faced with many health challenges, it must be acknowledged that there have been significant improvements in human health. People are now living longer and we have been able to make significant improvements in controlling vaccine-preventable and other communicable diseases. Child mortality has declined significantly and access to maternal care is increasing. Even as we make progress new public health challenges emerge. These include effects of climate change, urbanization, accidents and injuries, the ageing population and increase in the prevalence of noncommunicable diseases. It is a matter of concern that health inequities persist within and among countries. In the face of rising costs of health service delivery the challenge of reaching the underserved population becomes even more challenging. However, countries are engaging themselves in finding solutions to these problems through strengthening of their health systems. In this context, it is relevant to emphasize that PHC-based health systems remain the best option for ensuring equitable universal health coverage in an efficient and cost-effective manner. There is growing realization that health outcomes are the product of a complex interplay between socioeconomic, cultural and political determinants. Community education, empowerment and participation hold the key to improved health. It is imperative that health systems strengthening takes a comprehensive developmental approach rather than focusing only on health service delivery. This was recognized and recommended by participants of the Regional Conference on Revitalizing Primary Health Care held in 2008 to commemorate the Thirtieth Anniversary of the Alma-Ata Declaration on PHC. We need to continue our efforts towards ensuring that health systems deliver people-centred care. Not only have the health systems to become responsive to peoples needs but the balance between
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preventive and promotive care on the one hand and curative care on the other has to be maintained. Far too often budgetary allocations for health are disproportionately skewed towards allocations for tertiary care. The commitment of Member States of the WHO South-East Asia Region to revitalize PHC was reaffirmed during the Regional Conference on Revitalizing Primary Health Care held in 2008. The Region has a rich experience in PHC initiatives. Indeed, pioneering work based on PHC principles was initiated in several countries of the South-East Asia Region much before the Alma-Ata Declaration. Member States of the Region continue to innovate to revitalize PHC. Several initiatives are currently underway all over the Region that explore effective community participation in health through: community education and empowerment; enhancing equitable access to health care; improving referral care; ensuring financial and social protection of the vulnerable sections of society; adopting a multisectoral development approach to health; and working towards universal coverage. This publication is an attempt to provide glimpses of selected PHC innovations that Member States of the South-East Asia Region have initiated in recent years. It is hoped that this publication will provide information about the successes achieved and challenges faced by countries as they proceeded with revitalizing PHC in their respective settings. It is expected that the lessons recorded in this publication will be found useful by health planners, programme managers, public health professionals and others and will assist them in their efforts to develop PHC-based health systems strengthening. The WHO Regional Office for South-East Asia gratefully acknowledges the contribution of Voluntary Health Association of India (VHAI) in the production of this publication.
Dr Samlee Plianbangchang
Regional Director
Introduction
While the principles of primary health care (PHC) elaborated in Alma Ata in 1978 remain valid, the concept of Primary Health Care is undergoing a metamorphosis. Besides the early focus areas of basic health interventions, supply of essential drugs, maternal and child health, select communicable diseases, water, sanitation and health education, primary health care today focuses on everyones right to good health, promotion of healthier lifestyles, involvement of civil society, community participation, use of science and technology, global solidarity and joint learning. Around the world, countries are witnessing changing demographic and epidemiological profiles with a marked shift from communicable to non-communicable diseases and people living longer due to advanced medical and public health technology. In such a scenario, PHC has become the focal point for comprehensive response at all levels. It also requires substantial investment today in terms of material and human resources than before. In the quest to achieve the Millenium Development Goals, for all countries across the globe, primary health care is the main determinant as well as a key focus area for addressing public health challenges. Governments must bear in mind that primary health care is increasingly important in the times ahead and in view of the dramatic shifts in the epidemiological profiles, it must be ensured that they take continuous steps to make quality healthcare accessible, functional, affordable and effective. However, many countries are still to provide the much needed priority to PHC and public health in general. Their health systems are not geared up to meet the new challenges. Their health budgets lean towards secondary and tertiary care with preventive and promotive care receiving extremely low attention and allocation. Healthcare is assuming a commercial nature in these countries with the private sector expanding fast and assuming a virtual monopoly on health services. Out-of-pocket expenditure on health care has increased the financial burden on the people with no supporting or complementary insurance schemes. A surge in urbanization and changing lifestyles full of stress, debt and ambitions have increased the burden of chronic or non-communicable diseases. As far as the South-east Asia is concerned, the countries in the region are spread over a broad and diverse topography. The region experiences sudden and frequent political
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developments and natural disasters, is rich in cultural diversity, undergoing an economic boom and experiencing rapid changes in lifestyles. Nearly 600 million people in the Region live in urban areas and 25% of them are estimated to be poor. The large population leads to crowded living conditions, social tensions, exacerbation of communicable diseases, especially among the urban poor, and leads to an augmented risk of accidents, social and psychological ailments. Inadequate allocation of resources for health, education, industry, agriculture, and other niche skill areas deprives people of universal access to basic needs of safe, drinking water, bare minimum sanitation facilities, fundamental infrastructure like electricity supply, navigable roads and cheap and easy means of transport. In such a scenario, there is a critical need to re-assess the fundamental philosophy of primary health care in SEAR and weave them around the public health challenges of today. Since the concept of primary health care encompasses preventive, promotive and curative aspects of health, emphasis must be laid on integrating all these to provide a comprehensive health care package for communities. In addition, apart from improvement in health care delivery systems, health and healthcare should be designed around community participation in the decision-making and implementation of primary health care activities. Improvements in the economy, social and political fronts have a cascading effect on the health front. Measures must be taken, therefore, to address the social determinants of health, like social justice, empowerment, education, universal access and social protection. Every effort has to be made to design health services around the needs and expectations of people as this is intrinsic to effective service delivery. Further, health must be integrated into public policies across sectors. Governments must also pursue collaborative models of policy dialogue towards participatory, inclusive leadership which will ensure civil society participation and ownership of health actions. In addition, participation of key stakeholders, which include community members like self-help groups, volunteers, village health committee heads, service providers, district administration officials, partner grant agencies is very critical to enable health services to meet peoples needs and aspirations. This is what several programmes showcased in this document are striving for. In the midst of the enormous challenges and grim realities, these programmes have proved to be best practice models in primary health care by choosing practical, and sustainable paths. As the existing Government mechanism is only partially able to address social sector issues, many of the programmes are alternative efforts through partnership with
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civil society, government as well as international aid agencies to overcome health and development challenges at the community level. The Community-oriented Reproductive Health Project (CORHP) or Healthy Mother Project in Myanmar takes a community-oriented approach in order to improve the health of mothers. The ASHA programme from India is a sterling example in community volunteerism supported by the National Rural Health Mission, whereas the Arunoday project in North-East India is a recognized best practice model in public private partnership. The chapter on Indonesia shows how Jamkesmas, a health insurance programme aims to reach quality healthcare and financial protection to the poorest. The SISCA initiative from Timor-Leste is a mix of community-based health activities and a mobile health clinic that aims to provide integrated health services to rural communities or hamlets. On the other hand, the National Health Development Network programme in Sri Lanka involves collaboration between different sectors of health, agriculture, education, environment, non-profit societies and corporates and seeks to strengthen health care systems. The Strategic Route Map or SRM - a tool for change management is showcased in the chapter on Thailand. These are only some of the several nuggets shining through in this document. This publication is an attempt to share and highlight successful experiences in primary health care from various settings in health and development from South East Asia among policymakers, voluntary organizations, international agencies, programme personnel, researchers and social activists. From each of the Member countries of the WHO South East Asia region , one or two programmes have been showcased to enable wider sharing and learnings. It is hoped that countries will gain from the varied experiences and be able to benefit from the lessons learnt to shape the way forward in revitalizing PHC in their own settings.

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Background
In recent decades, Bangladesh has progressed steadily towards improving its maternal and child health indicators, especially with regard to Infant and Child Mortality, Total Fertility Rates, and Immunization coverage. The Maternal Mortality rate has declined from 574 maternal deaths per 100,000 live births in 1991 to 320 in 2001 (NIPORT et al., 2003), although current estimates by different agencies put this in the range of 270-290. However, maternal mortality is still unacceptably high in Bangladesh five times higher than in Sri Lanka or Vietnam and ten times higher than in Malaysia, for instance. According to the most recent Bangladesh Demographic and Health Survey (BDHS) from 2007: Maternal Mortality Rate in Bangladesh is 290 300/100,000 live births 88% of births are delivered at home. Skilled birth attendants attend only 18% of births. 80% Death occur at attempted home delivery. 69 % of the poor households do not access to any ANC. Improvement of services through supply side financing has not yet proved very successful. Millennium Development Goal 5 (MDG 5) requires Bangladesh to cut maternal mortality by 75% between 1990 and 2015, to 143 deaths per 100,000 live births. Achieving this target presents a severe challenge. To reduce maternal mortality, the government
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Demand Side Financing of health services refers to channeling Government health subsidies directly to consumers and thus, transferring purchasing power to those who need it most
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Demand Side Financing for Maternal Health : (DSF)
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of Bangladesh has implemented a number of supply side or input-oriented efforts, including strengthening Essential Emergency Obstetric Care (EOC) services in many health facilities, providing training to field-based health outreach workers (known as Family Welfare Assistants (FWAs) and Health Assistants (HAs) to create a pool of Communitybased Skilled Birth Attendants (CSBAs), and implementing the National Nutrition Program (NNP), which provides free food items for pregnant women in program areas for 150 days during pregnancy. Institutional delivery and skilled attendance at birth are the two indices most associated with improving maternal survival. EmOC services for pregnant women are now available in 59 out of 61 District Hospitals and in 132 out of 407 subdistrict-level Upazilla Health Complexes (UHCs). Bangladesh along with many Governments around the world has acknowledged the need to address not only supply-side but also demand-side barriers that prevent the poor from seeking basic health care services. Demand Side Financing of health services refers to channeling Government health subsidies directly to consumers and thus, transferring purchasing power to those who need it most. Evidence is emerging that demand side financing can substantially improve targeting of the poor while overcoming financial, transportation, and information barriers. Therefore, as part of its Health, Nutrition and Population Sector Programme (HNPSP), Bangladeshs Ministry of Health and Family Welfare (MoHFW) is also implementing a pilot Demand-Side Financing (DSF) maternal health voucher program in 33 upazillas (sub-districts) throughout the country. Under this ambitious and innovative programme, vouchers are distributed to pregnant women entitling them to access free antenatal, delivery, emergency referral, and postpartum care services, as well as providing cash stipends for transportation and cash and in-kind incentives for delivering with a qualified health provider.
Demand Side Financing for Maternal Health : (DSF)

Bangladeshs MoHFW and the Directorate General of Health Services (DGHS), with the technical assistance of the World Health Organization, launched this maternal health voucher scheme in 2004. The program also provides incentives to health care providers for identifying eligible
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The DSF program is primarily focussing on progress towards Millennium Development Goal 5 (MDG 5) to improve maternal health, by stimulating increased utilization of safe maternal health services by poor pregnant women, including Ante Natal Care (ANC), delivery by qualified providers, emergency obstetric and Post Natal Care (PNC). Focus is also put on increasing the use of qualified birth attendants and mitigating the financial costs of delivery. The country aims achieving a 75% reduction in maternal mortality by 2015. Innovative Design Bangladeshs health statistics particularly in the area of maternal and child health were not showing significant positive changes under the availability of services through supply
DSF maternal health voucher program distributes vouchers to pregnant women entitling them to access free antenatal, delivery, emergency referral, and postpartum care services, as well as providing cash stipends for transportation and cash and in-kind incentives for delivering with a qualified health provider
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women and providing maternal health services. When initially implemented in August 2006, women identified as extremely poor were eligible for vouchers; in 2008 eligibility was made universal in 9 upazillas.
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side financing and the access to services by the vulnerable classes was unsatisfactory, therefore the concept of Demand Side Financing (DSF) in itself was a new and challenging concept. The provision of vouchers to expectant mothers was something that had not been tried in the country. Here was a scheme that was aiming at directing subsidies to the target group in order to enable them to purchase the health services that they required. The voucher scheme is designed so that women can access safe delivery care at home or in institutions, necessary antenatal and post natal checkups, and ante natal and deliveryrelated complication management through ensured referral services. The Voucher is in fact a subsidy that grants limited purchasing power to an individual to choose among a assigned set of goods and services. Such a voucher programme, if implemented effectively, can be successful at targeting the very poor for subsidizing demand and in improving service quality by stimulating competition among providers. Another novel aspect of the programme is the tremendous scope provided for developing best practices in Public Private Partnership(PPP) and the involvement of doctors, paramedics, community workers, government health services, private hospitals and clinics and financial institutions like banks. The DSF program benefits extend beyond safe motherhood and reduced maternal mortality. For example, health facilities and non-maternal health patients will benefit from any quality improvements at the DSF facilities.
Objectives
The main objective of the DSF program is to accelerate progress toward Millennium Development Goal 5 (MDG 5) to improve maternal health, by stimulating increased utilization of safe maternal health services by poor pregnant women, including antenatal care (ANC), delivery by qualified providers, emergency obstetric and postnatal care (PNC).
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Role of Stakeholders
The Demand Side Financing (DSF) programme in Bangladesh has shown an interesting mix of stakeholders who have all contributed significantly to the success of the programme. Through an initiative of the Ministry of Health and Family Welfare of the Government of Bangladesh, the programme has successfully integrated the services of both the private and the public sectors and even that of financial institutions like the banks. The DSF voucher program is implemented by the MOHFW using pooled funds co-financed by the World Bank, the European Community (EC), Germany, Sweden, Canada, Netherlands, and the UNFPA. The World Health Organization, and the Department for International Development (DFID), provides technical assistance to the DSF program. This includes administrative and monitoring support through the posting of DSF organizers to each DSF upazila. These coordinators play a key role at the local level in assisting Upazilla Health Complex (UHC)2 management to run the DSF program. They are overseen by a National DSF Coordinator, based in the national DSF cell in Dhaka. In order to cater to the demand for maternal health services, besides the regular government health service providers, NGOs with hospital service units, private hospitals, doctors, paramedics working outside the periphery of government services have been involved in the programme. The beneficiaries of the programme are mostly the pregnant women living below the poverty line and who need to be made aware of the services that are available to them as per their requirement.
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Methodology
To put into action a programme so challenging and large scale in nature called for meticulous strategizing and planning, management and delineation of responsibilities and effective coordination of all stakeholders in a manner as to get the best services operational without too many operational setbacks or obstacles.
The beneficiaries of the programme are mostly the pregnant women living below the poverty line and who need to be made aware of the services that are available to them as per their requirement
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A few straight and comprehensive guidelines were developed for the implementation of the DSF programme which made provisions for certain mandatory criteria for beneficiary selection. Potential beneficiaries must be one of the following: Permanent residents of the union Pregnant for the first or second time, and having used family planning prior to the second pregnancy Functionally landless (owning less than 0.15 acres of land) Earning extremely low and irregular income or no income (less than Tk. 2,500 per household per month) Owning no productive assets, such as livestock, orchards, rickshaw or van. Planning is done at the upazilla level as per the estimated requirements and demands of each upazilla and the upazilla plans were incorporated into the overall country plan for effective and streamlined financial management. Glimpses of Innovations in Primary Health Care in South-East Asia Strengthening of capacities at all stakeholder levels is an important criteria towards ensuring safe and quality health services to all the beneficiaries The voucher distribution system is not uniform across upazillas. At the outset of the pilot program, all voucher booklets were to be distributed from the UHC, and in some upazillas this is evidently still the standard practice. Most voucher booklets, however, are distributed to women at the community level by FWAs, HAs, and CSBAs. This is particularly common in areas that are farther from the UHC. Occasionally village dais (traditional birth attendants) have also reportedly distributed vouchers. Women receive a booklet with separate coupons in triplicate for each covered service under the program. When a service is sought, providers keep two copies of the relevant voucher slip, one to submit for reimbursement and one to keep for documentation, and the third copy is returned to the woman. Funds for the DSF program are transferred from the Central level to Sonali Bank accounts in each DSF upazila to cover incentive payments to providers and voucher beneficiaries, as well as for the cost of procuring gift boxes for beneficiaries.
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Key Strategies
Targetting pregnant women is considered effective since the group is easy to identify and benefits, in conferring protection to the newborn as well as the mother, are considerable. The use of vouchers, in this context, serve both to strengthen the private market for services and as an important strategy in strengthening the public systems role in identifying priorities and people in need of assistance. Providing cash and gift incentives to the mothers for accessing services and for opting for institutional deliveries over home deliveries. Health care facilities are reimbursed for providing voucher-covered services at fixed rates. 50% of the reimbursement amount is deposited into the upazzila seed fund account, while the remaining 50% is distributed to the government service providers who provided those services, as an incentive.
The use of vouchers, in this context, serve both to strengthen the private market for services and as an important strategy in strengthening the public systems role in identifying priorities and people in need of assistance
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Benefits to a Voucher Holder: Maternal healthcare package 3 trips for antenatal care 1 session for normal and safe delivery of child 1 trip for postnatal care within 6 weeks of delivery services for obstetric complications-if complication occurs ie retained placenta, foreceps delivery, caesarian section Taka 500 ($ 7.00) for transport cost to voucher holders for institutional services Taka up to 500 ($7.00) for referral to District Hospital cash to mother taka 2000 Specified service package will be provided by Designated Providers & facilities from Public, NGO and Private sector Include Doctors, Nurses, FWVs, CSBAs, Government health facilities, NGO health facilities, Private clinics and hospitals Reimbursement through Sonali Bank
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For a more participatory and intersectoral approach to the programme, and also to ensure maximum coverage, accessibility and availability of services, NGOs and private sector involvement is an important strategy.
Highlights
Though the entire programme was a great success in totality, some aspects stand out as major achievements and highlights : Strong and exemplary leadership to the programme from the government (MoHFW) There has been a noticeable change in the health care-seeking behavior of the poor since the inception of the DSF program. Women are more proactively seeking antenatal, delivery and postnatal care services. They are also seeking more health information now. The programmes has become an effective means of targeting low income or other vulnerable people Glimpses of Innovations in Primary Health Care in South-East Asia Door-to-door visits by field workers to inform the community about the voucher program proved especially effective. It resulted in an increasing trend of hospitalbased delivery. With the DSF programme, public facilities showed an increase in service provisions. ANC 1, 2, and 3 service utilisation trend showed a significant upward trend in the span of a years time (April 2007 to April 2008). ANC 1 had increased from 30% to 50% in the specified time whilst ANC 2 service utilisation increased from 10% to approximately 38% and ANC 3 service utilisation went from 10% to approximately 38%. Likewise safe deliveries increased from less than 10% to 40%. Women felt positive about the program because they would get money, they could deliver in hospitals, thus they could avoid risk of impoverishment due to the cost of a C-section. Had the money not been provided to the mothers, they would have to spend money (separately) for the deliveries. Thus, the DSF is playing role in reducing poverty. The DSF program is strongly and significantly associated with higher rates of delivery
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with qualified providers. The likelihood of delivering with a qualified provider is more than twice as high in intervention areas as in the other upazillas The rates of maternal deaths and neonatal deaths have decreased.
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Challenges
The DSF programme which was launched in a pilot phase in Bangladesh brought forth very significant changes in the maternal and child health status in the country, specifically in the coverage area. It was a tremendous learning process for all the stake holders involved and brought to the fore several challenges that still need to be addressed before the programme is made universal throughout the entire country. Lack of Awareness about the Services The DSF initiative gained momentum and success in the pilot phase itself, however there still remains a lack of awareness about the services. More information and media campaigns etc. should be launched to improve awareness and understanding of specific DSF benefits, as well as broader safe motherhood messages. The Voucher Reimbursement arrangement : This should be speedened up so that women and families that avail of services may not be subjected to inordinate delays or processing glitches in the process of reimbursement.
Lack of trained Medical Officers (Gyn-Obs. & Anaesthesia)

This being such an ambitious programme launched on a large scale there should be adequate manpower in the form of trained medical personnel to handle emergency and other cases that visit the health centre. There is some indication that awareness of the importance of delivering with a qualified provider is nonetheless still limited, which raises concern about program sustainability and brings attention to the need for a targeted awareness-raising and behavior change campaign (BCC).
It was a tremendous learning process for all the stake holders involved and brought to the fore several challenges that still need to be addressed before the programme is made universal throughout the entire country
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Provision for supply of medicines and drugs under the scheme : During interviews, some patients reported that the vouchers were helpful, but that they often paid out-of-pocket for medicines. Shortages of supplies and medicines are an obstacle to smooth DSF program implementation. Many voucher recipients are still paying for medicines outside of government health facilities, due to stock-outs. The seed funds may be helping address these shortages but they have not solved the problem; cash incentives may help cover these out-of-pocket costs, but they are not provided at the time of service and therefore do not eliminate the financial barrier. Issues concerning the Service Providers Providers indicated that the incentives for participating in the program were small in comparison to the increased work load. The increased demand for subsidized services have overwhelmed health facilities and overburdened health personnel. Administrative and Operational Issues Glimpses of Innovations in Primary Health Care in South-East Asia One of the challenges associated with vouchers include high administrative costs and some substantial management complexities (as with conditional cash transfers) There also remains the potential risk of skewering service provision towards vouchersubsidized services at the expense of other valued health services. Ensuring Quality Care and Services Patient safety concerns are a primary concern and needs to be prioritised. (Blood Safety for C-section, quality care in Upazilla Health Centres) On the cost side the demand mechanism is likely to be more expensive since a mechanism will be required to identify and deliver vouchers to pregnant women and also to identify and accredit qualifying public and private facilities. Scaling Up the DSF Programme The initiative started off well, has made significant progress in the pilot phase itself and can scaled up to the national level, based on proper documentation of evidence, best practices and processes in order to justify implementation throughout the country.
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Outcomes
Coverage : By April 2008, 73% of the districts were provided with vouchers. It was noted that the services provided in DSF areas (33 Upazillas) were more widespread and effective as compared to the rest of the country. Demand For Services Increased access to and utilization of maternal health services by poor pregnant women and hard to reach area was recorded. There was a marked change in both demand for services and as a result a marked increase in service provision particularly in Public facilities. Post Natal Care which is mostly a neglected area, recorded an 84% turn out. EmOC services for pregnant women are now available in 59 out of 61 Districts Hospitals and in 132 out of 407 subdistrict-level Upazilla Health Complexes (UHCs). Increase of Institutional Deliveries There was an increased awareness/demand from pregnant women for ANC and delivery at the facility level with a significant 50% of the Ante Natal Care (ANC) customers undergoing safe institutional deliveries.
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Empowerment of Women and Decision Making gains Foothold

It is an encouraging and positive sign to see uneducated, poverty stricken pregnant women gaining the empowerment to procure maternal health services from service providers of their choice. Intersectoral Collaboration and Coordination The DSF programme received unanimous support and cooperation at all levels. Throughout implementation there has been evidence of a well networked local, political and administrative coordination. There has been an increase in the collaboration between Govt., NGOs and private service providers. NGOs providing services under the DSF programmes have now a mode of working towards sustainability of their clinics.
It is an encouraging and positive sign to see uneducated, poverty stricken pregnant women gaining the empowerment to procure maternal health services from service providers of their choice
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An early rapid assessment of the program conducted in 2008 found that the utilization of maternal health services increased despite wide variation in program implementation across study areas.
Learnings
One of the most important and significant learnings from this programme is that any developmental initiative that has an efficient leadership in the government mechanism can change the social and developmental indices of a country. The fast and significant improvement in both the provision and access of safe motherhood services under the pilot phase of the DSF programme prove that it should be extended throughout the country. Though there was a significant increase in provision of services and demand for the same in at public facilities, there is a felt need for EOC service upgradation and greater efforts should be made to encourage facilities to use the seed fund for quality improvements, as well as to procure drugs, supplies, labour beds, and equipment. The DSF initiative ensured multi sectoral collaboration through supportive government policies and brought together administrators, elected local community leaders, NGOs & private service providers working towards a common mandate through effective leadership, intersectoral collaboration and mobilization of both human and financial resources. The success of the DSF program could be expanded to include family planning counselling and essential neonatal care. A family planning page in the DSF voucher booklet would ensure that the service provider signs off on providing family counseling after delivery, and at the same time the FP needs of the couple would also be met. Further liasoning and advocacy could help to include more private and NGO facilities (that meet quality standards) as this would increase the availablility of services for a larger number of beneficiaries, as well as potentially improve quality of services by giving it a competitive edge.
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Bibliography
Bangladesh. Economic Evaluation of Demand Side Financing (DSF) programme for Maternal Health in Bangladesh. Dated February 2010. Under HNPSP of the Ministry of Health and Family Welfare. Bangladesh. Demand Side Financing Maternal Health Voucher Scheme in Bangladesh. Ministry of Health and Family Welfare. (www.searo.who.int/LinkFiles/FCH_d3-4voucher-scheme-Ban.pdf accessed on July 5th July 2010). Hossain, A. Vouchers as Demand Side Financing Instruments for Health Care: A Review of Bangladesh Maternal Voucher Scheme and Some Implications for Incentivising Human Resources in Health Phnom Penh, Cambodia April 26-27, 2010 International Conference on Improving Health Sector Performance: Institutions, Motivations and Incentives (http://www.cdri.org.kh/events/ihc/2.3.%20Atia%20Hossain. pdf accessed on July 5th 2010). Molla, A.A., Howlader, S.R., Rehman, A. And Mustafa, A Feasibility Study on Demand Side Financing(DSF) in Maternal Health Care Services at Rural Bangladesh. IHEA 2007 6th World Congress : Explorations in Health Economics Paper.
The DSF initiative ensured multi sectoral collaboration through supportive government policies and brought together administrators, elected local community leaders, NGOs & private service providers working towards a common mandate through effective leadership, intersectoral collaboration and mobilization of both human and financial resources
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Yet another learning from the initiative is that while there is overall awareness of the DSF program, more information and behaviour change communication campaigns should be launched to improve understanding of specific DSF benefits, as well as broader safe motherhood messages.
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Bangladesh Community Health Clinics
Background
Bangladesh became a signatory to the historic Alma Ata Declaration on Primary Health Care (PHC) in 1978. In 1988, the Government of Bangladesh (GoB) adopted the PHC approach as a guiding principle to the health systems development in Bangladesh. Several studies have highlighted that only a minority of the people of Bangladesh use public facilities for their health care needs. The reasons for this low utilization rate include supply and demand-side barriers such as travel expenses and opportunity costs, waiting time, staff attitude, shifting service availability and quality, erratic medical supplies including drugs. Such access barriers disproportionately affect health seeking behavior of communities, especially women.
Community Health Clinics

Community Health Clinics (CHCs) were conceptualized in 2000 as an additional tier to the existing PHC delivery system. They are designed as the ultimate interface of the formal public health system with the communities. Each CHC is planned to serve 6,000 population and is constructed on land donated by the communities. Running costs are born by the Ministry of Health and Family Welfare (MoHFW). At the heart of the Community Clinic concept, lies ownership and participation, local accountability and health promotion. Around 13,000 CHCs were expected to be built in 2001-2002, and 6,000 more to cater to increasing population. During the initial conceptualization, the process of building more than 13,000 Community Health Clinics and making them operational was much delayed and remained incomplete at the end of the governments term. By December 2002, 9,413 Community Health Clinics had
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Assessing the situation therefore, the GoB in its 2009 Election Manifesto, proposed to revitalize the Community Health Clinics (CHCs).
Innovative Design
The concept of setting up 6000 Community Health Clinics (CHCs) to provide primary health care in remote areas was in itself an ambitious and innovative idea and called for a lot of planning at both the macro and micro level.
Community Health Clinics (CHCs) are an additional tier to the existing PHC delivery system. They are designed as the ultimate interface of the formal public health system with the communities
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been constructed, of which 6,706 were functioning. However, no Upazilas (subdistricts) had fully implemented the static clinic system. Even within unions, not all administrative wards (three per union) had a community clinic functioning in some capacity. The Government elected in 2002 formally abandoned the community clinic system in 2003, and the Ministry of Health and Family Welfare (MOHFW) reintroduced domiciliary services and satellite clinics under the sectoral program for 2004-2007. However, the decision was not based on any formal evaluation of the static clinic system.
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With the objective of bringing basic health care services within the reach of the poorest and those remotely located, a CHC equipped with a health assistant and a family welfare assistant (to provide primary healthcare, to ensure the health rights and in the long run help in reduction of the maternal and child mortality rate), and located within reach of the people was an idea which if implemented effectively would become a boon to the people and also increase ownership of the community on the programme. The CHCs provide the government health workers the opportunity to become crucial Behaviour Change agents through the above concept. Service delivery and management are decentralized down to the upazilla and community level. Family planning workers were moved to a formal civil service (recurrent budget) payroll. This shift had implications for financial management, performance appraisal and workloads as well. The integration of family planning and health services brought a new set of tasks to be carried out by all frontline personnel. 37 tasks were identified as components of the health workers job description at the Community Health Clinics. Glimpses of Innovations in Primary Health Care in South-East Asia
Objectives
The CHCs were revitalised with the primary objectives to reduce maternal, infant and under-five child mortality rates, communicable diseases, unwanted fertility by providing services that are responsive to clients needs, especially those of children, women and the poor in the areas served by such clinics.
Methodology
The scope for implemention of Primary Health Care through the innovative concept of Community Health Clinics was full of challenges but providing tremendous scope for both the effective delivery of essential health services to the people as well as for community participation and ownership of a prestigious Government programme. The successful implementation of CHCs required meticulous planning and a systematic methodology to be followed at the different tiers of implementation. However, to understand the function of primary health care services and delivery in Bangladesh, it is good to have an idea of the different tiers of management.
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At the National level the Directorate of Primary Health Care and Line Director of Essential Services Packages is responsible for the planning and implementation of PHC activities assisted by a Deputy Director and three assistant directors of PHC. At the District level, the Civil Surgeon and the District team provide technical and administrative support by way of periodic supervision to the Upazilla Health and Family Planning Officer and team. They also coordinate management of referrals from Upazilla level and below. The first level of referral in the PHC System is at the Upazilla level. Curative care is provided by specialists in obstetrics and gynaecology, medicine, surgery, a battery of medical officers, and supportive laboratory and supplies personnel. Promotive and preventive services are supported by Health Inspectors, Sanitary Inspectors and Assistant Health Inspectors. At the Union and Ward levels the Upazila Health and Family Planning Officer is the overall administrative and technical head of the Upazilla Health Complex, as well as all health services up to the community level through the Union level facilities run by field level health and FWAs.
The CHCs were revitalised with the primary objectives to reduce maternal, infant and under-five child mortality rates, communicable diseases, unwanted fertility
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The specific Functions of the Community Clinics (CHCs) are: Registration of pregnant women BCC: hygiene, diet, immunisation, breast-feeding etc. informing pregnant women in advance to attend the clinic for FWV services and ensuring that pregnant women come for antenatal services maintaining the expected date of delivery information to provide assistance if danger signals appear. Referral to higher levels providing FP methods: pills and condoms EPI: informing families in advance about outreach clinics and ensuring that children are immunised at the correct times. Minor treatment: ORS, Vit. A, anti helminthics, ARI, DOTS for TB, MDT for Leprosy, anti malaria etc
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Intersectoral action for health has been initiated through intersectoral workshops at District and Upazila levels. Community participation being one of the pillars for the proper functioning of CHCs is established through Village Health Volunteer( VHVs) nominated by the community people. The MOHFW has specific criteria for selection of location and constructing Community Clinic (such as number of rooms, waiting space, washrooms etc.). The community donates the land, assists in constructing the clinic and provides maintenance and security services for the clinic. The CHC is constructed at a central location and caters to the population of 6000 each. There are on average four CHCs in a Union. There are at least 8 field workers per Union at present (belonging to Health and Family Planning directorates together). Glimpses of Innovations in Primary Health Care in South-East Asia For the Essential Services Package(ESP) and Behaviour Change Communications(BCC) service delivery, a team comprising of one Family Welfare Assistant (FWA) and one Health Assistant (HA) (or their equivalents after re-organisation) are the core personnel. A Family Welfare Visitor(FWV) provides additional clinical services and supportive supervision and visits each centre at least once a month. Each team has at least one female (FWA/HA) worker. Services at the CHCs are available on all working days. However depending on local arrangement, they may choose other opening times that suit local needs. Location and timing of the CHCs are based on negotiation between the upazilla manager and community members with participation of UHFWC in-charge Depending on the service needs of the catchment population, it may be necessary to provide domiciliary or outreach services for an additional half or whole day, but on most days, the two team members work together in the CHC. The decision on use of health worker time on focused domiciliary visits are made by the Upazilla Health Manager in consultation with the UHFWC in charge and the community.
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The function of the CHC is to provide first-level services of the ESP. Performance and quality standards are based on technical standards and norms for ESP interventions. There will be community based non-salaried volunteers who will assist field workers in outreach sites and CHCs.
Key Strategies
One of the main strategies of the CHCs was to bring the provision of ESP almost to the doorstep of the beneficiaries within 30 minutes walking distance from the Clinic. Each CHC caters to a population of 6000. The bringing together of community representatives with government administrators and managers was yet another strategy used to bring about aCHCountability as well as efficacy in the implementation process. Regular monitoring through supportive supervision was put in place to ensure acceptable quality of care
Community Clinics equipped with a health assistant and a family welfare assistant and located within reach of the people was an idea which if implemented effectively would become a boon to the people and also increase ownership of the community on the programme
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Domiciliary services are focused on groups or individuals who are at risk, the most neglected including the extreme poor, follow-up on drop-outs for family planning for back referred cases, surveillance, and follow-up for specific infectious diseases including Directly Observed Therapies (DOTS). These services are provided in most cases one day per week, by one of the team-members, with the other maintaining the services at the CHC.
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while simultaneously guaranteeing beneficiary community participation and inter-sectoral collaboration. The strategy moving the health services from the home to the clinic is the correct approach of making the community aware of its basic health rights and the need to access the services that are being made available by the Government of the country. As part of the ESP, FP services and education were readily available to both men and women and this acted in a path breaking fashion because on the one hand women were breaking new grounds in terms of mobility and were able to visit CHCs as per their convenience and effortlessly, whilst men were becoming more involved in the area of family planning.
Highlights
Coverage has increased with the introduction of CHCs. 80% coverage of population living within the half an hour walking distance to the service points can now access services which earlier may have been difficult for them to access. Providing services from a fixed - centre at the communiyt level is a significant shift from the previous domiciliary system and is one of the prominent features of CHCs.
Challenges
In many places the Community Health Clinics have been found to be under performing. The use of these clinics by the local people still remains low. In a Rapid Assessment supported by WHO in 2009 only 19 % of the clinics surveyed reported remaining open on all working days. 28% opened once a week while 38 % clinics were reported to be open only once in a month. The mean time open per day was 2 hours. It was also found that there was an acute shortage of drugs and equipment. On an average, these clinics reported not more than 7-10 patients a day. Despite a very low use and attendance of patients in the clinics, the mean consultation time for the patients in these clinics were only 0.73 minutes. This could well be indicative of a lack of motivation among the service providers of Community Health Clinics to perform their jobs.
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Most of the CHCs are well located in terms of access and though the objective of each CHC being within 30 minutes walkable distance from the beneficiaries in the specific area has not been fully achieved, overall, the locations are not a serious problem. Community Groups are unable to fulfill all their responsibilities. The problems of staff availability and skills, and the limited availability of services and drugs are really the responsibility of officials at Union and Upazilla levels. Staffing for the operational clinics is a challenge and was found below the planned levels, and even the skill levels observed were too low to allow high quality services to be provided. Serious shortages of equipment and furnishings persist, but the main problem remains inadequate and intermittent supply of drugs. Immunization services are being provided, but overall the child health and maternal health care rates are particularly low. The extraordinarily high expectations of most beneficiaries is a challenge that needs to be addressed. Beneficiaries expect doctor led services which was never intended under the CHC programme. This misconception on the part of the beneficiaries needs to be cleared. The beneficiaries also expect a major change in the availability of drugs which has yet not been achieved.
One of the positive outcomes of the programme is the community ownership and involvement. The land on which CHCs have been established has been provided by the community
Outcomes
The Community Health Clinics have put in place broadly facilities of the planned specification in the right locations. At present, the CHCs are playing at most a limited role in the development of ESP services for those most in need.
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The beneficiaries feel that the CHCs lack privacy, and do not have enough stock of the required drugs and medical supplies. Many beneficiaries are of the opinion that the service providers do not possess the adequate clinical skills and are very often rude in their behavior towards patients and their families.
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The CHCs provide one-stop community-level ESP services in a consistent location designed for easy access at the time of need and thus a much more comprehensive rangeof services can now be provided under this programme. Preventive and promotive services including missed opportunities in immunization are now linked to acute curative care and counselling under the CHCs. Earlier the service-delivery system at the grassroots level was both labour-intensive and costly, and had a limited range of services to offer at any one time. The frequency of field workers visit per household could not adequately meet the need of a family for healthcare, especially reproductive healthcare. With the setting up of CHCs there has been an effort to replace labour intensive and costly health care services with cost-effective extensive health and family planning services at one location. One of the positive outcomes of the programme is the community ownership and involvement. The land on which CHCs have been established has been provided by the community. Glimpses of Innovations in Primary Health Care in South-East Asia Involvement of community in management and operation of CHCs is through formation of Community Groups (CGs) representing people from all walks of life in the catchment area of each CHC. Some specific responsibilities have been given to the CGs by the government including land donation, site selection, supervision of construction, operational management, day to day repairs-maintenance, rehabilitation in the long-run and motivation of the community to seek health and family planning services from the CHCs. Providing services from a fixed-centre at the community level is a significant shift from the previous domiciliary system and represents one of the main features of CHCs.
Learnings
Though the concept of Community Health Clinics was an innovative and successful one, the process of implementation brought forth several significant learnings. The decision to establish Community Health Clinics did not involve any delegation of decision-making to villagers. Health Watch Committees though existent, do not have enough authority to monitor service provider performance and with no legal backing, this authority declined even further.
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Bibliography
Bates L., Islam Md. K., Schuler R.S., Alauddin Md., From the Home to the Clinic: The Next Chapter in Bangladeshs Family Planning Success Story Rural Sites. A USAID Study for the Frontiers in Reproductive Health Program. Revised November 2000. Normand C., Iftekar M.H., Rahman S.A., Assessment of the community clinics: Effects on service delivery, quality and utilization of services (http://www.hsd.lshtm.ac.uk/ publications/hsd_working_papers/bang_comm_clinics_web_version.pdf accessed on July 5th 2010). Sarker S., Islam Z., Routh S., Saifi R.A., Begum H.A., Nasim SM. A., Mesbahuddin M., Operations Research on ESP Delivery and Community Clinics in Bangladesh, Transition Plan on Shift from Outreach to Community Clinic-based Service-delivery System: A Study of Perspectives of Stakeholders by ICDDR,B: Centre for Health and Population Research (http://www.icddrb.org/uploads/originaluploads/wp146.pdf accessed on July 7th 2010). Ssengooba F., Rahman S. A., Hongoro C., Rutebemberwa E., Mustafa A., Kielmann T., McPake B., Health sector reforms and human resources for health in Uganda and Bangladesh : Mechanisms of effect.
Providing services from a fixed-centre at the community level is a significant shift from the previous domiciliary system and represents one of the main features of CHCs
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The lack of strong and visible official support for community groups undermined the authority and effectiveness of these new groups. Resources are needed for peoples effective participation in the form of official recognition and financial resources. With little financial support, community-run clinics and Health Watch Committees both closed down in great numbers. Stronger and effective networking and coordination between the community representatives and administrators and managers are likely to be more successful in establishing accountability because this can ensure the support of higher administrative or powerful members of society. A Rapid Assessment supported by WHO in 2009 indicated that in areas where CHCs are functional, service access has become more equitable and service utilization rates did increase. More supportive supervision visits by paramedical or medical staff need to be institutionalized to improve and maintain the quality of PHC services. Transition plans need to be developed to move from outreach to static extension services. Intensified support from the administration and local authorities is also still required to enhance and maintain the effectiveness of the community clinic management groups.
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Bhutan Integrating Traditional Medicine in Primary Health Care
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Background
According to World Health Organization (2002: 7), Traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being. Bhutans traditional medicine service, called So-Wa-Rig-pa and based on Indian and Chinese traditions is an integral part of Bhutans Primary Health Care programme. Despite the introduction of modern medicine, So-Wa-Rig-Pa, has retained its role in providing health care. Ever since the 17th century, So-Wa-Rig-pa has played a significant role, along with spiritual remedies offered by religious institutions. Since the inception of modern health services in 1961, an integrated system was foreseen as an effective strategy to reach the scattered population in the country of Bhutan. Significantly Traditional System of Medicine was incorporated in 1967 under the integrated system of health care delivery. Integrating Traditional Medicine in Primary Health Care The rich tradition of indigenous medicine, based primarily on herbal treatment, is kept alive by the Institute of Traditional Medicine Services, established in 1998 at Thimphu and 26 traditional units spread across Bhutan. Several forms of treatment are applied in traditional medicine, including indigenous surgical procedures.
Bhutans health care system integrates traditional medicine in primary health care
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The components of traditional medicine include plants, minerals, animal parts, precious metals and gems which are all used in different combinations to make over three hundred medicines in the form of pills, tablets, powders, ointments and syrups. These traditional medicines are produced entirely for domestic consumption, though there is plan to eventually export them in the future.
Innovative Design
What is unique in Bhutans health care system is that the traditional medical service is not kept separate from the Primary Health Care services. It functions as an integral part of the national health delivery system. It is available in all 20 districts and is housed under the same roof of district hospital for mutual consultation, treatment and cross referrals. Integration is not only at the level of service delivery under the Primary Health Care services, but at the level of medical education and knowledge sharing as well. The traditional medical students are attached to modern medicine hospitals for three months after completion of five years training in NITM for observation and to understand the modern medical system and different functions of the hospital. Likewise, health workers and nursing students of the Royal Institute of Health Sciences (RIHS) are also exposed to traditional medical services during their training programme through orientation visits and regular briefings. Medical doctors and other health science graduates who complete their studies from elsewhere, are also provided orientation on traditional medicine before induction into regular service. As a result, there is mutual understanding, cooperation and mutual respect for the different forms of medical science between the practitioners of both systems.
Objectives
To preserve and promote Bhutans unique system of medicine through capacity building, skill upgradation and fitting traditional medicine effectively into the framework of the national health care delivery system. Achieve health goals through sustained provision of quality general and public health services in a holistic manner through integration of traditional medicine within the gamut of Primary Health Care in the country.
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Provide the people of Bhutan with of both the integrated traditional and modern health care services. Sustained focus on primary health care (PHC) to be maintained to promote equity and expansion of coverage and maximum community participation. Improvement in the production and quality of traditional medicines and services through strengthening human resource, research and infrastructure development. Develop traditional systems to standards that enable its potential as a centre for wellness tourism. Identification and demarcation of areas rich with medicines plants for care and management by relevant Dzongkhag Administration. Successfully integrate traditional and indigenous system of medicine in the mental health care and to provide services for basic mental health to all Dzongkhags through integration of mental health care into the primary health care delivery system.
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The integration of traditional medicine(TM) into the countrys primary health care is proof of the commitment of the Royal government of Bhutan to not only preserve the rich traditional practices of healing and curing, but also of giving its people a choice between allopathic and traditional treatment. The Government, the medical practitioners of both streams, the paramedics and health workers and even the external agencies that fund health and developmental programmes within Bhutan accept this integration and work towards promoting it throughout the country. The TM system is quite popular amongst the Bhutanese people as well, specially amongst the older population. 10-30% of the daily OPD patients in the district hospitals are treated through the TM system. The national hospital in Thimphu treats about 200 250 patients per day in summer and about 150 to 200 patients per day in winter. The Institute of Traditional Medicine Services provides traditional medical treatment, while the Jigme Dorji Wangchuk National Referral Hospital is the biomedical centre.
Methodology
The tenets of traditional medicine have been incorporated in the medical curriculum. At the national level, regular interaction between the modern doctors of the Jigme Dorji Wangchuk National Referral Hospital(JDWNRH) and traditional physicians of the National Traditional Medicine Hospital(NTMH) regarding patient care and management including cross referrals of patients between the systems are ensured. Both systems of medicine are practised under the same roof and are available at all health units. As a source of impetus to the traditional systems of medicine, conferences and consultations of traditional medicine are held wherein physicians of all traditional medicine units participate to discuss about activities, achievements, constraints and annual work plans etc. Recommendations emerging from such conferences are endorsed by the Annual Health Conference, which is the highest decision making body for the health sector, and followed up accordingly.
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Key Strategies
For proper and holistic integration of both systems for better primary health care delivery, all traditional medicine units in the districts are under the control of the district health administration. It has been made available in all 20 districts and is housed in the district hospital. The traditional medicine units in the districts are directly under the control of the district health administration as per the decentralization policy of the Royal Government. District Traditional Medicine units are manned by one traditional physician known as Drungtsho and one traditional clinical assistant known as sMenpa. Patients seeking combined methods of treatment (modern and traditional) are handled jointly by the biomedical doctors and Drungtshos. Mental health is one such area, where the potential benefits of integration are being explored by the Ministry of Health in Bhutan. Research on determining the most effective parameters of integration is being initiated by ITMS in Thimphu. The Pharmaceutical and Research Unit - PRU manufactures traditional medicines and conducts research and development including botanical and pharmacognostical studies, phytochemical and clinical studies and standardization of the formularies and raw materials leading to product development. The National Institute of Traditional Medicine (NITM) is responsible for human resource development and trains Drungtshos, sMenpas, research assistants, research technicians and pharmacy technicians.
The traditional medicine system is quite popular amongst the Bhutanese people as well, specially amongst the older population
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Traditional medicines are supplied through the normal medical supply system from the Drugs, Vaccines and Equipment Division (DVED) of the Ministry of Health and the store management at the district level is fully integrated. The procurement of equipment and other supplies are also done through the DVED.
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Highlights
The Royal Government of Bhutan (RGoB) has succeeded in attaching high priority to universal access to basic health care services in the country, focusing on equity and quality . The provision of extending free basic public health care services has been further enshrined as a constitutional obligation. The governments mandate is to provide free access to basic public health services in both modern and traditional medicines . Bhutan has progressed well on health outcomes and is well on its way to attaining most of the Millennium Development Goals (MDGs). The key area of focus continues to be directed at further improving primary health care services as the foundation of well being of families and communities and thus contributing to Gross National Happiness (GNH). The Royal Government recognizes that health is a prime mover of socio-economic development and has consequently embarked upon a major expansion of both health and social services over the past four decades. Glimpses of Innovations in Primary Health Care in South-East Asia Since the launch of PHC approach to health care system in Bhutan, the health status of the people has been greatly improved through effective implementation of the eight essential components of PHC. Today, Bhutan has 29 hospitals, 176 BHUs, 514 out reach clinics (ORC) and 25 traditional medicine units in the country. The health services coverage is estimated at over 90%. In 2004, the country spent 4.6% of its GDP on health care with the government providing for 64.2% of that amount according to the WHO. During the past few decades, traditional medicine has undergone profound changes from a single indigenous dispensary in 1968 to a professionally managed, complex organization. The dispensary in Thimphu was upgraded to become a National Indigenous Hospital in 1979 and was renamed as the National Institute of Traditional Medicine (NITM) in 1988. In 1990 the Research and Quality Control Laboratory was established. To meet increasing demands, the NITM was upgraded to the Institute of Traditional Medicine Services (ITMS)
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in 1998 with three divisions: National Institute of Traditional Medicine (NITM), National Traditional Medicine Hospital (NTMH) and Pharmaceutical and Research Unit (PRU). Other important achievements include a sustained focus on integrated primary health care, concerned with equity and expansion of coverage. Bhutans successful integration of traditional medicine services and allopathic services has provided alternative choices for the people. Traditional medicine in the country has greatly increased with traditional Drungtshos (Doctors) providing indigenous medical services in all Dzongkhags (Districts). Each relevant stakeholder has effectively collaborated and contributed through their specific efforts in generating the good health outcomes for Bhutan. The financial resources for delivering health have been increasing at a considerable pace and government now allocates around 8% of the GDP to health. The availability of traditional medicines along with biomedicine has broadened the health care choices of patients. The fact that the Royal Government of Bhutan provides traditional medical services at the central level and at some basic health units, gives the patients a choice of therapeutic alternatives and more holistic health care. As traditional medicine is indigenous, sustainable and affordable, the system could be successfully preserved, promoted and effectively integrated into the overall national health care delivery system. The implementation of integrated district health systems has been recognized internationally through the award of the prestigious Sasakawa Health Prize Award for the Mongar health service development in 1993. Many districts have also been awarded the Tobacco Medal by the World Health Organization (WHO) in recognition of the successful implementation of the health programmes. The primary health care award has been awarded to RIHS for its contribution to PHC development in the country. Mental health care training has been introduced at RIHS Having achieved much success in increasing health service coverage, the health sector is shifting its focus towards enhancing quality of health services. The financial resources for delivering health have been increasing at a considerable pace and government now allocates around 8% of the GDP to health.
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As traditional medicine is indigenous, sustainable and affordable, the system could be successfully preserved, promoted and effectively integrated into the overall national health care delivery system
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Challenges
Although all kinds of diseases are treated by traditional hospitals, the treatment regimens are said to be more effective against chronic diseases, such as backache, migraine, sinusitis, arthritis, asthma, rheumatism, liver problems, paralysis and old age syndromes. The treatment methods at the NTMH include herbal therapy, herbal bath and herbal steaming. Localized herbal steaming is gaining popularity among the Bhutanese. Some patients seeking combined methods of treatment (modern and traditional) are handled jointly by the biomedical doctors and Drungtshos. The potential benefits of integration are being explored by the Ministry of Health in Bhutan. Research on determining the most effective parameters of integration is being initiated by ITMS in Thimphu and needs to be pursued for the most effective use of an integrated approach to treatment, specially in the case of mental health. Only traditional medicines are manufactured at the Institute of Traditional Medicine Services (ITMS) in Thimphu. The components of traditional medicine include plants, minerals, animal parts, precious metals and gems which are all used in different combinations to make over three hundred medicines in the form of pills, tablets, powders, ointments and syrups. These traditional medicines are produced entirely for domestic consumption, and are not exported. Although, Bhutan has succeeded in making the programme selfsufficient in terms of budget after the operationalization of the Health Trust Fund, the country will still be dependent on the outside world for the drugs, vaccines and other supplies like laboratory reagents and medical equipment. Bhutan has no pharmaceutical industries in terms of Primary Health Care services and use of modern medicine, and relies on imports for its entire requirement. Since all allopathic medicines and vaccines are imported from outside, quality control is a concern for the Bhutanese. Research and development initiatives need to be increased to evaluate the advantages and efficacy of the two systems. Yet another challenge is to maintain high standards in the quality of traditional treatment delivery so as to take it to the level of a centre of excellence for promoting health/ wellness tourism.
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Outcomes
From a single indigenous dispensary in 1967, the traditional system of medicine has rapidly advanced and been successfully incorporated into a countrys health care system with due endorsement from the government. Bhutanese traditional treatment has become particularly popular for the treatment of chronic d iseases like Arthritis, asthma, Sinusitis, Rheumatism, Liver ailments, digestive problems, and problems related to mental health. With the successful integration of both traditional and modern forms of medicine presently the primary health care services are catering to the health needs of 90% of the population in the country. In Bhutan it is not uncommon that a patient will consult both the modern and traditional physician and collect herbal and allopathic medicines. The National Institute for Traditional Medicine (NITM) has emerged as the premier institute for training of health functionaries at all levels as required by the Department of Medical Services. The prompt supply of effective traditional medicines and drugs has played a crucial role in the delivery of quality health services. At the same time the shortage or non availability of traditional medicines has been significantly reduced with the commissioning of the Pharmaceutical and Research Unit (PRU). Introduction and expansion of existing facilities such as herbal steam sauna, hot stone baths, acupuncture, herbal massage and other forms of traditional treatment in the district hospitals on cost sharing basis are being explored. The Wellness Centres using all indigenous medical care services will form part of medical tourism.
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Bhutanese traditional treatment has become particularly popular for the treatment of chronic diseases like Arthritis, asthma, Sinusitis, Rheumatism, Liver ailments, digestive problems, and problems related to mental health
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Learnings
It is seen that the integration of traditional medicine in Primary Health Care in Bhutan has proved that it is possible to constructively harness a symbiotic working relationship between traditional and religious practitioners and modern health care workers to provide culturally acceptable care to the largest number of people, as it maintains a rich fusion of modern and traditional health care under the same roof. The Bhutan experience has paved the way for initiating similar systems in other countries as well. This successful best practice of integration of the traditional system of medicine into the primary health care system of a country can be replicated for a more holistic approach to health care. The experiences of integrating two conceptually very different health care systems within one ministry provides tremendous scope for experience sharing. Few countries (eg India and South Korea) have supported the practice of a traditional medical system along side biomedicine and even fewer countries (eg Bhutan, China, Mongolia and Vietnam) have officially recognized and supported one integrated medical system under the same ministry and health care delivery system. As traditional medicine is indigenous, sustainable and affordable, with the successful integration of both traditional and modern forms of medicine presently the primary health care services are catering to the health needs of 90% of the population in the country. Another very significant learning from the Bhutan model is that traditional and modern medicine complement each other and do not need to compete. Traditional medicine yields better results specially in some cases whilst modern medicine yields better results in others, while sometimes the results are the same. There is a sense of wellbeing and satisfaction amongst people because they feel that that their wellbeing is not ignored and that they have options as to the stream of treatment that they may prefer to choose. As a result of the use of the traditional medicine, care is also being taken by the government to preserve Bhutans flora, fauna and environment.
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Bibliography
Ong C.K., Bodeker G., Grundy C., Burford G., Shein K., WHO Global Atlas of Traditional, Complementary and Alternative Medicine. Google Books. Revitalising Primary Health Care, World Health Organisation (http://www.searo.who.int/LinkFiles/ Conference_BHU-8-June-08.pdf accessed on July 28th 2010). Selvaraj M., Ramach andran L., Environment, Demand for Health and Economic Situation of Bhutan Environmental Informatics Archives Volume 5 (2007). Wangchuk P., Wangchuk D., Aagard-Hansen J. Review Traditional Bhutanese Medicine(gSo-ba Rig-pa) : An Integrated Part of the Formal Health Care Services. South East Asian J Trop Med Public Health Vol 38 No. 1 January 2007.
There is a sense of wellbeing and satisfaction amongst people because they feel that that their wellbeing is not ignored and that they have options as to the stream of treatment that they may prefer to choose
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Background
In the Democratic Peoples Republic of Korea (DPR Korea), human life is given utmost priority and Primary Health Care (PHC) is proposed as one of the main policies of state health from the early days of public health construction. In DPRK, the PHC is organized and delivered based on the Household Doctor System (HH). The developing process of household doctor system showed that the system was enforced focusing on hygienic and anti-epidemic work of the institutions. The HH doctor system is an advanced health care system to take care of population and provide treatment as per section in charge, so that the entire population is benefited by the comprehensive health care systematically.

In August 1982, the WHO established the WHO collaborating centre for PHC in Korea. It is placed in the Institute of Public Health Administration of MoPH. After 1988, the government took up measures to develop the section doctor system into household doctor system. The HH doctor system is a system by which one doctor is responsible for universal and comprehensive health care of a household; the HH doctors take charge of a definite number (130) of households to manage the health of the population. Thus the PHC system went through several changes in DPR Korea and saw the emergence of the House Hold doctor system and a health infrastructural set up that provides for Ri (Rural area) and polyclinics within 30 minutes walking distance, whilst the city (district) and county hospitals providing primary and specialized services are located within a couple of hours from the area and population they are designated to cover.
The PHC system went through several changes in DPR Korea and saw the emergence of the House Hold doctor system and a health infrastructural set up that provides for Ri (Rural area) and polyclinics within 30 minutes walking distance
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The Primary Health Care services in DPR Korea, as in the other South-East Asian countries focuses on the 8 essential elements of PHC ie. Health Education; Nutrition; Maternal and Child Health; Immunisation; Water and Sanitation; Endemic Diseases; Common Ailments and Injuries and Essential Drugs. Human life and health are high on the priority list of the Government which has taken complete responsibility of health through a universal medical care system which includes overall public health management including the training and distribution of health workforce as well as distribution of health facilities and drug management in a planned and scientific manner, based on the health need assessment of the country. The Government has distributed health facilities according to the specifications of residential areas and the need for health services, taking the access to health services in the country to the significant level of 97.3% as per information available.
Innovative Design
Glimpses of Innovations in Primary Health Care in South-East Asia DPR Korea achieved noticeable improvement in the health and longevity of its population with the creation of a state-funded and state-managed public health system. The country has a nationwide medical service with wide network of health facilities at different levels sufficiently housed with health care providers. As per information available, DPR Korea spends approx. 6% of its gross domestic product on health care. In DPR Korea, preventive medicine has been made the foundation for health policies. According to the Public Health Law enacted on April 5, 1980, The State regards it as a main duty in its activity to take measures to prevent the people from being afflicted by disease and directs efforts first and foremost to prophylaxis in public health work. All health facilities are owned socially, most of them are state-owned and operated under the unified guidance and physical assistance of the state, while some peoples hospitals and clinics in Ri-level are run by cooperative farms. What can be termed as an innovation that has made significant change in the PHC services and overall health status of the people in DPR Korea is the concept of the House Hold (HH) Doctor System.
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The House Hold (HH) doctors has proved to be one of the pillars of Primary Health Care in DPR Korea. In fact, the entire PHCs in the country is organised around the HH doctor system. It is responsible for the healthcare of all population is enforced in the country. Care has been taken to integrate traditional and modern medicine at the PHC level in order to provide choices to people. The HH Doctors not only serve as health care providers but also coordinate health education and hygiene propaganda. IEC and BCC activities are carried out in partnership with personnel from education institutions to continuously promote healthy lifestyles and correct health & nutrition practices. The HH doctors have strengthened the governments efforts in controlling locally endemic diseases like malaria and expansion of DOTS for TB control ensuring remarkably high coverage and success. Roles and Responsibilities of HH doctors: Health Educator - advocate for hygiene and promotion of healthy lifestyles Community mobilizer mobilise the community and organise communitybased activities Health service provider Treating patients at household level and at Ri clinics and Ri hospitals, referral as well as regular house hold visits Monitoring and investigation - Screening and early diagnosis of diseases and in case of epidemics Emergency services - Emergency care and referral Registration of vital events and special population groups Documentation - Data collection and reporting
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The active and widespread network of HH doctors and health facilities provide strong foundation for integrated disease surveillance programme. For instance during the resurgence of malaria in DPR Korea in 2007 the HH doctors enabled rapid action by organizing mass vaccination programmes within a short period of time.
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The HH doctor system has been implemented to ensure health services and coverage for the entire population. Sick-call treatment, visitation treatment, women consultation, birth assistance, infant consultation, specialized diagnosis and treatment are all part of this system for curative services additional to promotive and preventive services offered by HH doctors at facility and through household visits. In general, medical examinations are required twice a year, and complete records are kept at local hospitals. The HH doctors have several responsibilities beyond their medical capacity and are required to mobilise the community, impart health education and perform a host of other duties as well. Through the HH doctors substantial ground has been gained in terms of health and in particular maternal and child health. DPR Korea now has a reasonably moderate maternal (97 per 100,000 live births) and infant mortality (20.2 per 1000 live births). The immunization coverage has also increased substantially (>90% for primary immunization), with >98% coverage of births by skilled attendants and institutional deliveries, provision of curative services (75-80% at peripheral levels) and timely referrals. Glimpses of Innovations in Primary Health Care in South-East Asia According to one source, persons are required to follow the advice of their assigned physician and generally accept treatment. In the countryside, medical examination teams (kmjindae) consisting of personnel from the provincial and central hospitals make rounds to investigate the health situation along with local doctors. Hygiene propaganda work, is used as a means of educating the people on sanitation and healthy lifestyles. Ri (Rural area) hospitals and polyclinics conduct the activities of preventive healthcare, sanitary propagation, whilst the HH doctor system is used to cater to health delivery services. This system, also known as the doctor responsibility system, assigns a single physician to be responsible for an area containing several hundred individuals.
Objectives
The government has set the mandate of public health as the prevention of diseases and enforced universal free medical care system that enables people to have equitable and fair access to health care irrespective of age, sex, occupation and position. The main objectives of DPRKs Universal Free Medical Care System are:
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To protect and promote the lives and health of people with the equitable provision of basic, essential and quality health services to the entire population, focusing on prevention and health promotion To maximize the access to health care irrespective of age, gender, occupation or status To prioritise disease prevention over treatment
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Methodology
The DPR Korea programme on Universal Free Medical Care has both technical and methodological systems in place. The system is decentralised from central level to the province to county, the county to Ri. Today, County peoples hospitals with the basic specialized departments such as internal medicine, paediatrics medicine, surgery, obstetrics and gynaecology, traditional Korean medicine and dentistry are run as first referral units while Ri hospital and clinics in rural areas provide basic and essential health services. The urban polyclinics, the main PHC units with basic specialized services for households, obstetric and gynaecological surgery, dentistry and laboratory are run in urban areas. There is a rational distribution system of health personnel, especially at PHC level, nationwide. In the distribution of health personnel in-charge of outpatient treatment, the principle is to distribute 75-80 percent at direct sections, 10-15 percent at city, district, county levels, 3- 5 percent at provincial level, 0.5-1 percent at the central curative and preventive establishments. The health care of the staff and their families living around the industrial hospitals is provided by the hospitals themselves, making them responsible for the population residing in the surrounding areas. Health workers in charge of households are involved in health education. However, the students from universities and schools are also encouraged to take part in this activity. Educational institutes provide health education to children in nurseries and kindergartens suitable to their mentality on common knowledge and practice and to pupils in high schools with an allotted time for health education. Regular training of voluntary officials and other paramedic manpower engaged in the health delivery services is organized to continuously update their knowledge and skills.
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Health workers in charge of households are involved in health education. However, the students from universities and schools are also encouraged to take part in this activity
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There is a regular reporting system in place from peripheral to central level and the information compiled through the reporting system at MoPH is used to analyze and assess the health situation and map out health policies and actions. In DPR Korea, drug supply system for rational provision to all the treatment and preventive institutions is through the drug supply stations set up at the central, provincial, city and county levels, as well as for control of medicine resources. In terms of supply of essential medicines, the production, storage, use of the medicines is based on the Law of Medicines Management. The drugs are registered in line with the regulations and procedures formulated by the state, and the drug reactions are regularly monitored through all the treatment, prevention establishments and pharmaceutical testing stations.
Key Strategies
The DPR Korea initiative is well strategised to meet the primary objective of equitable provision of basic, essential and quality health services to its people focussing on the prevention and promotion aspects. At the same time strategies are in place to meet any existing gaps in the health care delivery system. The key strategic areas include: 1. Identification of key health priorities and conducting needs assessment to find out the health requirements of the people and preparing a proper programme implementation plan accordingly. 2. Ensuring an efficient and functional health system in place in terms of proper infrastructure down to the community level, adequate human resources, service delivery and community participation. 3. Advocacy for development of innovative financing and mobilising both national and international finance for addressing gaps in the health care delivery mechanism. Besides the government health manpower and infrastructure an organizational governance structure for mobilizing and guiding community in health systems strengthening has also been set up within the community including Ri (dong, oup and industrial area) along with the health inspection committies and HH doctors, thus rendering strong guidance to mobilize the community in promoting public health.
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4. Supervision, control and assessment of the different components of the programme by the respective institutes, provincial governmental bodies, others like sector-wise supervisory and monitoring agencies, with all the institutes and agencies working in close collaboration with each other. Therefore, multi sectoral coordination at the subnational level is one of the key operational strategies of DPR Korea health initiative. 5. Prevention and Control of Communicable Diseases with particular focus on malaria and TB as well as increasing immunisation coverage for communicable diseases. 6. Promotion of Mother and Childrens Health by scaling up continuum of care with essential and referral newborn care, Integrated Management of Childhood Illness (IMCI) and improving obstetric care to bring down maternal mortality. 7. Prevention and Control of Non-Communicable Diseases like lifestyle-related diseases, injuries, tobacco control, disabilities etc. 8. Focus on other social and environmental determinants of Health like upgrading of water and sanitation systems in health facilities, as well as disaster preparedness and response to epidemics, pandemics and other natural disasters.
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Highlights
PHC services in DPR Korea have been made accessible to all. The ri hospitals/Clinics and polyclinics for providing PHC are distributed in the position of arrival of within 30 minutes walking; the city (district), county hospitals for providing the primary and specialized service are in position of arrival of within one hour by transportation means. The HH doctor system is functioning efficiently and the number of doctors providing the health care through this system is 44,760; ie. an average of 130 households by one House Hold doctor. Health education and health propaganda is well organised and plays a key role in the PHC in the country. The hygienic propaganda work system is divided into two parts in DPR Korea; the special hygienic propaganda work system and mass hygienic propaganda work system. The hospitals and the clinics of PHC level directly conduct the hygienic propaganda and its executors are the HH doctors. The health workers regularly visit all the families to impact hygienic knowledge and give guidance and help related with health care, thus the propaganda work is intensified. Even educational institutions, publishing
Health education and health propaganda is well organised and plays a key role in the PHC in the country.. The hygienic propaganda work system is divided into two parts in DPR Korea; the special hygienic propaganda work system and mass hygienic propaganda work system.
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and broadcasting sector, cultural and art sector and social organizations take part in health education drives and campaigns. The government has taken active measures to improve the nutrition state of its people-especially children. In spite of difficult conditions, the food supply for the children was regularised by mobilizing the internal sources and by the effective use of international assistance. The national surveillance and survey system for monitoring and assessing the nutritional level of children is established with proposed periodic survey for nutrition status. Maternal and Child Health has been given high priority in the national agenda. The health centres are now equipped with specialized delivery rooms to ensure the maximum access to health care and improved maternal health care. Pregnant women are registered early and almost all within the first Trimester of their pregnancy, followed by a systematic monthly observation and the delivery is done under inpatient care. The government has directed efforts to improve obstetric care at PHC level and strengthened the technological and methodological guidance to obstetric care in remote areas. Specialists from Pyongyang Maternity Hospital are deputed to remote areas to provide technical assistance for improving skills and competency levels of doctors on deliveries and managing complications. The treatment and prevention institutions at PHC level conduct activities to prevent diseases like pneumonia and diarrhoea, focusing on the implementation of IMCI strategy, the effective approach for child disease management. Provisions have been made for quality emergency care for the population in remote areas through the provision of transporation through ambulance services to several county hospitals. At the PHC level all efforts and resources are channelised to ensure provision of essential drugs for mothers and children. Over the years Maternal and Child Health indicators in DPRK have showed significant improvement: registration of pregnant women increased from 97.1% in 1998 to and 99.4% in 2006. Deliveries attended by skilled health personnel was 99% in 2006 (of which institutional deliveries was 89.5%). Maternal Mortality Rate reduced from 105 in 1996 to 97 in 2002 and to 85 as per 2008 Census. Infant Mortality Rate was reduced from 21.8 to 20.23 during 2000-2005 and per 2008
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census is 18.7 per 1000. Under 5 Mortality Rate has also shown significant improvement. From 46.3% in 2003 it moved to 40.87 in 2005 showing considerable decrease. Expansion and modification of water reservoirs in the city, construction of new water reservoirs and lay-up of water works in rural area have been conducted to minimize the damage owing to water infection and for the overall improvement of drinking water and sanitation . According to a nation-wide sample survey in 2004, the households with access to water service was 85.1% and households with access to water from pump tube-well or protective booth-well was 14.9% whilst population with access to adequate sanitation was 99.2%. DPRK has an integral epidemic surveillance and control system. The government has rehabilitated and modernized the vaccine production factories and ensured regular production and quality of drugs. It has also mobilized internal and external resources for the procurement of vaccines. To sustain high level of immunization coverage (98%) for the children, the government has strengthened the production capacity of vaccine production factories and organized a large number of non-standing immunization teams for regular immunization. Consequently, the immunization coverage has been improved and sustained.
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Immunization coverage (%) Name Vaccines for DPT3 Measles Polio BCG
2000 81 91.5 98.3 81.5
2006 82.2 96.9 99.8 99.8
2008 91.7 99.2 99.3 96.9
Along with ensuring PHC, the government has established a drug resources control and supply system for prevention and treatment. Essential drugs are supplied through drugs control stations at each level. Care is taken to follow the rational use of drugs. As per WHO recommendations/stipulations 40 kinds of essential drugs are recommended for use at PHC level including in the urban polyclinics, ri hospitals/clinics-the main units of PHC.
To sustain high level of immunization coverage (98%) for the children, the government has strengthened the production capacity of vaccine production factories and organized a large number of nonstanding immunization teams for regular immunization
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No primary health initiative can be successfully implemented without community participation. In the DPR Korea programme, the community is actively involved in strengthening health systems through planning, organizing, implementing and monitoring PHC in the country. Community participates in establishing clean living environment and healthy life style by participating in and conducting health education.
Challenges
Given the vast network of health facilities and variable state of the physical status, it is important to upgrade the infrastructure. Further strengthening of human resources especially to enhance knowledge and skills for improving the quality of health care being provided. Rationalize distribution of primary health care facilities especially between plain and mountainous regions and urban and rural areas and ensure adequate human resources. In order to sustain free universal access to health care, maintaining and continuously upgrading the skills of health workers remain a challenge. Felt needs to equip the facilities and train the HH doctors in early detection, confirmation and treatment of selected endemic conditions like Malaria Emerging conditions like Non Communicable Diseases and re-emergence of certain communicable diseases put additional challenges to the HH doctors for addressing life style conditions on one side and strengthen anti-epidemic drives and control measures on the other side. Maximize the production capacity of the vaccine producing factory to be self reliant in sustaining high immunization coverage. Additionally, there is need to refurbish the cold chain system for ensuring quality immunization. Government with assistance from partners is already addressing these challenges. Prevention and Control in case of resurgence of diseases like Malaria is a challenge which needs to be considered in terms early detection, diagnosis and treatment.
Outcomes
One of the most significant outcomes of the Free Medical Care System is the improvement and enhancement of health infrastructure with focus on Primary Health Care and referral
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linkages with higher level facilities. The extensive and comprehensive health infrastructure includes 6263 ri clinics and Polyclinics, 1575 ri and County Hospitals and several industrial hospitals in factories and enterprises. There are specialized hospitals at the central and provincial levels including the maternity centres and paediatric hospitals in every province and some of the cities. The sanitary and anti-epidemic institutions, specialized in control of infectious diseases, are located at central, province, city and county levels. The number of HH doctors providing the health care at ri clinics and through household visits is 44,760; averaging about 134 households by one House Hold doctor. Based on the tenets of PHC, DPR Korea is working to further strengthen the healthcare system. Access to first level health service for the population in the health system is provided by polyclinics or Dong clinics in urban, ri peoples hospital or Ri clinic in rural and industrial hospital or industrial clinic in industrial areas. Peoples County hospital at upper level of city and county, is the general hospital with several specialized departments, which provide the specialized health services and fulfil the function of first referral of PHC. Ri clinics/hospitals and polyclinics, the direct service providers of PHC, are so set up in areas within a walking distance of 30 minutes. City, district, and county hospitals, to provide primarily specialized care, are distributed within the reach of one hour travel by transport vehicle. The Government has established administrative, technological and methodological guidance system for PHC. Efforts to bring enhanced focus on research for accurate analysis and assessment of health situation and the establishment of health information system in the country are underway. Initiatives to conduct research in assessing the health need of the country and contribute to
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As an outcome of the countrys mission to provide quality PHC services to its people, concerted efforts are being made for the development of modern medicines as well as traditional Koryo medicine including hydro-physiotherapy and rehabilitation
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the formulation of national health policies and planning are being envisaged through appropriate capacity building. As an outcome of the countrys mission to provide quality PHC services to its people, concerted efforts are being made for the development of modern medicines as well as traditional Koryo medicine including hydro-physiotherapy and rehabilitation. Traditional medicine has been generalized mostly at PHC level: 50-60% in municipality, district or county hospitals and 60-70% in ri-clinics and hospitals. Naturopathy is widely used for the treatment of diseases at PHC level. There are abundant and diverse sources for naturopathy like mineral spring, spa and mud in the country and the potential of these have been tapped for treatment of chronic diseases and health promotion purposes. Various measures have also been taken to improve health care for injuries. Emergency care at PHC level has been strengthened. To ensure the responsiveness and quality of emergency care, emergency units at PHC level have been distributed rationally and activities have been carried out to improve the skills of emergency care providers in a planned manner. Factory hospitals, located in industrial area with factories, coal mines and business enterprises, provide health services focusing on field care in the work areas, based on section workshop (mines) system.
Learnings
To address regional gaps, the government is making all efforts to further rationalize the distribution of the PHC network per population density and residences. There is a need to expand and modernize the health facilities including infrastructure upgradation and equipment Building capacities of health workers especially HH doctors through continuing education programmes and regular training would improve the quality of care and contribute towards reduction of mortality and morbidity, Governments commitment in sustaining universal free medical care system is noteworthy despite it being so resource intensive and therefore technical and financial resources from all partners need to be geared towards strengthening health system with focus on primary health care.
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The Universal Free Medical Care system in DPR Korea has been developed as an undertaking for the people and of the people themselves, and thus it has been implemented almost on a mission mode through excellent coordination and collaboration of various health institutions and enterprises. The mass media used in health education and sanitary information is an effective way for health promotion and spreading of health awareness. Collaboration with related sectors such as education can be further strengthened and participation of community organizations such as cooperatives can be further enhanced. Enhanced technical assistance and capacity building support from WHO, the UN and other international organizations would contribute further in strengthening PHC system and in sustaining the gains so far.
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Bibliography
Country Studies Public Health (http://country-studies.com/north-korea/public -health.htmlaccessed on August 1st 2010). Democratic Peoples Republic of Korea National Health System Profile (http://www.searo.who.int/ LinkFiles/DPR_Korea_CHP-DPRK.pdf accessed on August 1st 2010). DPR Korea. Medium Term Strategic Plan for the Development of the Health Sector in DPRK 2010-2015 (Draft) Ministry of Public Health in partnership with WHO. Health Care in North Korea (http://en.wikipedia.org/wiki/North_Korea accessed on August 1st 2010). North Korea Public Health ( http://www.mongabay.com/history/north_korea/north_korea-public_ health.html accessed on July 31st 2010). Revitalising Primary Health Care, Country Experience : DPR Korea (http://www.searo.who.int/LinkFiles/ Conference_DPRK_15June-08.pdf accessed on July 31st 2010). Yong H.R. Strengthening Community-Based Health Workforce in DPR Korea
The Universal Free Medical Care system in DPR Korea has been developed as an undertaking for the people and of the people themselves, and thus it has been implemented almost on a mission mode through excellent coordination and collaboration of various health institutions and enterprises.
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Background
The National Rural Health Mission launched in 2005 seeks to provide effective health care to Indias rural population throughout the country with special focus on 18 states, which have poor public health indicators or weak infrastructure. These 18 States are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh. The Mission is aimed at overhauling the health system, particularly its broad framework to enable it to effectively manage the objectives stipulated under the National Common Minimum Programme and promote policies that strengthen public health management and service delivery in the country. One of core components in the NRHM is the female health activist in each village The Accredited Social Health Activist (ASHA). She is the health change agent at the village-sub-centre level and the interface between the community and the public health system.
Innovative Design
The ASHA initiative is innovative in the sense that it is mandatory for every Panchayat to appoint an ASHA keeping in mind the individuals general acceptance in the community and her literate background. Therefore, every village in the country has to have a female Accredited Social Health Activist (ASHA) - chosen by and accountable to the Panchayat
One of core components in the NRHM is the female health activist in each village The Accredited Social Health Activist (ASHA). She is the health change agent at the village-sub-centre level and the interface between the community and the public health system
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(Village Council or grassroot unit of self-governance). She will act as a link between the community and the public health system (NGOs, Health Authorities, Anganwadi Centres ( AWCs - child-focussed activity centres) etc. Each state has the freedom to choose a statespecific model under the NRHM. The States will have flexibility to adapt these guidelines keeping their local situations in view. The general norm as decided under the programme is One ASHA per 1000 population. However, in tribal, hilly, desert areas, the norm can be relaxed to one ASHA per habitation, dependant on workload etc. The ASHA acts as a bridge between the Auxiliary Nurse Midwife (ANM) and the village. She is above all, a volunteer, receiving performance-based compensation for her work in promoting universal immunization, referral and related services for Reproductive and Child Health (RCH) programme, construction of household toilets, and other healthcare delivery programmes. She is trained on a specific aspect of public health for the Cascade Model of training proposed through Training of Trainers which includes contract as well as distance learning model in partnership with NGOs/ICDS Training Centres. Glimpses of Innovations in Primary Health Care in South-East Asia The ASHA is given a Drug Kit containing traditional/alternative and allopathic formulations for common ailments. The kit is replenished regularly.
Objectives
The ASHA functions primarily as a health services consultant and caters to the day-today demands/queries of her designated habitation, primarily below poverty-line (BPL) families, women and children. She offers health advise, counsel and provides services to the families as per her defined role and responsibility. The ASHA facilitates preparation and implementation of the Village Health Plan along with the Anganwadi workers, ANM, functionaries of other Departments, and Self Help Group members, under the leadership of the Village Health Committee of the Panchayat. The scheme of ASHA has now been extended to all the 18 high focus States. Besides, the scheme would also be implemented in the tribal districts of the other States Overall, the objectives of the ASHA initiative are as follows: Building awareness on health and, particularly its social determinants Mobilizing the community towards indigenous health planning
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Increasing utilization and accountability of the existing health services Promoting good health practices in the community Providing a minimum package of curative care as appropriate and feasible for that level Undertaking timely referrals
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Co-ordination with Self-help Groups: ASHA would be required to interact with SHG Groups, and Anganwadi workers so that a work force of women will be available in all the villages. They could jointly organize check up of pregnant women, their transportation for safe institutional delivery to a pre-identified functional health facility. They could also think of organizing health insurance at the local level for which the Medical Officer and others could provide necessary technical assistance. Meeting with ANM: ANM should have a monthly meeting with the ASHAs stationed (5-6 ASHAs) in the villages of her work area at the Anganwadi Centre during the monthly Health and Nutrition Day to assess the quality of their work and provide them guidance. Monthly meetings at PHC level: Medical Officers managing the PHCs hold monthly meetings attended by ANM and ASHAs, Block Facilitators etc. The health status of the villages is carefully reviewed and payment of incentives to ASHAs under various schemes is also organized simultaneously. These meetings are also an opportunity to assess the support received from the Village Health and Sanitation Committee and their involvement along with replenishment of ASHA kits. Management Support for ASHA: Officials in the Integrated Child Development Services are expected to offer full support to ASHA activities. The management support at the Block, District & State level should be fully utilized in creating a network for support to ASHA including timely disbursement of incentives, redressal mechanisms, databank on all ASHAs, quality of their output, outcomes of periodic health surveys of the villages to assess the impact of these female community volunteers.
The ASHA facilitates preparation and implementation of the Village Health Plan along with the Anganwadi workers, ANM, functionaries of other Departments, and Self Help Group members, under the leadership of the Village Health Committee of the Panchayat
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Methodology
The chief strategy is that the ASHA must be primarily a woman resident of the village, who is married, widowed or divorced and preferably in the age group of 25 to 45 yrs. ASHAs are expected to have effective communication skills, leadership qualities and be able to reach out to the community. She should be a literate woman with formal education up to Eighth Class. This may be done away with, only if no suitable person with this qualification is available. ASHAs will enlighten the community on basic information about nutrition, sanitation, hygiene, working conditions, information on existing health services and their utilization. The ASHA will facilitate the community in accessing health and health related services available at the village centers, such as Immunization, Ante Natal Check-up (ANC), Post Natal Check-up (PNC), ICDS, sanitation and other services being provided by the government. She will counsel women on birth preparedness, importance of safe delivery, breastfeeding and complementary feeding, immunization, contraception and prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infection (RTIs/STIs) and care of the young child. ASHA will also arrange escort/accompany the women who require treatment at the nearest available facility i.e. Primary Health Centre/ Community Health Centre/ First Referral Unit (PHC/CHC /FRU). She will be a provider of Directly Observed Treatment Short-course (DOTS) under Revised National Tuberculosis Control Programme.
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She will report promptly on the births and deaths in her village and any unusual health problems/disease outbreaks in the community to the authorities. Along with counseling on hygiene, the ASHA will promote construction of household toilets,as required under Total Sanitation Campaign. ASHA can help Anganwadi Workers (AWW) to complete and update the village health register by maintaining a daily diary. The diaries, registers, health cards, immunization cards may be provided to her from the untied funds made available to the Sub-Centres. ASHA can help the ANM and the AWW to monitor and organise village health days. They can also work with SHGs in the village, to conduct regular check ups and provide technical assistance. She will organize/attend meetings of village women/health committees and other group meetings and attend Panchayat health committees. To do justice to such numerous responsibilities under her belt, the ASHA needs a flexible work schedule. Her work would be scheduled and planned in a manner that it does not interfere with her normal livelihood. She is required to work two-three hours per day, on about four days per week, except during some mobilization events and training programmes.
Key Strategies
In order to provide health benefits to the communities and guide them, the ASHA must be comprehensively trained herself. Her effectiveness should be revised as capacity building of ASHA is critical in enhancing the worth of her work. To achieve the schemes objectives, necessary training would be provided. Induction Training: After selection, ASHA will have to undergo series of training episodes to acquire the necessary knowledge, skills and confidence for performing her defined roles.
ASHAs will enlighten the community on basic information about nutrition, sanitation, hygiene, working conditions, information on existing health services and their utilization
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ASHA will act as a depot holder for essential provisions being made available to every habitation like Oral Rehydration Solutions (ORS), Iron Folic Acid Tablets (IFA), chloroquine, Disposable Delivery Kits (DDK), oral pills & condoms, medication for diarrhoea, fevers, and first aid for minor injuries, etc. A Medicine Kit will be provided to each ASHA carrying a minimum package of curative care as appropriate.
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Considering the varied range of functions, induction training may be completed in 23 days spread over a period of 12 months. Training materials: A facilitators guide, training aids and resource material along with a periodically-replenished drugs kit would be given to ASHAs according to the roles and responsibilities. The training materials produced at the national level would be in the form of a general prototype which states may modify and adapt as per local needs. Periodic Training: About two days, once in every alternate month, training and interactive sessions will be held to help refresh and upgrade their knowledge and skills, trouble shoot problems they are facing, monitor their work and also for keeping up motivation and interest. ASHAs will be compensated for attending these meetings. On-the-job: After ASHAs begin work, ANMs while conducting outreach sessions in the villages have to contact ASHAs of the village and use the opportunity for continuing, updating education. NGOs are also invited sometimes to take up the selection; training and post training follow up. Glimpses of Innovations in Primary Health Care in South-East Asia Continuing Education and skill upgradation: A resource agency in the district of state (preferably an NGO) is identified by the State. The resource agency chosen by the State in collaboration with open schools and other appropriate community education schemes will develop relevant illustrated material to be mailed to ASHAs periodically for the ones who opt for an eventual certification. Venue of training: A venue with adequate capacity and central to the district should be chosen to facilitate training. In most situations this could be the PHC or alternatively Panchayat Bhavan or other facilities that are available. National Level: At the national level the National Institute of Health and Family Welfare (NIHFW) would in coordination with the National Rural Health Mission and its technical support teams, and the Training Division of the Ministry will coordinate and organize periodic evaluation of the training programmes. The findings of these concurrent evaluations should be shared with State Governments. State level: At the State level, the State Institute of Health and Family Welfare (SIHFW) in coordination with the State Training Cell of Directorate of Family Welfare will oversee the process of training, monitor and organize concurrent evaluation of training programme.
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Highlights
ASHA is an honorary volunteer and would not receive any salary or honorarium, but is compensated for her time and attention in the following situations : For the duration of her training so that her loss of livelihood for those days is partly compensated; and if she attends the monthly/bi- monthly training, regularly. The implementation framework for the NRHM has recently been approved; a provision has been made for an expenditure of Rs. 10,000 (to be jointly operated by the ANM and the Sarpanch (Head,Panchayat)) per ASHA during a financial year. The limit does not include the performance-based compensation, which the different programme divisions would oblige for from their own funds. Group recognition/ awards may also be considered. Non-monetary incentive e.g. exposure conventions etc can be considered. visits, annual
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It is proposed that funds for making the payments to ASHA may flow from Centre to States through Standing Committee of Voluntary Agencies to District Health Societies. The District Health Societies will further compensate to the ASHAs based on measurable outputs under the overall supervision and control by Panchayat. For this purpose a revolving fund would be kept at the Panchayat. The guidelines for such compensation would be provided by the District Health Mission, led by the Zila Parishad.
Challenges
The real challenge is to build leadership and personal commitments among ASHA who serve as Community Health Workers, without which this initiative would not meet its objectives. This is essential also because, lack of leadership competence can lead to demotivation and dissatisfaction among them. In several settings, ASHAs face constant infrastructural challenges like lack of transport facilities to mobilize the community for meetings or while taking a pregnant woman to the nearest health centre.
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Replenishment of the drugs kit is a crucial factor in effective functioning of ASHAs. This does not happen regularly in many cases and the health activists are constrained to offer services with limited accessories, medicines due to delays, non-availability or shortage of supplies. Timely payment of incentives is a continuing constraint. ASHAs who have not received monetary compensation from Panchayats for months together due to bureaucratic hurdles may feel demotivated or forced to take up other activities to earn income.
Outcomes
The Government of India has set up following indicators for monitoring ASHA: Process Indicators: (a) Number of ASHAs selected by due process; (b) Number of ASHAs trained, (c) % of ASHAs attending review meetings after one year; Glimpses of Innovations in Primary Health Care in South-East Asia Outcome Indicators: (a) % of newborn who were weighed and families counseled; (b) % of children with diarrhoea who received ORS, (c) % of deliveries with skilled assistance; (d) % of institutional deliveries, (e) % of JSY claims made to ASHA, (f) % completely immunized in 12-23 months age group. (g) % of unmet need for spacing contraception among BPL; (h) % of fever cases who received chloroquine within first week in a malaria endemic area; Impact Indicators: (a) IMR; (b) Child malnutrition rates; (c) Number of cases of TB/leprosy cases detected as compared to previous year.
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The success of NRHM to great extent depends on performance of ASHA and her linkages with the public health mechanism. The health system has to give due recognition to ASHA and take prompt action on the referrals made by her; otherwise the system cannot be sustained. Every ASHA must be familiar with the identified functional health facility in the respective area where she can refer or escort the patients for specific services. The persons manning these health facilities should be sensitized to effectively respond to the instant needs of the local people. The role of the State & District level Missions would be to provide support to ASHA from village to the district level without any blockage on the way.
I reside in Sitapur districts Dhadra Mallapur village. This village consists of very few educated families. I always wanted to contribute to the health and happiness of my people. My objective was to make them understand about hygiene, cleanliness etc. Most Case studies women now understand that many diseases can be prevented by keeping ones surroundings clean. They also realize that repeated pregnancy causes serious harms to the a womans body apart from other problems. The birth process should take place in a specialized hospital so that the lives of mother and child are secure; only breast milk should be given to the newborn child until he/she is 6 months old. He/ she should also be vaccinated for polio, tetanus, hepatitis A and B before turning 5 years old. These precautions should be taken by everyone in the village. As an ASHA, I am satisfied that they pay attention to my efforts and respect me for who I am. - Khalikul Nisha, Uttar Pradesh, India
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ASHAs are selected by the District Health Society envisaged under NRHM. So far till March 2010, over 3,51,000 ASHAs have already been selected from various States, out of which, more than 2,26,000 have been given the first phase of training as per latest available Government (NRHM) data.
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At the age of 14, in 1994 I was married off to a barber. We have 3 sons and 1 daughter. I became an ASHA in 2006. It was easier for me to become an ASHA, and convincing people proved very challenging. I organised the women in my village and shared with them the concept of NonScalpel Vasectomy (NSV). The people of my village held many inhibitions against NSV, believing that this weakens the individuals body.
Case studies
In 2007, I managed to convince a man for the procedure. I also encouraged his wife to accompany me to the weekly meetings. She shared her positive experience with other women there. By November 2008, I registered five more NSVs. After this procedure, they are very satisfied and encourage others too. Since then, 60 individuals from Mahoba have undergone the process. I was also instrumental in the vaccination of 18 new-born babies. The ANM head in my village is a role model for me. -Sunita Devi, Uttar Pradesh, India
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Learnings
Smooth collaboration of ASHAs with SHGs, ANMs, Health facilities and Panchayat is essential for optimum functioning. ASHAs who are unable to earn the confidence of their community representatives and volunteers may face obstacles in their work. There needs to be regular evaluation and monitoring of ASHAs work by State authorities. In the absence of this, a health activist would be unable to meet the programme objectives. After the initial phase of training, follow-up sessions are important to keep ASHAs updated on the new information, evidence and knowledge of promotive and preventive aspects of public health. Training of trainers is necessary to pass on skills to other able members of the community and creating new volunteers.
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Bibliography
ASHA Accredited Social Health Activist, National Rural Health Mission, Ministry of Health and Family Welfare, Government of India (http://mohfw.nic.in/NRHM/asha.htm, accessed on 16 July 2010). National Rural Health Mission, 2005-2012, Mission Document, Ministry of Health and Family Welfare, Government of India, New Delhi (http://mohfw.nic.in/NRHM/Documents/Mission_Document.pdf, accessed on 18 July 2010). Observations and Learnings from across the States, Third Common Review Mission Report, 2009, National Rural Health Mission, Ministry of Health and Family Welfare, Government of India, New Delhi.
The real challenge is to build leadership and personal commitments among ASHA who serve as Community Health Workers, without which this initiative would not meet its objectives
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Project Arunoday
Background
The state of Arunachal Pradesh is the largest state, area-wise, in the north-east region. Arunachal Pradesh was given a state status on 20th February 1987. It is situated in the North-Eastern part of India with 83743 sq. kms area and has a long international border with Bhutan to the west (160 km), China to the north and north-east (1,080 km) and Myanmar to the east (440 km). Known as the Land of the Rising Sun in India, the state of Arunachal Pradesh, has exhibited an exemplary model of public-private partnership or more appropriately, Public Nonprofit Partnership in public health. Since its launch, the National Rural Health Mission (NRHM) has been successful in initiating a gradual transformation of the health care delivery system aimed at improving the health status of people across many settings in India. Following a path-breaking decision of the Government of Arunachal Pradesh in the year 2005, 16 Primary Health Centers (PHCs) were brought under the Public Private Partnership (PPP) project of National Rural Health Mission (NRHM).
Innovative Design
The project is an innovative model as it is based on the broad vision and framework of the NRHM wherein the role of the voluntary sector is deemed critical for the success of NRHM. The Mission provides for partnership programmes with NGOs for capacity building, delivery of health services and monitoring and evaluation. In view of the poor state of public health delivery in the state of Arunachal Pradesh, the State Government decided
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to handover the management of Primary Healthcare Centres (PHC) to non-government or voluntary organizations working in the area of public health. Four NGOs, including VHAI were chosen to manage these PHCs in each of the four districts, which were literally dysfunctional till the end of year 2005. The name PPP sometimes creates confusion among common people; however, its truly Public-Nonprofit-Partnership, where the NGOs do not make profit like other models in the infrastructure sector. The project design of Arunoday aimed at establishing functional health facilities through revitalizing existing infrastructure and putting service delivery system in place. The emphasis was on manpower planning and infrastructure strengthening. An additional focus area was community involvement and participation.
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Objectives
Some of the key objectives of Arunoday were: To increase universal access to primary health care in the community To improve health and nutrition status of communities to the level that is essential to live with dignity To enable communities to access facilities as per standards laid down by WHO, Government of India and State Government of Arunachal Pradesh To place community ownership and participation as a top priority To make available quality healthcare in operational areas based on the principles of equity and equality To strike a balance between preventive, promotive and curative approaches with special emphasis on women, children, disabled and aged ones.
The project design of Arunoday aimed at establishing functional health facilities through revitalizing existing infrastructure and putting service delivery system in place
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Role of stakeholders
The PHC Management Committee is usually constituted under the leadership of Deputy Commissioner of the respective district in the state. Public leaders are also actively involved in the functioning of the Committee besides other line department staff. The National Rural Health Misison (NRHM) strongly believes that people have the capacity to transform their own institutions and the Arunoday PHC Management Committees truly reflects this spirit. The community takes a very active interest in all the areas where Primary Health Centres exist. In some villages, they built traditional houses for opening the PHC-Sub Centres and provided free accommodation to the NGO-programme staff too. The community as the key stakeholder has virtually lead the process of transformation under the Project Arunoday.
Methodology
Glimpses of Innovations in Primary Health Care in South-East Asia VHAI has been managing following 5 Primary Health Centres (PHC) at Arunachal Pradesh since January 2006. Later, it was given charge of one Community Health Centre (CHC) by the Arunachal Government.
PHC/CHC Nacho Deed Neelam Thrizino Gensi Lumla District Upper Subansiri Lower Subansiri West Kameng West Siang Tawang Approximate Distance from State Capital 480 kilometres from Itanagar 200 kilometres from Itanagar 340 kilometres from Itanagar 320 kilometres from Itanagar 520 kilometres from Itanagar
The Arunoday methodology was based on the fact that everyone has the right to primary healthcare. Providing basic health services is an o pportunity given to the service providers, both in Government and non-profit sector, as people deserve it. Addditionally, its the people who deserve to be at the centre of this process of transformation. A mechanism would be devised to provide appropriate support through the State Government to strengthen the primary health care system by extending community health and development services to the people.
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The process of managing these PHCs began with a baseline survey by (VHAI) using quantitative & qualitative methods of health systems research. Key summary findings of the study showed that existing PHCs were almost dysfunctional, there was high morbidity, je ct Arun absence of medical staff, poor maintenance, shortage of medicines and equipments and lack of supervision by the health administration. Outreach services were not reaching the community in nearly 90% of the villages. 24-hour duty system was not prevailing Government VHAI People of Arunachal in a single PHC to attend emergency cases. The health Pradesh information system was suffering from considerable neglect and similar to many remote, inaccessible settings of India, although financial resources and manpower PHC Management Committee were available, poor governance was the prime malady. Before VHAIs takeover, the survey revealed that the health indictors in the settings these PHCs catered to, Sub Centres were worse than the district figures. Arunachal Pradeshs Villages Human Development Report (HDR) 2005, indicated the immunisation coverage in Arunachal Pradesh was less than half the immunisation coverage at the national level. The National Family Health survey-2 (NFHS-2) found that in Arunachal Pradesh only 20.5 per cent of the children (in the 12 23 month age group) were vaccinated fully against BCG, Polio, DPT, and Measles during 1998-99. The figure of the country, as a whole, was 42 per cent. According to the District Nutrition Profile (DNP) survey, 1995-96, as high as 56.8 per cent of children in the 0-4 age group were underweight. VHAI first examined the above findings of the baseline survey and chalked out a comprehensive plan which included interaction with the community to see the chief requirements and problem areas in PHC management. Partnership is not necessarily the only key to successful PHC management so, Arunoday shortlisted collective responsibility and accountability as one of the key focus areas. It was decided that the State Government, VHAI-Arunoday and the community need to share the responsibilities collectively by understanding each others strength and weakness. This balance of partnership, collective responsibility and accountability was identified as the key to achieving the project outcomes.
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Key Strategies
Some of the key strategies envisioned in the programme and reflecting in its activities are: Besides, curative services, the PHCs must focus on preventive and promotive aspects of health. Decentralized planning and implementation methods must follow a lateral approach instead of the standard top-down approach. Recruitment of staff with technical as well as local knowledge Outreach activities like health camps, mobile health vans to enable senior citizens, or people living in extremely difficult terrains to access healthcare. Inclusion of alternative systems of medicine Promotion of team spirit among the staff to keep them motivated and buoyant in challenging situations, timely disbursal of salaries Timely supply of drugs and strengthening of of infrastructure/equipment Pro-poor approach towards health delivery Glimpses of Innovations in Primary Health Care in South-East Asia
Highlights
In the last five years, the project has witnessed greater awareness among community members to demand quality healthcare that should match Indian Public Health Standards. The PHC-management Commitees have played an important role in this aspect. Two projects on alternative systems of medicine have been introduced in Thrizino and Gensi PHC areas. These focus on empowering the local healthcare service providers or traditional healers. Three targeted intervention projects were implemented with the support of Arunachal Pradesh State AIDS Control Society to help control HIV/AIDSamong high-risk groups. The two projects Project Dosti and Project Khushi have been very successful in reaching their goals. Besides other projects, condoms social marketing and needle syringe exchange programmes have become quite popular among the different stakeholders. From PHC to CHC: Impressed with Arunodays achievements, the Government of Arunachal Pradesh handed over the first Community Health Centre (CHC) to VHAI on 1st August 2009 at Deomali, Tirap District. Training to a large number of ASHAs have been organized under the project on the various modules of NRHM and Malaria Control.
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Following the launch of the NRHM, when Project Arunoday was initiated in 2005, in view of the deep-rooted systemic problems within the public health delivery mechanism in the state, there were numerous areas of concern and enormous challenges: Firstly, in the Arunachal state setting, 28 per cent of the people are expected not to survive beyond the age of 40 due to overall poor access to healthcare, and lifestyle problems like substance abuse. Nationally, the proportion of people who are expected to die before 40 is only 16.7 per cent. Thus, substantial improvements in medical care were required within the state delivery mechanisms to increase longevity of the people. One of the key challenges was the the PHCs were located far off several hundred kilometres from the state capital of Itanagar. The hilly and steep terrain, inaccessibility, and scattered habitations posed constant challenges, preventing proper access to medical facilities. Many villages are situated in remote areas, with low population density and lack of basic facilities like telephone, electricity, transport etc. Since PHCs in the state were not properly functional, motivating the staff in NGO runPHCs also posed problems. Community involvement as key stakeholders took time as the people had to be convinced that the health centres would be revamped and they would have a key role to play. Several community leaders were skeptical about the results, and the team had to spend time and discuss the strategies with them to show that results could be achieved. One challenge faced constantly through the project period was the smaller salary and overall budget in Arunoday in comparison to what the Government offered. The problems of insufficient funds persisted through the programme period, funds released by the State Government was consistently delayed, due to which VHAI had to pitch in with its own funds to sustain the activities and pay staff salaries on time. In addition, the team was unsure about how long the project would continue. Dysfunctional Government system and lack of good governance was a major challenge. In the initial months, many Government officials of the State Health Dept. were critical and not very supportive. Department officials hardly appreciated the humble achievements under Arunoday, rather NGOs were viewed as taking the credit of Government officials away.
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The hilly and steep terrain, inaccessibility, and scattered habitations posed constant challenges, preventing proper access to medical facilities
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There was a clear disparity between the rural and urban areas, as most of the facilities were concentrated in the urban areas.
Outcomes
Project Arunoday registered the following outcomes in the last 5 years: Communities have better access to healthcare in PHCs especially in OPD, Indoor and Emergency units. The PHCs cater to the need of communities by providing appropriate Reproductive and Child Health services as well as timely treatment for common ailments. Major communicable diseases are kept under control through greater awareness of the principles of health promotion. Patient-satisfaction in PHCs is improved and maintained. Peoples knowledge, attitude and practice on health-promotion are considerably enhanced. Community residents as well as local government and district administration officials from different sectors are actively contributing towards the smooth management of PHCs. Proper utilisation and integration of different systems of medicines.
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Comparing the progress in VHAI-managed PHCs & CHC

Indicator Baseline (before NGOtakeover) 00 Present Situation (June, 2010) 05 Remarks
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No. of Specialists providing services in Deomali CHC
A Medicine Specialist, one Pediatrician, a General Surgeon, an Ophthalmologist and a Gynecologist have been providing regular services on weekly basis since VHAIs takeover. VHAIs Anesthetist is in stand-by for attending planned surgeries, whenever required in Deomali CHC. VHAIs Doctors do provide services in 24x7 manners, and there are significant improvements in the quality of care. All the VHAImanaged PHCs have at least one MBBS-qualified doctor, and at present no PHC has less than three fulltime Medical-Officer. VHAIs Nurses work in CHC/PHC and Sub Centers. NGO-staff provide services in 24x7 manner. All the Laboratories are functional and conduct pathological & biochemical investigations.
No. of Graduate Doctors (MBBS, BDS, BAMS & BHMS) in five PHCs and one CHC Availability of the Nurses in five PHCs and one CHC Availabilities of Laboratory Technician in five PHCs and one CHC Functional Sub Center under PHCs. No. of Beds available for the Indoor Patients Functional Ambulance X-Ray Patients turnover Immunizations Community participation in decision-making
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All the VHAI-managed Sub Centers have at least three staff and few of the Sub Centers are located in very remote areas; literally with no road communication. The conditions of indoor in PHCs and CHC have improved in every direction; i.e. cleanliness, availability of beds, services, etc. Services available round-the-clock. One X-Ray. has been installed. Nearly four times increase in patients turnover after NGOs takeover. This is the average improvement, which varies in different places. The Hospital Management Committees meet regularly and contribute towards the improvement of PHC/CHC. Sometimes the Deputy Commissioners of respective districts preside over it.
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51 06 01 4N 4N Regular
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Learnings
The successes and innovations under the PPP model in healthcare as implemented under Project Arunoday has important learnings within the context. To replicate similar successes in other areas, the Government needs to tackle the issue of absenteeism and inefficiency in the delivery of services. Many Primary Health Centres (PHCs) in the remote areas of the State are non-functional due to irregular attendence of doctors, compounders, and nurses. Another problem commonly referred to by people in remote areas is the distance to the nearest medical centre. Thus, access and quality of service are both key issues in the state of Arunachal Pradesh.
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Further, the Government should take steps to fill vacant posts of medical personnel in all the PHCs. The problem of overstaffing of PHCs in the more accessible areas, especially in semi-urban and sub-urban areas, and understaffing of PHCs in the inaccessible areas, needs to be addressed immediately. Non-availability of medicines is another common complaint, again voiced more in the remote areas. This project can be sustainable and replicated in other settings if all the stakeholders (Government, NGO & Community) would adopt a more pragmatic-approach, and effectively utilize their strengths. As times change, it makes greater sense to move move with collective strength, rather than finding fault, while ensuring better healthcare for the common people. It is important to highlight that Arunodays PPP model has been appreciated by other NRHM-implementing States too. In fact, it has set the tone for greater health-sector reforms in the whole of North-East India.
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It is important to highlight that Arunodays PPP model has been appreciated by other NRHMimplementing States too. In fact, it has set the tone for greater health-sector reforms in the whole of NorthEast India
Bibliography
Annual Report 2007-09, Voluntary Health Association of India, New Delhi. VHAI Arunoday Annual Project Reports, 2005-10, Itanagar, Arunachal Pradesh. 81
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Background The Primary Health Care (PHC) in Indonesia is implemented mainly through health center, sub-health center, mobile health center and many type of community based health activities (CBHA) such as village maternity home (VMH) and village health post at village level; integrated service post (ISP or posyandu) at sub-village level. The activity of Posyandu focuses on five major health issues i.e. family planning, maternal and child health, nutrition improvement, immunization and diarrhea prevention. Besides Posyandu, there is village maternity home (VMH) which is managed by village midwife to provide maternal and child health services within the community. The midwives are selected, trained and certified by the government and then posted to villages and provided with equipments and supplies. The community provides or constructs the VMH building. The midwife is expected to work together with TBA as a partner to help improve access to Maternal & Child Health services. The midwife is responsible for professional care like: ANC, delivery of the baby, PNC, Neonatal Care, etc.; and the TBA is responsible for traditional needs such as massage of the mother, caring the baby, etc. Village Midwives Programme The health risks associated with pregnancy and childbirth are greater in developing countries especially among less affluent and marginalized and rural communities. Like most of the developing countries a majority of village women in Indonesia give birth in their houses relying on traditional birth attendants and midwives for help during delivery making the birth process risky for both mother and child. Maternal health and health care as well as infections contracted during the birth process are important causes of neonatal deaths in Indonesia. Reducing the number of child deaths is also a major policy
Since neonatal deaths constitute a significant portion, it is important to understand their determinants and propose effective policy measures to lower their incidence
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objective in developing countries. Since neonatal deaths constitute a significant portion of such deaths, it is important to understand their determinants and propose effective policy measures to lower their incidence. Therefore the Indonesian government focused attention on the importance of adequate and equitable provision of health personnel to raise levels of skilled attendance at delivery and thereby reduce maternal and neonatal mortality. As a result, the issue of safe-motherhood gained prominence in Indonesia which led to the implementation of a village midwife program that trained and placed over 50,000 midwives in villages across the country in the 1990s to provide health care to women. The Village Midwives Programme (bidan di desa) was initiated in 1989 with the aim of making midwives available in all the 68,000 villages in Indonesia to address the lack of access to skilled birth attendants and to provide women with prenatal care during pregnancy and assistance during delivery. The ultimate goal of the programme was to reduce maternal mortality through increased skilled birth attendant. Glimpses of Innovations in Primary Health Care in South-East Asia
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Innovative design
Safe motherhood initiatives in past have not emphasized reductions in infant mortality as their primary objective, such initiative on improving maternal health through community based approaches as the one undertaken in Indonesia play an additional role in lowering untimely deaths of children. Since the main causes of death of neonates are related to maternal health, complications through pregnancy and the birth process, and the care provided to neonates, the placement of skilled birth attendants in villages with limited access to health facilities and heavy reliance on traditional birth attendants would cause a decline in infant mortality through reduction in the incidence of neonatal deaths.
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Objectives
The ultimate goal of the programme was to reduce maternal mortality through increased skilled birth attendant. The objective of the programme is to make at least one trained resident midwife available in all the 68,000 villages in Indonesia to address the lack of access to skilled birth attendants and to provide women with prenatal care during pregnancy and assistance during delivery. Role of Stakeholders The program was implemented primarily by the Ministry of Health with cooperation with other ministries, especially the Ministry of Home Affairs and Ministry of Womens Roles, and with support from various international donor agencies, such as the World Bank, UNICEF, WHO, and Aus Aid.
The issue of safemotherhood gained prominence in Indonesia which led to the implementation of a village midwife program that trained and placed over 50,000 midwives in villages across the country in the 1990s to provide health care to women
Methodology
The midwives are recruited from three-year nursing academies and are given an additional year of midwifery training. Once assigned to the community, they operate as multi-purpose providers of health services with a particular focus on pregnancy,
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delivery and post-partum care. Midwives largely work in the community, but are each attached to a health centre (at sub-district level) where they work for a few hours a week, largely providing care for pregnant women and children. They serve one or more villages. The midwives many equipped with a small birthing room at their house or clinic provide outreach and reproductive health services including antenatal and perinatal care, family planning and basic primary health-care services, including immunization and counseling about proper nutrition. The midwives also play a role in promoting community participation in health, working with traditional birth attendants, and referring complicated cases to health centers and hospitals. Village midwives have contacts with the community in various other settings which also allow them to impart information on nutrition, food preparation, sanitation and other health-promoting behaviors to the community members. Key Strategies Glimpses of Innovations in Primary Health Care in South-East Asia Bring the services close to the people: The programme was intended to ensure safe motherhood through skilled care thereby attempting to reduce persistently high rate of maternal and neonatal mortality. Realizing the strong Indonesian preference for home birth, the government decided to place a trained midwife in every village. The programme was an effort to increase the rate of professional delivery of primary health care along with skilled attendance at time of delivery within the community. A midwife in every village is an endeavor to redress the urban/rural imbalance in service provision. Health workforce capacity building: To prepare the large number of village midwives needed, preservice training programs that included varying lengths of nursing training were developed, followed by 1 year of midwifery training. Over the years, Indonesia selected, trained and certified around 80,000 village midwives. Each received three years of nursing training followed by a year of midwifery training before being posted to their villages. The majority of midwives are employed under civil service terms and conditions. The remainder is employed on a contract basis, either by local or central government. They were initially given a three-year contract for their services, then later, a second three-year contract.
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Highlights
At the beginning of the programme there were 13,000 midwives available to village women in Indonesia (World Bank, 1991). By the end of the 1996/1997 budget year, 52,042 midwives were in place, covering 96 percent of the 54,120 villages that had needed midwives in 1989, many of whom were equipped with small birthing units. There are now (in 2010) approximately 80,000 selected, trained and certified midwives in Indonesia Midwife density increased from 0.2 -2.6per 10,000 people between 1986 and 1996. In rural areas, births attended by skilled midwives increased from 22% in 1990 to 55% by 2003, and socio economic inequalities were reduced for professional attendance at births. In 1989, as many as 19,500 women died each year in Indonesia as a result of complications during pregnancy or childbirth today it has reduced to 9,600 (in 2010). These womens lives were saved largely as a result of the governments investment in the midwife in every village program.
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Between 1991 and 2007, the percentage of Indonesian births attended by skilled personnel more than doubled, increasing from 32 percent to 79 percent. Both maternal and newborn mortality rates were lowered by more than 40 percent from 390 maternal deaths per 100,000 live births in 1989 to an estimated 228 in 2007 and from 32 newborn deaths per 1,000 live births to 19 during the same period. Traditional birth attendants were the primary source of delivery attendance in the early1990s, but their significance has declined relative to midwives since the mid- 90s.
Challenges
While there has been progress in institutional deliveries over time, inequities between rich and poor continue to be a problem. The poorest wealth quintile in Indonesia still has a very high maternal mortality rate estimated at 706 per 100,000 live births. Glimpses of Innovations in Primary Health Care in South-East Asia Although the village-based midwives are under the general formal supervision of the health centre, they are to manage normal deliveries alone and some may not have the skills to recognize an obstetric emergency and the need for referral. In the cases reviewed, it was found that the midwives facilitated referral effectively, reducing delays in reaching health facilities. Midwives emergency diagnostic skills were accurate but they were less capable in the clinical management of complications. In particular, the lack of clinical training and experience limited midwives ability to manage complications with delivery. The limited access and financial support for referral to emergency obstetric-care centres is a big challenge. Indonesias health centres are poorly equipped and poorly stocked and while the increased pool of midwives may have increased skilled attendance, it has not yet been shown to have increased access to emergency obstetric care, particularly for the poor. Although provision of emergency care is not a formal mandate of the village-based midwife programme, it is one of the most important obstacles affecting access to life-saving emergency obstetric care in Indonesia. The distribution of midwives reflects inequitably distributed provinces and remote villages in particular being underserved compared with urban areas.
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Transport infrastructure is also less well developed, affecting the midwifes accessibility, her ability to reach a woman in labour and her capacity to refer her to hospital in case of an obstetric emergency. Many villages have a nurse as an assigned provider because there is no midwife available. The nurses role is principally organizational (they are licensed to manage deliveries only in emergencies), but in reality they do offer delivery assistance without midwifery qualifications, and in only few cases with in-service training. Midwives are attracted to urban areas because they can generate viable and sustainable clinical practices. Most, irrespective of their contract status or place of work, offer private services outside their government working hours, under a formal arrangement designed to enable public sector providers to supplement their government pay. Working in remote areas carries with it professional isolation, greater pressure from a more traditional community and less opportunity for career development. Remote postings also do not have the capacity to provide an adequate income for midwives and therefore may be unsustainable without subsidy. The extra income earned from private work with a wealthier population exceed that gained through government subsidy, and a renewal of a rolling contract is not valued as high as a tenured contract with security of employment until retirement and a pension for life. Studies suggest that in urban areas, where the density of midwives is 4.8 per 10 000 population, where assigned midwives spend more time than in other areas on village-based clinical work, and where other physical barriers such as transport are unimportant, skilled attendance is still low, suggesting that supply alone is not the problem. Women who deliver with a traditional attendant may have a strong attachment
The midwives many equipped with a small birthing room at their house or clinic provide outreach and reproductive health services including antenatal and perinatal care, family planning and basic primary healthcare services, including immunization and counseling about proper nutrition
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In contrast to rural villages, urban areas have a more stable and experienced workforce. In addition, a larger proportion of assigned providers are resident, who focus their professional attention on one village only and therefore spend more days per month on clinical work there and be a better-known figure in the community. In remote villages the area of responsibility per assigned provider is larger so the midwife is less likely to be a familiar figure. In some locations, midwives are responsible for up to five villages.
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to birth traditions and would call a midwife only in the event of an emergency. While demand for professional birth attendance may be stimulated through public health messages, the financial barriers to using a midwife are acute, particularly among the deprived populations. Supervision and mentoring of midwives is not adequate in all areas, with responsibility often falling to the head of the nearest primary care clinic. Ongoing lack of supervision coupled with diverse duties and unclear job descriptions meant that many midwives worked in isolation with few opportunities for job support or learning, thereby affecting retention as well. Indonesia achieved a similar density of skilled midwives to that in Malaysia and Sri Lanka, where reductions in maternal deaths were achieved, but it lagged in density of doctors, nurses, and referral facilities.
Outcomes
Glimpses of Innovations in Primary Health Care in South-East Asia The introduction of midwives in villages led to positive health outcomes in the communities. By providing help during the childbirth process to women who would have otherwise relied on traditional birth attendants, the midwives have improved the environment in which women give birth in villages, especially in those communities that did not have easily accessible health facilities. The presence of the trained midwives at the village level have been more effective at providing quality antenatal, intrapartum and postnatal care, early detections of birth complications and timely referrals to health facilities, improving maternal health and providing better care for neonates which are likely to have lowered the neonatal mortality. A study in eastern Indonesia indicated reduction of early infant deaths associated with delivery by village midwives. Although the primary purpose of this community-based program was to promote safe-motherhood and lower maternal mortality, the results suggest that it has been effective in lowering the incidence of neonatal mortality. The midwives have played an important role in lowering the incidence of tetanus infections of neonates through the use of a sterilized knife to cut the umbilical
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cord after birth, a practice that traditional births attendants may have been more negligent about. By encouraging prenatal checkups and referring clients to hospitals and puskesmas (community health centers) in the case of complications, the presence of a midwife in the community have helped women seek timely help and avoid complicated births in the house, which have lowered infant mortality risk. In some areas, midwives improved the nutritional status of women and infants, through counseling The trends suggest that the reliance in traditional birth attendants is falling with an increase in midwife-assisted deliveries. There has been a significant increase in the fraction of births at the office of the midwife, suggesting that the program may have had an impact on the choice of services by women.
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Learnings
The developing countries grappling to reduce their maternal and infant mortality rates and striving to improve countrys maternal and child health status have many lessons to learn from the Indonesian village-based midwife programme. The most important lesson is - reduction of maternal and newborn mortality requires a health-systems approach that is both top-down (with clear policies, standards, and training) and bottom-up (from communities for participation, demand, and accountability). In addition to providing quality care for all births, affordable and accessible high quality emergency obstetric care is essential. Programmes should also aim to establish a platform that can readily adapt to advances in service standards and other community-based interventions. Scale-up of services should be driven by local evidence, be tailored to conditions and needs within each country and district, and be sustainable. The costs and benefits of scaling up community approaches, including all features of quality of care, supervision, and support, should be weighed for each location in comparison to other approaches, such as facility-based birth care. Monitoring and assessment are integral to maintenance of quality of care while increasing skilled birth attendance. Ongoing, rather than episodic, monitoring should include not
Reduction of maternal and newborn mortality requires a health-systems approach that is both top-down (with clear policies, standards, and training) and bottom-up (from communities for participation, demand, and accountability)
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only the process indicators for emergency obstetric care but also routine use of clinical audits to improve service quality and build skills and job satisfaction for both providers and clients. Through such processes, programmes can be scaled up, optimized and continue to be effective despite changing demands and resources. For complex interventions such as skilled care at birth and emergency obstetric care, the priority should be on accessibility and quality of services, not only on numbers of personnel. Maintenance of fully skilled midwives in communities, rather than so called community midwives can be part of such a system, only if quality of implementation in scaling up and support is prioritized. Village midwives should: receive appropriate support for the management of obstetric emergencies; engage with communities to promote birth preparedness; and work in partnership with formal and informal providers in the community.
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Given the challenges, the measurable effects of the programme are testament to the dedication of midwives and the ongoing government commitment to address the problem.
Bibliography
Ambruoso, L. D, Achadi. E, Adisasmita , A , Izati, Y, Makowiecka, K. and Hussein, J. (2007) Assessing quality of care provided by Indonesian village midwives with a confidential enquiry. J. Midwifery, Volume 25, Issue 5. Ensor. T, Quayyum. Z, Nadjib. M, and Sucahya. P.(2008) Level and determinants of incentives for village midwives in Indonesia. J. Health Policy and Planning 2009; 24:26-35 Makowiecka. K, Achadi. E, Izati. Y andRonsmans. C. (2007). Midwifery provision in two districts in Indonesia:How well are rural areas served? J. Health Policy and Planning 2008; 23:67-75 Shrestha, R.(2007) The Village Midwife Program and the Reduction in Infant Mortality in Indonesia. (http://paa2007.princeton.edu/download.aspx?submissionId=71863 accessed on 18/07/2010) The Indonesian Village Midwifery Program: Evaluation of a Scaled Up Initiative (PPT). 2007 Women on the front lines of health care. State of the Worlds mother (2010). (www.savethechildren. net/.../SOWM2010_EXEC_SUMMARY_2010_EO_EmbaroStamped.pdf accessed on 18/07/2010)
The program has significant impacts on reducing neonatal mortality through the improvements of maternal health and the birth process, but not postneonatal mortality
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The program has significant impacts on reducing neonatal mortality through the improvements of maternal health and the birth process, but not post-neonatal mortality. This is due to the fact that neonatal mortality is influenced by safe environment for births and care provided to neonates, while post neonatal mortality is mainly determined by nutritional status and other environmental factors which should be cooperatively addressed by all sectors concerned.
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Health Insurance for the Poor
Background
Primary health care has been a key priority for Indonesia even before the Declaration of Alma Ata in 1978. A research in 1976 revealed that nearly 200 community - based health activities (CBHA) had been implemented and carried out across various settings in the country. One of the major programmes has been the Posyandu (Integrated Service Post) which covers five major focus areas, i.e. family planning, maternal and child health, nutrition improvement, immunization and diarrhea prevention. The Village Maternity Home (VMH) is another programme managed by the village midwife as a way to make maternal and child health services close to the community Following a monetary crisis in 1997, community-based health activities in Indonesia underwent major transformation and reform. Decentralization changed the overall health planning structure, and thereby became dependent on the districts. Health policies were now increasingly based on local priorities which were concerned more with curative aspects of health than promotive and preventive health. Soon after when the democratic era was ushered in, all sectors including health were revived and upscaled. At the central level, the Health Ministry laid emphasis on the following major strategies: (i) Activate and empower community to live a healthy life (ii) Improve the access of community toward quality health services (iii) Improve the system of surveillance, monitoring and health information
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(iv) Increase health financing, decentralize health services and achieve universal health coverage The first two strategies are closely related to primary health care (PHC) and this indicates the important role of PHC in health development in Indonesia. Presently, many districts and cities in the country implement health programmes and some of the interventions do not really respond to the local needs but many are good and applicable.
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Health Insurance for the Poor the Askeskin/Jamkesmas Initiative

The Indonesian government launched an ambitious plan to achieve universal health insurance by 2014. A first step towards meeting this had already begun with comprehensive public health sector reforms in 2005, as social health insurance was expanded to the informal sector and the poor. Prior to that, since 1998, the Government of the Republic of Indonesia made a provision for a special fund to support health services for the poor, including maternal and neonatal health. The fund was given directly to facilities such as health centres and hospitals, but in 2005, a special health insurance programme for the poor was launched called Askeskin. It replaced the earlier Kartu Sehat programme which catered to the poor as part of the Social Safety Net Programme. The distinctive feature of the new system was the issue of health cards by Askes, the existing health insurance provider for many formal sector workers, with the Government paying premiums on behalf of the card holders. In general, health insurance participation has been low in Indonesia. Coverage by these programmes has not changed much over the past decades. Community health insurance schemes are so small they cannot be included as a separate category. Participation increased to some extent in 2008 compared with the early stagnant rate of about 20 percent, but current schemes still covered less than half the population. Recent increases in coverage are mostly attributed to the expansion of the Askeskin/Jamkesmas health insurance scheme for the poor, which cover nearly 14.3% of the population. The other main schemes, Askes covers civil servants and Jamsostek is for formal sector workers, both covering about 6.0 and 2.0 % of the population, respectively, while private insurance companies and other schemes cover another 3 %.
The distinctive feature of the new system was the issue of health cards by Askes, the existing health insurance provider for many formal sector workers, with the Government paying premiums on behalf of the card holders
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The Asuransi Kesehatan Masyarakat Miskin, or Askeskin, was initiated with the aim of reaching quality healthcare and financial protection to the poorest 40 million people initially. The programme reimbursed providers in two ways: (i) a capitation payment provided to health centers based on the number of registered poor; and (ii) a fee for service payments covering third class hospital beds reimbursed through P.T. Askes, a state-owned insurer. All public hospitals were automatically qualified as providers; private, mostly nonprofit hospitals were contracted as providers individually. The Askeskin programme differed from the other health insurance programmes for the poor in two major ways. Rather than being a purely government run programme, it provided lump-sum grant to the insurance agency, P T Askes which then implemented the programme through insurance cards and reimbursed hospital claims. By 2008, Askeskin expanded enrollment to cover over 70 million people. It also later evolved into Jaminan Kesehatan Masyarakat, or Jamkesmas, as an insurance programme for universal health coverage run by the Ministry of Health. Currently it covers nearly 77 million people in the country.
Objectives
The initial Askeskin programme laid the foundation for universal health coverage through the key objectives : To improve access to healthcare To improve the quality of health services for the poor To provide financial protection against health shocks and illnesses for poor households that lack access to formal insurance To increase the coverage of maternal and child health and shifted the pattern of birth delivery care from traditional birth attendants (TBA) to midwives On the whole, the Jamkesmas programme being implemented throughout the country is aimed to be one of the key building blocks of the governments proposed universal coverage scheme, designed to synchronize the multiple health insurance schemes. The Jamkesmas programme covers 14.3% of the population.
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Presently, in the Jamkesmas programme, there are five key institutions involved in the insurance administrative processes: (1) The National Social Security Council (2) The National government agencies including Depkes, Ministry of Health (MoH), the Ministry of Finance (MoF), the Ministry of Home Affairs (MoHA) which administers the decentralization process, the Coordinating Ministry for Social Affairs (Menkokesra), and the Planning ministry (Bappenas) (3) Provincial and district governments (4) Public and private providers of care (5) The insurer/third party administrator (PT Askes/Jamsostek)
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Beginning with Askeskin, later the programme metamorphosed into Jamkesmas, managed by the Ministry of Health and PT Askes, the state-run insurance agency was no longer involved, except in managing the enrollment of members and the distribution of insurance cards. Under the new system, district health offices directly managed contracting and claims processing through several private hospitals contrary to Askeskin which mainly utilized only public providers. PT Askes remains the administrator of membership in the Jamkesmas programme since it has operated the programme since 2005. It operates under a contract with the MoH to administer the membership part of the programme separate from other programmes. It obtains a list of the number of persons eligible each year from the Central Bureau of Statistics which is a part of Bappenas (the National Planning Agency). The agency then distributes the cards and registers enrollees into the programme. The Jamkesmas target population is identified and consistently monitored using an annually administered national survey known as the SUSENAS. It is a social and
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The Asuransi Kesehatan Masyarakat Miskin, or Askeskin, was initiated with the aim of reaching quality healthcare and financial protection to the poorest 40 million people initially
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economic household survey to define total household consumption for GDP estimation purposes. Based on standard definitions of the poor in terms of daily household consumption, the total number of poor is arrived at. The sub-national distribution of this total has also been defined in a similar manner. Many district governments followed the same system and established district-based insurance schemes called Jamkesda, that covered the poor or those not covered under Jamkesmas. These schemes take different forms - some are modified verions of Jamkesmas, while others focus on specific services, such as in Yogyakarta, where maternal and child health services for 104,500 children and pregnant women are covered under a district-led scheme. The Ministry of Home Affairs (MoHA) is responsible for the development of a national identity card to be distributed throughout the entire population. The card is the basis for enrollment into the national health insurance programme. For Jamkesmas, while the benefit package is the same nationally, districts set the reimbursement rates for various services based on local conditions, as local district governments have jurisdiction to establish hospital fees. Until 2009, reimbursement was based on services provided (feefor-service), although there are maximum reimbursement rates on type of services. Since 2009, Jamkesmas has been in the process of transitioning its reimbursement system from fee for service to one based on diagnosis-related groups (DRGs). All hospitals are being incorporated into the DRG payment process in 2010. There are verificators in every network hospital to make sure that reimbursements are made only for genuine claims with a full medical record. Verificators process claims and send them electronically to the MoH. They have standard review procedures which they follow to document every case. These standards were developed by the MoH. Once the claim is received by MOH, it begins the reimbursement process to providers.
Key Strategies
In order to achieve the ambitious objectives set under the Jamkesmas initiative, the Indonesian Government adopted the strategy of launching two phases to implement the new health card programme.
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For the second phase from June to December 2005, a higher target of 60 million was set, to include the estimated number of poor and near-poor. However, a major change in coverage was made. Direct funding of the health centres was resumed, with funding going from the Ministry of Finance via the BRI Bank to the District Health Office. Fund holding by P T Askes was limited to the amount allocated to pay for use of hospital services. Health card holders continued to get free treatment in the health centres. Under the revised system, funding for services delivered by Puskesmas is thus allocated directly to each district, as previously, with an allocation also to the provincial government to fund support services. Askes received the funding for hospital health services for the poor who hold their issued cards. In 2007, the coverage of this programme was estimated at 76.4 million. It should be noted that the funding arrangement was changed again in 2006 where the funds for both primary out-patient care through health centres and inpatient care at hospitals were channelled through P T Askes. Later, the funding arrangement was once again changed to a separate system for direct funding to local health centres and for social health insurance through Askes covering in-patient care. One reason for the frequent policy changes was the insufficient budgetary allocation by the government. In 2007, the Department of Health initially allocated only Rp. 1.7 trillion for this programme, while the estimated premium for P T Askes was Rp. 4.3 trillion.
The biggest challenge in the card system has been the process of actual identification of the poor
Challenges
The biggest challenge in the card system has been the process of actual identification of the poor. This was also seen in the earlier Kartu Sehat programme. Statistics from
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In the first period, January to May 2005, a target of 36.1 million covered individuals was set. This was equivalent to the estimated number of poor people in Indonesia, at just under 17 per cent of the population. Districts were allocated quotas on the basis of the estimated number of poor people living in the district, with the local authorities providing the lists of qualifying individuals to the local branch of Askes. The cards then issued covered both free outpatient primary care in the local health centres (Puskesmas), and free treatment at hospitals, generally 3rd class public hospitals. Askes received funds to cover both areas, and in turn reimbursed hospitals and health centres on a fee for health services provided to card holders.
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Indonesia (BPS) data which was used as the basis for financial allocations to districts and in estimating quotas of poor people until recently had simply been a sample survey of under 1 per cent of the population. Hence, other methods had to be used to assess the number of poor at the local level. Districts set up sub-district teams to undertake this process and some used the local Family Planning (BKKBN) estimates of household economic level. Others applied Statistics Indonesia (BPS) criteria, or their own methods. There was no uniform assessment system. Another paramount concern is the solvency of the Jamkesmas programme. Increasing utilization of health care increases the cost of health insurance, particularly for the poorest populations covered by Jamkesmas as currently there is no co-payment provision within the programme. While utilization of services has increased, the capacity of local service delivery may not be able to keep pace with increasing demands without additional partners from private primary health care providers. Currently, it is the responsibility of the local government to bridge the gap between the actual cost of insuring its population and what the central government provides via Jamkesmas reimbursements. Without further support for the poorest localities, this growing responsibility will become a challenge. Another significant challenge is that at the policy level, all aspects of health financing reform in Indonesia are witnessing major changes due to increased decentralization. Although the concept at first appears simple with districts responsible for implementing health services, the system of flow of funds becomes quite complex - some targeted at health, others at social welfare etc; some payments made through insurance agencies, others made directly to public providers (hospitals, health centres, and personnel) - make for an intricate and fragmented process of finance disbursement pattern. Recent studies indicate that many poor districts now receive more funding, but are unable to spend it appropriately because of local capacity constraints. Capacity building is therefore essential to ensure the system can continue to build administrative expertise and expand coverage. The central government recognizes this problem, and is considering alternate strategies to develop further approaches to co-finance service delivery at the local level. There is also a lack of enforcement of the many existing standards in Indonesia (e.g., clinical treatment standards, hospital standards, standard drug formulas). Neither government officials nor professional associations have really addressed the problem of
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Yet another challenge is that Jamkesmas may be a very useful tool for improving health outcomes and utilization of certain health services, however, these mechanisms are not being widely utilized nor is there an operational research programme in place to ensure this.
Outcomes and Highlights

While there are no formal evaluations of the Jamkesmas scheme, the Indonesian government and many international organizations, including the World Bank and GTZ, are collaborating to improve the programme to address both policy and implementation challenges. Data from the government suggest that Jamkesmas has made a significant impact in almost all settings where it is being implemented. As of January 2010, the Jamkesmas programme is being implemented throughout the country and will serve as one of the key building blocks of the governments proposed universal coverage agenda, hopefully by 2014. Till date, data from the government suggest that the scheme has made a significant impact, reaching 76 million poor and near-poor enrollees. In addition, total utilization has increased by 50% for ambulatory care and about 106% for inpatient care2 and the rates of service use between the most affluent and the poorest have nearly equalized. Overall, the key strategies of free access to many providersboth private and public and a comprehensive benefits package have made the Jamkesmas successful more attractive to the majority of the populationeven those covered under other insurance programmes. A recent survey in early 2008 entitled Study on Benefit Package Based on Communitys Preference conducted by Center for Health Financing Policy and Health Insurance Management at the University of Gadjah Mada has shown that 79.8 % of people who were already enrolled with health insurance schemes, such as Askes and Jamsostek, preferred to be entitled with Jamkesmas benefits as they felt the coverage provided was superior to that provided under their existing plan.
Capacity building is therefore essential to ensure the system can continue to build administrative expertise and expand coverage
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how to ensure quality clinical standards of treatment. Jamkesmas has a greater ability to enforce these standardsas they can apply controls over the release of funds in the form of reimbursementsthan is possible by either the MoH or professional associations.
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Learnings
As a preliminary analysis, insurance programmes like the Jamkesmas can encourage providers to target certain services by adjusting the reimbursement rates for various services. Family planning is one example where providers prefer short term methods, such as oral contraceptives and injectables, as the primary methods for promoting family planning. If Jamkesmas increased its reimbursement rate for long term methods such as IUDs, to a level that motivates providers to provide the service, they may more actively offer it as alternatives to patients. There is also a lack of enforcement of the many existing standards in Indonesia (e.g., clinical treatment standards, hospital standards, standard drug formularies). Neither government officials nor professional associations have really addressed how to ensure more rigorous
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Second, from the standpoint of public health programming, Jamkesmas may be useful for driving forward public health priorities. If Jamkesmas made minor changes in its payment/ reimbursement policies on important health problem areas (e.g., maternal health, TB), there could be significant positive implications on how these diseases are treated by providers.
Bibliography
Health Insurance for the Poor, Health System Strengthening Using Primary Healthcare Approach, Regional Conference on Revitalizing Primary Health Care, Jakarta, Indonesia, 6-8 August 2008, WHOSEARO, 2008. Indonesia Providing Health Insurance for the Poor, ILO Subregional Office for South East Asia, 2008 (http://www.ilo.org/public/english/region/asro/bangkok/events/sis/download/paper25.pdf, accessed on 30 July 2010). Social Security in Indonesia: Advancing the Development Agenda,International Labour Organization, 2008, (http://www.ilo.org/wcmsp5/groups/public/---asia/---ro-bangkok/---ilo-jakarta/documents/ publication/wcms_116153.pdf, accessed on 28 July 2010). 103
clinical standards of treatment. Jamkesmas has the ability to enforce these standardsas they can apply controls over the release of funds in the form of reimbursementsthan is possible by either the MoH or professional associations. To help address the issue of enforcing standards, provider payment and monitoring structures are being reassessed. This assessment is reviewing how different provider payment systems might influence provider behavior, how to enforce that providers adhere to treatment protocols, promote specific health services, and remove existing disincentives to adhere to protocol. There are also currently pilots of various payment methods underway.
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Background
Healthy Settings action began in the South-East Asia (SEA) Region countries more than a decade ago. Starting with the Bangkok initiative in 1993, the programme has encompassed majority of the countries in the region. The range of initiatives/actions from cities, townships, schools, hospitals, marketplaces, villages, neighbourhoods and islands provided a variety of settings for the development of Best Practices from which lessons can be learnt and replicated. This intiative by WHO has matured into one of the most successful and effective approaches to supplement and tap local capacities, strengthen community-based initiatives and make progressive steps towards decentralization, being promoted by many national governments. The Healthy Settings programme has also been a fore-runner in local-level initiatives for intersectoral collaboration. Furthermore, the Millennium Development Goals (MDGs) provide a global set of objectives towards which all member countries should enable the Healthy Settings programme to become even more meaningf ul for generating partnerships. This concept recognizes that people form an integral part of the earths ecosystem, and therefore their health is fundamentally interlinked with the total environment. A healthy and productive life is determined by two set of factors; those factors and risks within the control of individuals like health behaviour, and those caused by existing social, physical and economic environment surrounding the individuals. The latter set of determinants are addressed in the Healthy Setting concept. The regional healthy settings programme is being actively pursued in nine countries of WHOs South-East Asia Region. They are addressing a wide range of health issues from water, sanitation and food safety, to community empowerment for women on income generation. Healthier settings will have healthier people who have more time for work and earning better incomes. With proactive municipal governance, this increased capacity has successfully translated into better sustainable community development.
Healthier settings will have healthier people who have more time for work and earning better incomes
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In the journey towards a more healthy and prosperous Maldives, the government positioned health promotion as the overarching principle and the healthy settings process as the vehicle to achieve it. The Healthy Atolls Programme (Healthy Settings) is an exemplary model of best practices in the area of innovations, linking health to sustainable development, practice of health promotion, new approaches and skills in management at the community level, effective resource mobilisation for community development and proactive and supportive governance. In Maldives primary health care basically dwells within the premise of the overall health needs of the community. Health services in the Maldives are provided through a countrywide referral networking by Family Health Workers. These health workers look after the health concerns of the inhabited islands, Atoll Health Centres, and four regional hospitals along with a central level hospital in Male. The health system is managed well as an average of one doctor caters to 1400 population and 1.1 family health workers caters to 1000 population. During the period 1990-2003, Maldives made significant progress in stabilizing population growth. During this period, the crude birth rate (CBR) declined from 41 to 19 whereas the crude death rate (CDR) declined from 6 per 1000 population in 1990 to 3 in 2005. The total fertility rate (TFR) during 1990-2000 declined from 6.4 to 2.8. The average annual population growth rate reduced from 2.8 percent in 1990 to 1.69 percent in 2000-06. While this is a significant decline from its all time high of 3.4 percent in the late 80s, population growth is still critically high, given the size of the country and the available resources. Maldives also made significant progress in improving child health during the period under reference. The Infant Mortality Rate (IMR) declined from 34 per thousand live births in 1990 to 12 in 2005. Similarly, the Child Mortality Rate (under 5) declined from 48 per thousand live births in 1990 to 16 in 2005 (Maldives key indicators- 2006)
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Innovative Design
The innovativeness of the Healthy Villingili Island Project lies in its comprehensive approach, community involvement and ownership from inception and decentralisation. The concept of Healthy Settings established a more effective working relation between the health sector and other sectors to create a healthier environment by solving health and related problems closer to their source.
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Objectives
The broad objective was to establish a well functioning healthy atoll programme in the Gaaf Alif Atoll. The programme though initiated in Villingili island, would later be expanded to the other islands of the atoll in the subsequent years with the objective of implementation in the entire atoll by 2005. The following issues were identified as the key focus areas in the project. Personal Hygiene Educating the island communities on the importance of personal hygiene and improving the sanitation conditions on the island. Access to safe drinking water Awareness generation on the importance of safe drinking water and ensuring that all households in the island have access to safe drinking water through a community-organised approach to purchasing water storage tanks. Women and Child Health : Providing all island women in the reproductive age group, information and guidance on safe motherhood, breast feeding and detection of risk signs/factors in pregnancies. Ensuring ante natal check-ups at the health clinic and family planning advice and services in place as per needs assessed. Nutritional Concerns : Health and Nutrition education to all island homes through home to home visits and interactions. Development of kitchen gardens and inculcation of healthy eating habits in children.
The Healthy Atolls Programme (Healthy Settings) is an exemplary model of best practices in the area of innovations, linking health to sustainable development, practice of health promotion, new approaches and skills in management at the community level, effective resource mobilisation for community development and proactive and supportive governance
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There has been total control of contagious diseases. Diseases like Malaria have not been registered in the past ten years and leprosy rate has also lessened in the last decade. Other common diseases like TB have also been controlled.
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Acute Respiratory Infections (ARI) : Prevention and control of ARI and common cold, specially amongst chidren. Solid Waste Disposal : Educating the island inhabitants on ways of safe management of solid waste. Prevention and Control of Fly Breeding : It was proposed to plan and construct Koshis and other means for disposal of solid waste, thereby controlling the fly menace. Mosquito Breeding : The island inhabitants would be adequately capacitated in the area of managing rain water tanks, and septic tanks to prevent mosquito breeding. All unused wells on the island would be sealed or properly protected. Tobacco Control : Tobacco Control became one of the main objectives of the project with the aim at making the atoll smoke free and bringing it in line with the national policy. As part of tobacco control, focus would be on promoting smoke free educational institutions.
Glimpses of Innovations in Primary Health Care in South-East Asia The Healthy Atolls Programme (Healthy Settings) like all other developmental initiatives aimed to have a correct and health mix of all stake holders. The programme is an intiative of the people by the people of the atoll, but the other stake holders include the Central and local government, influential individuals, NGOs, community groups, training institutes WHO, entrepreneurs and civil society.
Methodology
While the Villingili Healthy Island Plan of Action was being drawn up, the defining elements to make it a success were put in place in terms of a well written plan of action, an efficient managerial set up and an operational mechanism to ensure community participation. Focus was put on the development of Local Task Force/s (LTF): This included members of the Central and local government, individuals, NGOs, community groups, training institutes etc. Identifying and assessing priority issues: Here again the LTF, with the people prioritised issues that were raised while building a vision for the Healthy Setting Concept in the area. Also, health and environment departments were involved in identifying linkages and in planning priorities issues for the programme.
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Appointment of Partnership Task Force, Coordinators and Office: A number of members of the LTF became members of this task force. A programme office was set up and coordinators appointed to execute the plan. Sepreate working committees to were also set up to address priority issues. Preparation of the Programme Plan and creation of awareness on it: To start with baseline data was collected and a Plan of Action was drawn up. Since the programme for a healthy Villingili island was being drawn up, the plan made scope for discussion and raising awareness for possible alternative living conditions and lifestyles in communities, to be improved through cooperative efforts and partnerships. The plan included both the correct mix of awareness creation and developmental activities. Resource Mobilisation: After the development of the plan and the prioritization of issues, focus was put on mobilising resources from different sources like the community, government and private sector for implementation of the planned initiatives and work. Evaluation and Assessment : Alongwith the planning of the programme, provisions were created for evaluation, to assess both its impact and progress. The evaluation process was designed to allow necessary adjustments and improvements in the plan implementation.
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Key Strategies
The Healthy Villingili Island project is unique in that it did not strategise or follow a ready made project template kind of approach to community development. Health Promotion : This was used as the over-riding principle and as the entry point for making inroads into other areas of concern. The concept of the Healthy Settings was used as the tool for community involvement and ownership in terms of planning, implementation, management and review. This could be replicated as a Best Practice model for the other atolls as well. An Achievable Workplan : A healthy island work plan was prepared in simple language by the stakeholders, with the community members taking an active part in the planning process. Keeping in mind the issues that needed to be
The Local Task Force (LTF) responsible for the implementation of the Healthy Island plan comprised of members of the central and local Government, NGOs individuals, community groups, training institutes etc.
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targeted and the objectives that needed to be set, the plan was kept achievable, practical and specific. Working Towards Effective and Independent Management : The island administration took on overall responsibility and operational teams were formed.The Atoll offices role was that of a facilitator and gave the island community the independence for carrying out the implementation. Gaining Political Goodwill, Support and Recognition : The Maldives government endorsed the WHO proposed Healthy Settings initiative and adopted the Healthy Settings within its policy purview as a means for promoting the southern Atolls Development Programme. Once the programme had government endorsement, it helped in getting more active support from the necessary government departments (Health and Family Welfare, general administration etc. and made it easier for inter sectoral coordination, (health, water and sanitation, waste disposal etc.) since the programme was in line with the governments plans and policies. Glimpses of Innovations in Primary Health Care in South-East Asia Raising Awareness and Building Public Support : The Local Task Forces (LTF) responsibility was to develop, with the support of the people impacted by the programme, a vision for the Healthy Setting. This would need the articulation of the setting concept to the population, creating acceptance for it, and the inclusion and involvement of people.
Highlights
Community Participation and Ownership played a key role in ensuring effective implementation at all levels. Funds were generated by the community and people took the responsibility of managing tasks like garbage disposal, laying of sewage pipes etc. Public participation became one of the key strategies that worked effectively for the success of the programme. The objectives set were largely achieved and issues endogenous to the community were thrashed out and decided by the community itself. Major issues like effective management of solid waste, development of kitchen and fruit gardens, clean drinking water, health and hygiene and improved maternal and child health have been tackled at the community
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The issues of good governance and intersectoral collaboration are also amongst the noteworthy highlights of the Healthy Villingili Island Project. Committment to the cause and effective team work and coordination amongst all the stakeholders helped sustain the programme through the stages of conceptualisation, institutionalisation, implementation, sustenance and expansion. Effective Resource mobilisation was yet another significant feature of the programme. Notable contributions have been made by the local residents for developmental activities. For instance, the purchase of water tanks through the revolving fund of the Ministry of Atolls Administration are financial commitments the community has made towards improving their health and their well being. It has also brought into play the traditional Maldivian culture of the communitys collective efforts of resource mobilisation from within the community for local development. Other than the above effective leadership, decentralization of power, legislative changes, financial, administrative municipal autonomy, capacity building, networking, engagement of civil society, e-governance and intersectorality in producing equity, efficiency, transparency and accountability all worked positively for a sustainable healthy settings.
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Challenges
The process of implementation was faced by several constraints and challenges due to both external and internal reasons. Often the community was unable to take timely and effective decisions due to legal and technical constraints for which both inter-sectoral coordination was required from different government departments like Health, Environment, Planning, Agriculture etc. For instance, (lacking knowledge in the technical aspects of bio diversity and environmental concerns) the community was faced with the problem of combating mosquito breeding due to unmanageable mango groves, where to locate the fish waste storage container, how to reduce or eliminate tree disease, how to effectively recycle waste-water from sewers etc.
The concept of the Healthy Settings was used as the tool for community involvement and ownership in terms of planning, implementation, management and review
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level through approaches conceived by the community, with the necessary technical and training support from other stakeholders.
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Though the programme has been a successful and exemplary model, there are other serious issues that are challenging and need to be dealt with a combination of political will, technical know-how, inter-sectoral and inter-department coordination, expert guidance and community will. Such issues include the loss of fresh ground water to the sea, for eg. all the flush water goes to the sea. The future problem of salinity intrusion into the islands fresh water aquifer needs to be addressed seriously and urgently; pollution of the sea, on the south eastern side of the island by the sewer outfall; lack of funds for solid waste disposal, absence of permit to the Environment Ministry to reclaim the marshy mangrove area which is both ideal for mosquito breeding but also provide the island with natural storm drainage. There was a felt need for having a referral mechanism in place for optimising implementation at the project area.
Outcomes
Glimpses of Innovations in Primary Health Care in South-East Asia The Positive outcomes of the Healthy Villingili Island programme ensured that in the subsequent phase (2004-2005) the intiative was further expanded to the other islands in the Atoll. Major changes were observed in the following areas : Availability of Water : The community is making good use of rain water through a roof run-off collection system. In the span of a year, the volume of stored water increased about 75 percent from 1.9pcd in 2002 to 3.3 ltrs. Pcd in 2003. Health: There was significant stabilization in population growth and the CBR declined from 41 to 19 between 1990 and 2003. IMR decreased from 34 per 1000 life birth in 1990 to 12 in 2005. There has been no accorence of diseases like Maleria and Leprosy in the last decade. Hygiene : All households were given health and hygiene education by the Task Force assigned to this focus area and as a result, the more wealthy(shop owners and fishermen etc.) amongst the community agreed to lay sewer lines along the length of their respective roads and give individual house connections for a fee of MRf 1500 each. The pipeline
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Unused water wells were either protected or destroyed to prevent mosquito breeding, as was the closure of septic tanks and closure/elimination of all storage of stagnant water. The island community planned, cost-estimated and constructed a Koshi and other requirements for implementing a proper fish waste disposal process. Besides this the teams assigned to this focus area educated the people on how to effectively use fish waste as plant food and how to get dispose of the waste which gave scope to flies for breeding. Exercising of good preventive measures in the case of both fly and mosquito breeding has brought about significant change in hygiene maintenance. Nutrition : Mothers were educated on nutrition and other aspects of health and messages for better feeding practices were delivered during home visits. Workshops on nutrition were conducted for teenagers and every household was encouraged to have its own kitchen and fruit garden. Fruits were also made available in the markets at more affordable prices. The haemoglobin count in pregnant mothers was monitored and showed a significant increase. Less prevalence of low birth weight babies was also recorded. De worming of children done on a regular basis. Information on pre venting diarrhea, malaria, and aspects of mothers health was given to many households. How to prepare oral salt solution from sugar and salt at the household and breastfeeding (exclusive for six months) information was also provided. Solid Waste Disposal : In consultation with the island inmates, 2 ends of the island were selected as dumpsites in comparison to indiscriminate waste disposal earlier. Though initially the community built Kuni Koshi (waste dump site) was make shift, there were definite plans to have more permanently designed disposal sites in the next phase. Tobacco Control : The community was educated on the ill effects of smoking and anti smoking posters and were put up in homes and on fishing boats. The Ministry of Health gave away certificates of recognition to all non-smoking households. People have become more environmentally conscious and are ready to take up challenges of environmental protection.
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The community is making good use of rain water through a roof run-off collection system. In the span of a year, the volume of stored water increased about 75 percent
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owner too the responsibility of managing the system. All school toilets were provided with regular supply of soap for hand washing etc.
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Learnings
One of the most significant learnings from the Healthy Villingili Island Project was that community involvement and commitment to any developmental initiatives is a key factor for its success. The Healthy Vilingili project successfully harnessed both manpower and financial resources from within the community. For instance, each household was willing to pay MRf 1500 for lateral connection to the main sewer line with the purpose of keeping the sewer open and unclogged. Similarly the cost (appx. MRf 30-50,000 each) of laying the shallow sewer lines was borne willingly by the community. Such initiatives on the part of the community ensures both a sense of ownership and accountability which are prerequisites for a successful community development initiative. Another very important learning that emerged from the Healthy Villingili Village example was that the community should be encouraged to handle the do-able things that they can achieve on their own, with perhaps some technical assistance and capacity building from experts. Support and help should be available for only those aspects which the local communities are unable to handle on their own for reasons like lack of technical expertise or due to resource constraints. The community also learned that the preventive methods are a great way to ensure good health and hygiene. So whilst the availability of hospitals and health centres are definitely an asset, the community realised the importance and value of living in healthy and hygienic conditions to achieve and maintain good public health standards. Establishing a rapport with the community and explaining if things are not progressing as desired, rather than taking the stance of a watchdog has worked better in soliciting support and achieving compliance in matters like waste disposal, antenatal care for expectant mothers etc. Positive feedback and encouragement kept motivation levels up. Besides appreciation and acknowledgement, for better progress, the community also requires timely and well coordinated support at the central level. Follow up requests for advice from concerned Ministries like Agriculture, Environment, Fisheries etc. should be addressed effectively. The Healthy Villingili Island programme goes a long way in proving and reaffirming that communities can be very effectively involved in both financing and delivering of services for local development.
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Amongst the other learnings that emerged is that it is important to identify and define the health and development problems in the community before finding solutions for them. Identifying community concerns and planning for the same should remain the responsibility of the community and should not be made to confirm to pre-defined norms. It is important to have community involvement from the planning stage itself, right through the implementation process as well. However it is equally important to have a proactive team leader or coordinator to provide the necessary guidance essential for achieving desired results in any given setting. The Healthy Settings action is a continuous process, it should not be time bound, donordriven and should be be sustained by the continuous involvement of the community.
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Bibliography
Country Health System Profile Maldives http://www.searo.who.int/en/Section313/Section1521_10898. htm accessed on July 27th 2010 Healthy Settings Background (http://www.searo.who.int/en/Section23/Section24/Section25.htm accessed on July 28th 2010) Healthy Settings Documentation Healthy Villingili Island- A Review of Progress , October 2002- February 2004 http://www.searo.who.int/en/Section23/Section24/Section28.htm accessed on July 27th 2007) Report of the Intercountry Workshop for Healthy Settings Coordinators, November 2007 (http://www.searo.who.int/LinkFiles/SDE_SEA-EH-551.pdf accessed on July 27th 2010)
An important learning that emerged from the Healthy Villingili Village example was that the community should be encouraged to handle the do-able things that they can achieve on their own, with perhaps some technical assistance and capacity building from experts
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Background
The Government of Union of Myanmar has laid down social objectives to uplift health, fitness and educational standards for the entire nation. This is fulfilled by the National Health Policy developed in 1993 by the National Health Committee (NHC), the highestlevel policymaking body for health matters, under the chairmanship of the Prime Minister. This committee adopted the HFA (Health for All) goal with primary health care as the main approach and provision for suffi cient and skilled human resources for development of a national health care system. The role of NGOs and private sectors was also upgraded under the new policy. The Ministry of Health, Myanmar then laid down the National Health Plan (2001-2006) under the guidance of the National Health Committee. The objectives of the National Health Plan (2001-2006) were: To implement the national objective of uplifting the health, fitness and educational standards of the entire nation To implement the National Health Policy To develop a new health system in keeping with the political, economic and social conditions To strengthen rural health services In Myanmar, mothers and children, who are the most vulnerable groups, constitute over 60 percent of the total population. Maternal and child health care services are provided both in urban and rural settings and it is also a crucial component of the national health plan. Essential reproductive health care, including maternal and child health care, essential obstetric care, prevention and management of post-abortion complications, management of RTIs / STIs and adolescent reproductive health, have been implemented as one of the activities of the national health plan.
In Myanmar, mothers and children, who are the most vulnerable groups, constitute over 60 percent of the total population. Maternal and child health care services are provided both in urban and rural settings and it is also a crucial component of the national health plan
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Overall, within the country, maternal care coverage is reasonably good with more than three-fourths of all pregnancies receiving antenatal care from trained personnel. Expanded programme on immunization, control of diarrhoea and acute respiratory tract infection and other relevant programmes for promoting the health of children have been initiated all over the country even in far and remote border areas.
The Healthy Mother Project

Despite the implementation of the National Health Plan and its various objectives,in many settings, the access to reproductive health services and information that citizens have is still very limited, particularly in rural communities. The reasons for this are inadequate knowledge and expertise among health and medical care providers, insuffi cient number of providers, poor access and urgent need for revamping of the health care system to make available facilities, services, basic drugs and contraceptives. This is what the Communityoriented Reproductive Health System Project or the Healthy Mother Project is trying to address, by improving womens reproductive health through focus on safe motherhood. Glimpses of Innovations in Primary Health Care in South-East Asia
Innovative Design
The Community-oriented Reproductive Health Project (CORHP) or Healthy Mother project takes a community-oriented approach in order to improve the health of mothers. It aims to ensure self-reliant reproductive health among communities through a variety of activities. Peoples participation is being used to build self-sufficient community support systems, and health education is being promoted to raise individuals awareness of their own health and the need to maintain it. Training is also key in mobilizing human resources for the project, and is being provided to maternal and child healthcare providers, in addition to health promoters and medical professionals. Another intervention undertaken in the project is to provide the opportunities to share experiences of good practices among all stakeholders, such as community fund for assisting referral cases, poor in-patients or transportation arrangement in emergency cases. The project is based on the key principle that women who are planning to bear children must understand the importance of staying healthy so that they are fulfil their roles as mothers. The programme emphasizes the fact that healthy women who have good health
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throughout their childhood and adult life will be better able to deliver healthy children. In addition, women with knowledge about childbearing and pregnancy when they are young can use it practically when it is time for them to have children of their own.
Objectives
The Healthy Mother Project, a five year programme is being implemented at Kyaukme and Naaungcho townships and has the following objectives: Overall improvement of quality of Reproductive Health (RH) status in Myanmar with specific objectives to: Promote an effective, supportive system for care provision and close monitoring during pregnancy, delivery and post-delivery periods Improve health facilities, basic medical equipment and commodities Prevent unwanted pregnancies and abortions Strengthen midwifery and communication skills of basic health staff and community volunteers Enhance community knowledge and skills on Reproductive Health
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The project is being implemented by the Department of Health (DOH), Ministry of Health (MOH), Union of Myanmar and the Japanese Organization for International Cooperation in Family Planning (JOICFP) with support from the Japan International Cooperation Agency (JICA). In the framework of the JICAs technical cooperation project in partnership with DOH, JOICFP will contribute to the project by transferring technical and management skills for the establishment of community-oriented approaches, and achievement of community mobilization
Healthy Mother Project takes a community-oriented approach in order to improve the health of mothers. It aims to ensure self-reliant reproductive health among communities through a variety of activities
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Methodology
The project follows a community-based capacity building and skill-building approach in the implementation of its various activities by strengthening capacity of the project management personnel and RH service providers through: 1. Improvement of the quality of reproductive health services with special focus on safe motherhood by: Conducting the baseline and end line surveys on RH services, health facilities, and community perspectives on RH Training and refresher courses for RH service providers Training for basic health staff and female maternal and child health (MCH) volunteers on leadership, management and counseling skills Strengthening referral services to higher level health facilities 2. Increase awareness and knowledge on RH issues among community people, particularly, women, through: Production and dissemination of need-based IEC and BCC materials Training Basic Health Staff (BHS) on IEC/BCC Providing health education on RH to community people including pregnant women, by trained BHS 3. Strengthening the linkage between RH services and community people through: Conducting training and refresher programmes for MCH promoters Ensuring home visits by MCH promoters to assist women in the community during pregnancy, delivery and post-delivery periods Organizing teamwork for effective referral services from community level to health facilities 4. Establishing a community support network for RH and safe motherhood initiatives in the community Establish project Steering Committees at central, township and village levels for effective implementation and sustainability of the project Involve community leaders, local district administration officials, community women, youth as female MCH volunteers 5. Identify applicable, community-oriented approaches for wider replication Document and share the progress, experiences and learnings from the project with key stakeholders Conduct workshops for sharing experiences from the project
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Key Strategies
The project focuses on certain key strategies to achieve the increased utilization of reproductive health and safe motherhood services by community people, especially women of reproductive age, in rural areas. These are: Improving the quality of reproductive health services through training of the governments basic health staff (especially midwives), upgradation of health centers, with basic essential medical equipment and building community awareness. Strengthening community peoples knowledge and awareness of reproductive health, to promote health-seeking behaviour and increased access to RH services. The mediums for these would be skill training of BHS, educational materials, participatory health education sessions, provision of home-based maternal records and clean delivery kits. Building strong teamwork among BHS, AMWs, and MCH promoters, in collaboration with skilled birth attendants, community leaders and members, for effective collaboration in RH/MCH promotion activities in the community to ensure that pregnant women or mothers with children under five years of age would receive proper health care services when needed. Strengthening community support mechanism for MCH/safe motherhood activities by securing voluntary participation from all stakeholders, such as community leaders, government health staff, and MCH promoters.
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The project focuses on certain key strategies to achieve the increased utilization of reproductive health and safe motherhood services by community people, especially women of reproductive age, in rural areas
Highlights
The knowledge of RH/MCH issues among the community has improved significantly, especially, in reproductive health. Significant improvements in the utilization of RH/MCH services have been observed, such as the percentage of contraceptive use increased from 41.2% in 2006 to 52.6%
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in 2009; the percentage of married women who have given birth with skilled birth attendants increased from 47.4% in 2006 to 66.8% in 2009; and total fertility rate fell from 3.29 in 2006 to 2.72 in 2009. The midwifery skills and knowledge of BHS improved significantly. Ninety BHS, including midwives received multiple skill development trainings; 233 AMWs received refresher trainings; 110 community representatives attended consecutive series of workshops and seminars. The activities of MCH programmes have had considerable impact on the promotion of RH/ MCH.
Challenges
The project faces a daunting task of building leadership, commitment and skill among female MCH volunteers, without which this programme would not meet its objectives. It is important to train and produce competent volunteers as they are the vital link between the community and health care providers. The project places considerable emphasis on training and skill-building of reproductive health care providers. Therefore, it should be ensured that the training imparted is need-based and an evaluation process is conducted to test the post-training capacities and work progress. The quality and availability of IEC materials is a crucial factor in effective functioning of the project activities, so the project faces the constant challenge to develop quality materials and making them available to project stakeholders on the ground. It is vital to monitor the functioning of the community-based Steering Committees to ensure that the members take interest in project activities and report regularly on the outcomes and problem areas for timely course correction.
Outcomes
The Healthy Mother Project in Myanmar has registered good progress in the following key areas: The quality of reproductive health (RH) services has been improved through refresher trainings for auxiliary midwives (AMWs), upgradation of health facilities and supply of basic medical equipment
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Team spirit for safe motherhood was created among MCH promoters, AMWs, PDC chairperson/community representatives, midwives, and medical professionals at the hospitals The trainer-trainee relationship has encouraged trust and credibility among BHS and MCH promoters Emergency transportation and Community Welfare Fund were established to support referral services and emergency transportation Peer education among MCH promoters was initiated for them to share information and exchange experiences Awareness of community people in relation to RH was enhanced and respective health seeking behaviors were improved accordingly.
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Learnings
There is an urgent need to maintain the momentum built during the project period for the betterment of the health of mothers and children in Myanmar. The project helped to establish the fact that community-based health volunteers are a vital link between basic health staff and the community. In this project, the Maternal and Child Health (MCH) Promoters fulfilled that role effectively. Sharing of lessons and experiences from the project and replication in other settings for overall improvement of reproductive health in the country would lead to similar community-based models across the country. The project reiterates that strengthening of community support systems is essential for reproductive health and safe motherhood. Bibliography
Country Health System Profile, Myanmar, WHO-SEARO, 2007 (http://www.searo.who.int/en/Section313/ Section1522_10913.htm, accessed on 25 June 2010). Healthy Mother Project progresses in Myanmar, OICFP E-News (http://www.joicfp.or.jp/eng/enews/2006_oct/05-Myanmar.php, accessed on 27 June 2010). Healthy Mother Project in Mynmar (online brochure), MOH/DOH Myanmar, JICA, JOICFP. The Community-Oriented Reproductive Health Project in the Union of Myanmar <Healthy Mother Project>, Japanese Organization for International Coorperation in Family Planning (JOICFP) (http://www.joicfp.or.jp/eng/where_j_operates/myanmar6.shtml, accessed on 24 June 2010). 123
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Background
Modern health services started in Nepal in 1933 when the Department of Health Services was set up followed by gradual establishment of government hospitals and health centres. The next few decades witnessed several health programmes focusing on malaria, maternal child health, smallpox and other communicable diseases in various districts of the country. As a signatory to the Alma Ata Declaration of 1978 Nepal became committed to provide accessible, quality health services to people through primary health care approach. The Government of Nepal began efforts to encourage community participation and self-reliance in health care delivery. A radical National Health Policy was introduced in 1991 to set up one health facility in every village and a PHC in every electoral constituency. The focus was on strengthening district health system and poverty alleviation. Presently, the PHCs function through a network of district and grassroot-level service delivery system, the lowest being the Sub Health Post.

Nepal has one of the most effective community health volunteer initiatives as compared to many other countries. Female Community Health Volunteers (FCHVs), functioning today in over 97% of rural wards are the backbone of the countrys health programmes spread across the country. The programme was started in 1988 by the Ministry of Health and Population to foster community involvement and increase outreach of health services. FCHVs work in a number of health programme areas, mostly focused on reproductive health and child health, although they may have also received brief training in many other public health programs of the Ministry of Health and Population (MoHP). Their work is divided between education of the public, promotion of government health services and direct provision of select services.
A radical National Health Policy was introduced in 1991 to set up one health facility in every village and a PHC in every electoral constituency
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Their main role in primary healthcare can be summarized as under: Family Planning Education and promotion regarding all family planning methods Distribution of oral contraceptive pills and condoms Maternal and Newborn Health Knowledge about pregnancy, antenatal care, with vitamin and iron supplements Provision of iron supplements in selected districts Promotion of birth preparedness, including use of a skilled birth attendant and/or emergency preparations (particularly in selected districts)
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Child health Promotion of good nutrition, hygienic and healthy behaviors Treatment of simple pneumonia with cotrim and referral of serious cases (CBIMCI/ CBAC program districts) Treatment of diarrhea with Oral Rehydration Solution (ORS) Treatment of diarrhea with zinc (pilot districts) Distribution of Vitamin A and deworming tablets Support for childhood immunizations and provision of polio drops during national immunization days In addition, they also contribute to the community-based management of childhood illnesses, safe motherhood and neo-natal activities.
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Innovative Design
Female Community Health Workers are local women who are selected from their communities. They receive 18 days of training plus refresher training on maternal and child health. Initially beginning with one FCHV per ward, soon after additional FCHVs were appointed through a population-based approach and at present all 75 districts have FCHVs. Numbering 49,000 till date, their work is crucial since it is at the grasssroot-level and focuses both on health awareness, education and delivering health services in rural areas on maternal and child health, distribution of Vitamin A capsules, oral rehydration salts, deworming, immunization and family planning. In addition, they also provide treatment for acute respiratory infections at community-level and referrals to health facilities in programme districts. FCHVs are not paid salaries, but instead they receive incentives from the Ministry of Health and Population. They are also given signboards and ID cards and the Ministry honours their contribution on the Annual FCHV Day. FCHVs may also receive items like bicycles, umbrellas etc. from Village Development Committees and payment from NGOs for specific activities as incentives.
Female Community Health Workers are local women who are selected from their communities. Their work is crucial since it is at the grasssroot-level and focuses both on health awareness, education and delivering health services
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Objectives
Most health problems in Nepal, particularly in rural areas are related to maternal and child health and the existence of limited skilled staff in the health sector provided the rationale for the Government to initiate the FCHV programme by training community women in the management of key health issues. The FCHV progarmme initiated by the Nepal Government in 1988 had the following objectives: Mobilizing and involving the community, especially women in health programmes related to mothers, infants, young children, immunization, vitamin supplemention and sensitive health issues like family planning. Developing self-help initiative, instill awareness and imparting education about the promotive and preventive aspects of health. Increasing the outreach of Government health programmes for the achievement of the Millenium Development Goals 4, 5 and 6.
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Increasing the utilization of available PHC services, establish key referral links between communities and health services. Improving the functioning of Village Development Committees
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The Ministry of Health and Population, Government of Nepal and the community are the main stakeholders of the FCHV programme. The Government has pro-actively facilitated the programme with the objective of reducing maternal and infant mortality rates, reducing fertility rate and vitamin supplementation for under-nourished children and women. The chief contribution of the Government is through capacity-building of FCVs, empowering them with necessary skills to fulfill their role as community health educators and providers, facilitate distance education and monitor the initative. The Government also has an important role in managing the programme and making it sustainable by involving community-level stakeholders like VDCs, district administration, health centres, Health Facility Management Committees as well as District Health Offices/ District Public Health Offices. The Ministry of Health and Population also has several other support mechanisms for FCHVs like endowment funds, radio programmes for FCHVs, maintaining an FCHV database and conducting surveys. International agencies like the USAID are also among the main stakeholders, involved in monitoring and survey of the programme in several districts to provide an objective assessment of the FCHV initiative and performance evaluation to improve as well as address the limitations.
Methodology
The National Family Health Programme provides technical assistance to the FCHV programme by supporting trainings and assisting the Government departments with strategic planning, guidelines, revised approaches and development of training materials. The FCHV programme began with an initial strategy of developing at least one local, community-based female volunteer in each ward and this approach was to be strengthened
Most health problems in Nepal, particularly in rural areas are related to maternal and child health and the existence of limited skilled staff in the health sector provided the rationale for the Government to initiate the FCHV programme by training community women in the management of key health issues
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nationally and implemented as the primary approach. The overall strategy was to empower rural women to take care of their own health, their children and family members health, through basic health knowledge and skills. It was also aimed to increase community awareness on the joint roles and responsibilities of the Government, district administration, community, self-help groups, Mothers Groups etc. Later, additional FCHVs were recruited in 28 districts as per a revised population-based ratio to serve more areas. But this revised approach was adopted carefully and only in cases where local administration and village communities requested for increased number of volunteers. There was also a supplementary strategy of strengthening the FCHV programme to give equal opportunity in health to socially disadvantaged, the poor and the disabled as per the provision of basic right as human right as stipulated in the Nepal interim Constitution of 2007. In addition the Government provides revolving funds at the VDC level for the development of FCHVs.
Key Strategies
Glimpses of Innovations in Primary Health Care in South-East Asia Within the overall strategy, meetings of Mothers Groups are encouraged as the most effective venue to provide education on maternal and child health, safe pregnancies and deliveries, family planning etc. The FCHV conducts the meetings and has to pass an 18-day training course supported by training materials, essential kit with medicines and first aid box. Her requirements are resupplied by the Village Health Worker or the nearest health centre. A refresher course is provided every 5 years for FCHVs to update their skills and knowledge Those volunteers who are unable to perform their tasks, or become too old to travel or take out time are replaced.
Highlights
Over 97% of rural wards in Nepal are covered by FCHVs. In 2006, FCHVs treated nearly 1,96,065 pneumonia-affected children, and provided counseling to 2,227,777 families having children suffering from cold,and coughs. FCHVs distributed Vitamin A supplements to almost 95% of children between 6-59 months.
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Over 8,18,000 packets of ORS samples were distributed by FCHVs to treat diarrhea cases among children under 5 years. 80% of the deworming coverage and 90% of Vitamin A supplements were provided by FCHVS. FCHVs possess better knowledge on HIV/AIDS than rural women. 84% of FCHVs report that they provide better education on HIV/AIDS than their community.
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Challenges
Since FCHVs are the backbone of Nepals public health programme, to enable them to function effectively, it is essential that they enjoy the confidence and support of the communities they serve, the overall functioning of the health system, regular supply of medicines and close links with health workers and centres. Some of the main challenges faced by FCHVs are that they can only perform to a certain point due to lack of formal education and primarily because it is a voluntary responsibility. They cannot be burdened with too many responsibilities. Also, there are still many FCHVs who are yet to receive basic training and need additional training on pregnancies, deliveries and child care. They also need to be constantly updated on new developments in the area of health so it is very important to give them access to mediums of information and knowledge. Despite a sizeable endowment fund to support FCHVs, only some part of it has been utilized to sustain their activities. Further, those FCHVs who are getting old or are unable to work, are reluctant to give up this work voluntarily. Last but not the least, it is for the communities to take ownership of the FCHV initiative since it is catering to them, but this has proved difficult. This needs to be done to sustain the programme on a long-term basis.
Outcomes
Overall, as observed from various documents and reports, the FCHV programme has greatly contributed to the outreach of the public health programme, touching even remote and inaccessible districts. Women who have studied very little have been able to play a key role in improving maternal and child health.
The overall strategy was to empower rural women to take care of their own health, their children and family members health, through basic health knowledge and skills
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FCHVs are present in nearly all rural wards in the country, are fairly stable in their positions, and reasonably representative of their communities. The FCHV initiative on the whole has managed to save the lives of women and children, reduce childhood anaemia, TB, register a wide-ranging Vit A distribution and deworming coverage.2 The programme has also resulted in increased number of treatment and referral cases, especially in the area of pneumonia. Most FCHVs are able to counsel and discuss family planning issues with women and men equally. They also manage to keep the discussions confidential. Although pills and condoms are not the regular family planning methods, FCHVs provide about one-third of public sector distribution of these and play a larger role in NFHP districts, which has led to increased awareness on the benefits and methods of family planning. FCHVs have fairly good knowledge about the basics of how a baby is delivered and benefits of breastfeeding. Most of them are able to make post-partum visits and distribute medicines/Vit A capsules to new mothers. Glimpses of Innovations in Primary Health Care in South-East Asia FCHVs are able to function effectively as the vital link between communities, village health workers and health centres.
Learnings
The FCHV initiative is living proof that it is public health service delivery is possible through community representation, spirit of volunteerism, limited training and very little resources. FCHVs are able to play a critical role in maternal and child health. It has also empowered women, given them a status within the community and improved the general health of the community. Some studies have revealed that a sense of responsibility towards the community, need for recognition and motivation to earn religious merit are the key factors for keeping these community volunteers motivated to volunteering. Overall, these volunteers cited the feeling of contributing to the community, acquiring health knowledge and the opportunity to improve their familys well-being as the chief driving force behind their work. Evidences exist to suggest that even women with low literacy levels with basic training are able to
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The programme may be used to provide health delivery to remote, inaccessible and underserved groups like tribal groups and dalits. The success of this programme has lead to its key stakeholders the Government, the Community and donor agencies to ensure that it is sustained and developed further.
Bibliography
An Analytical Report on National Survey of Female Community Health Volunteers of Nepal, Ministry of Health and Population, Government of Nepal, 2008 Country Health System Profile, WHO-SEARO 2007 (http://www.searo.who.int/EN/Section313/ Section1523_6866.htm, accessed on 3 July 2010). National Family Health Programme, Technical Brief # 1, Female Community Health Volunteers, USAID
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give counseling, basic health advice and distribute medicines, vitamin supplements, as well as literate women. However community support and encouragement are essential and their knowledge levels need to be upgraded periodically.
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Background
In 1977 the World Health Organization developed a vision of Health for All by the Year 2000 (HFA) for world health. Next the Declaration of Alma-Ata (1978) stated that PHC was the strategy to achieve that vision. Prior to the declaration, in Srilanka, the Health Unit program of the Rockefeller Foundation, helped to create a primary health care system in the country. This program established a community-based public health network across the country, which became the basis of the national health policies in Sri Lanka. The outstanding health status in contemporary Sri Lanka is the result of these early efforts to build a comprehensive network of primary care services throughout the country. Subsequent to the Alma Ata declaration the PHC strategy reordered priorities in the health sector, moving from a curative approach that was disease orientated to promotive one that emphasized on the prevention of diseases, elimination of health risks and the promotion of good health. Conceived in these terms the improvement of health required more than the services delivered by the health sector alone, the contribution of other sectors, agriculture, education, housing, essential services and transport were explicitly recognized as vital for improving the health of the population. This approach called on the health sector to extend and collaborate with other sectors, in incorporating health goals and health criteria into their policies, strategies and programs. Thus, intersectoral action (ISA) became one of the main principles of PHC.
The outstanding health status in contemporary Sri Lanka is the result of a comprehensive network of primary care services throughout the country
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In 1980, the Government of Sri Lanka endorsed the goal of Health for All by the year 2000 (HFA 2000) with primary health care as its focus. To further facilitate achieving HFA 2000, greater emphasis was placed on decentralization of health administration and priority given to the identification of primary health care components and development of an implementation model for application on a national scale. As an outcome of this a National Health Development Network was established. National Health Development Network Sri Lanka signed the charter for Health Development in 1980 for achieving the goal of Health For All by the year 2000, with primary health care as the key strategy. As a part of this strategy health development network for Intersectoral Action for Health (IAH) was established in 1980, which comprises the National Health Council chaired by Prime Minister; the National Health Development Committees chaired by the Secretary, Health; and the District Health Development Committees chaired by the district minister. A secretariat has also been established to coordinate NGO activities. Glimpses of Innovations in Primary Health Care in South-East Asia The apex is the National Health Council with the Prime Minister as the chairman. The other members of the Council are, the Ministers of, Health, Agricultural Development and Research, Higher Education, Education, Finance and Planning, Local Government, Housing and Construction, Home Affairs, Labour, & Rural Development. The National Health Council is responsible for the following functions: 1. provide national level political leadership for health development 2. guide Ministries, departments and other organisations engaged in health activities 3. coordinate activities of Ministries and other organisations 4. create greater awareness among people of the importance of health and 5. promote community participation and involvement The Council is supported and serviced by the National Health Development Committee (NHDC). The senior officers of the relevant Ministries and other officers whose activities impinge on health are the member of NHDC. The NHDC set up six Standing Committees on each of these subjects- PHC, health manpower, drugs, health and medical research, traditional medicine and appropriate technology.
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The NHDC established in November 1979 has three principal functions: 1. To review the activities in the health and health-related sectors with a view to identifying constraints and ensuring speedy implementation of programmes and projects 2. To identify priority issues and recommend policy initiatives for formulation of national health policy and 3. To promote and coordinate the health-related activities of the relevant Ministries and organisations The Sri Lankan Government established District Health Councils (DHCs) to promote multi-sectoral action and intersectoral coordination at district level, in each of the 24 administrative districts of Sri Lanka. They propose programmes for the respective districts on the policy guidelines set out by the National Health Council; give leadership at the district level for health and health-related activities; and recommend, if they think fit, the establishment of divisional health committees and village level organisations to perform the same functions as the DHCs. For planning, policy-making and development administration at distrct level, District Development Councils (DDC) were set up in each of the 24 districts. A DDC has the Members of Parliament of the District and elected representatives of the people as its members. The District Minister, a Member of Parliament, is the head of the district administration. All activities of government departments and public sector organisations in the district come under the purview of the DDC and the control of the District Minister. Further, this decentralized set-up was brought closer to the village by setting up health committees at the level of the Gramodaya Mandalayas (Village Councils). With the establishment of District Development Councils, there was a certain amount of delegation of political power and decentralization of the administration. The planning of PHC in the district, the achievement of the goal of HFA and the delivering of health services now fell within the competence of DDCs. In these functions, the District Health Councils played a leading role in preparing position papers, planning health services in the district and making recommendations to the DDC and the District Minister in regard to intersectoral action. They were also in a position to communicate effectively with the six standing committees of the NHDC on the districts needs of PHC, health manpower, drugs, health and medical research, traditional medicine and appropriate technology.
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The improvement of health required more than the services delivered by the health sector alone, the contribution of other sectors, agriculture, education, housing, essential services and transport are explicitly recognized as vital for improving the health of the population
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The mechanisms for intersectoral action are so structured that much of the initiative for action by the NHDC has to originate from the DHCs which actually face the day-to-day tasks and problems of delivery of health services to the people. Far reaching changes in the general administrative structure were made in order to decentralize the administration and enlist popular participation in regional administration. National Health Development Network in Sri Lanka*
National Health Council (NHC)
Cabinet of Ministers Health Minister Minister of Womens Affairs Teaching Hospitals and Family Health
National
National Health Development Commitee (NHDC) Standing Committees 1. Primary health care 2. Manpower 3. Drugs 4. Medical research 5. Indigenous medicine 6. Technical cooperation between developing countries and appropriate technology for health District Development Council Health Committee
Deputy Minister (Health) Secretary (Health)
Project Minister, Indigenous Medicine
Director General of Health Services
District
Regional Director of Health Services Divisional Health Officer Sub-divisional Health Officer Public Health Inspector Public Health Midwife Village Health Workers
Assistant Government Agent Division Gramasovaka Division Village
Pradeshiya Mandalaya Health Committee
Gramodaya Mandalaya Health Committee
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Primary Health Care Delivery and Support System in Sri Lanka*

Gramodayan health centres (clinic cum residence) (1:3000 population) Subdivisional health centres, complete with staff quarters (3 for each AGA Division, providing essential health care to a population of 3000 and functioning as a referral centre for a population of about 20,000) Divisional health centres, complete with staff quarters (1 for each AGA Division, providing essential health care to a population of 3000 and functioning as a referral centre for a population of about 60000) 24 District hospitals to provide referral support to primary health care 9 Provincial hospitals 4 Teaching hospitals 1 Postgraduate teaching hospital
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Primary health care complex
Referral level providing specialized care and training
* Mills. A, Vaughan. J.P, Smith. D.L and Tabibzadeh. I. Health System Decentralization. Concepts, Issues and country experience. WHO( 1990)
Innovative Design
The National Health Policy of Sri Lanka clearly identifies inter-sectoral action for health as an important element in the health development process. The health development charter has recognized relationship between part or parts of the health sector with part or parts of another sector which has been formed to take action
The health development charter has recognized relationship between part or parts of the health sector with part or parts of another sector which has been formed to take action on an issue to achieve health outcomes in a way that is more effective, efficient or sustainable than could be achieved by the health sector acting alone
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on an issue to achieve health outcomes in a way that is more effective, efficient or sustainable than could be achieved by the health sector acting alone. In its entirety, the development network involves working with more than one sector of society, that is, collaboration between different sectors that may include government departments such as health, agriculture education, environment; ordinary citizens; nonprofit societies or organizations; and business to improve the health status. It seeks to strengthen health care systems to facilitate efficient delivery of health care in a sustainable manner, but also seeks to harness participation of the community in caring for its own health and encompasses both curative and preventive aspects of health care, addressing the health of all citizens.
Objective
To attain an acceptable level of health for all its citizens by the year 2000 through primary health care services.
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The National Health Council (NHC) sets out the policies of the Government in regard to health care, mobilization of non health sectors, the modalities of coordinating multisectoral action and measures for enlisting popular participation in health care. The NHC play an active role in monitoring the health situation and ensuring intersectoral collaboration. Management of all healthcare institutions, other than teaching hospitals and field services, is the responsibility of the provincial councils. The Provincial Director of Health Services (PDHS) supervises the Divisional Directors of Health Services (DDHS) administratively. Full financial control is delegated to the DDHS from the Provincial Health Directorate to implement the health activities. Providing health care services in the public sector is the responsibility of the Central Ministry of Health (MoH) and in the Provincial Councils is of Provincial Ministries of Health. The Central MoH is responsible for managing national facilities and Teaching Hospitals, procuring drugs and supplies, while the Provincial MoHs are responsible for managing provincial/district health facilities.
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Methodology
Organization of a Rationalized Health Network A detailed National Health Service plan for medium-term, up to 2010, relating services to population needs for primary, secondary and tertiary health care is prepared. This specifies the optimum configuration of services for a given level of total annual health expenditure, show the implications for the state sector of assumptions about growth in private sector services, and identify priorities for capital investment. It takes into account, demography and epidemiology, current and future treatment methodologies, including a gradual shift to ambulatory care for diagnostic and surgical procedures and the potential of new technology, e.g. laser and laparoscopic surgery etc., to reduce inpatient stays. The national health services plan is used to guide the allocation of recurrent and capital financing to provinces. Mechanisms are put in place to ensure that this process is transparent and equitable. Donor investments also fit into this plan. As a key strategy to achieve intersectoral action & coordination at all levels, National Health Development Network was established
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In addition appropriate referral strategies including admission and discharge policies are introduced to ensure that patients receive treatment at the most appropriate level. This includes home-based-care when and where appropriate. The supportive services too are developed in a parallel manner.
Key Strategies
As a part of strategy for intersectoral action & coordination at all levels, the Government established the National Health Development Network with the National Health Council (NHC) as the apex body. To implement the decisions of the Council, a National Health Development Committee, chaired by the Secretary, Ministry of Health, and its six Standing Committees were established. A plan of action for the implementation of HFA 2000 was formulated in 1981. Under the plan, existing large hospitals including teaching hospitals were to provide general and specialized curative services. Below the secondary care hospitals, divisional health centers (DHCs) and subdivisional health centers (SDHCs) were established by upgrading the existing medical institutions. Another level of health service delivery was created through the establishment of Gramodaya Health Centers (GHCs) which are community oriented Maternal and Child Health Service delivery centres which are closely linked to the village communities. GHCs, are under the care of the public health midwife providing services for a population of about 3,000 population. This is the most peripheral unit with DHCs and SDHCs as referral institutions for GHCs. DHCs, SDHCs, and GHCs constitute the primary health care complex where both curative and preventive services including family planning were delivered. The introduction of provincial council system restructured the entire Provincial, District and Divisional level administration. With the devolution of powers and functions to the provincial councils, the Provincial Ministries of Health was given the responsibility of formulating policy, the management of Teaching Hospitals, Special Hospitals, Specialized Campaigns, technical training institutions and bulk purchases of medical supplies. Further decentralization of powers was introduced in 1992 by appointing Divisional Directors of Health Services (DDHS) to provide comprehensive healthcare to a population ranging from 60,000 to 80,000.
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Highlights
In 2001 there were 25 Deputy Provincial Directors of Health Services (DPDHS), to assist the eight Provincial Directors of Health Services. The NHC has taken up a number of matters needing urgent intersectoral collaborative action. They include among others, malnutrition, HIV/AIDS, environmental health especially in the context of dengue and other mosquito borne diseases, thallasemia, alcohol and tobacco control, mental health etc. Intersectoral committees have been set up to address major issues such as avian influenza, prevention of injuries, school health, nutrition, communicable diseases etc which meets regularly and recommend policy and actions.
Challenges
The health system faces several major problems in its organization and management. One major issue is confusion and conflicts over roles, responsibilities and lines of accountability between central and provincial levels of the MoH which has been caused by devolution. Sri Lanka has an extensive network of public health clinics and hospitals. However, decentralization is incomplete, with excessive reliance on tertiary and secondary level hospitals and under-utilization of primary care facilities which often lack staff and service quality. Developing coordination of public and private healthcare providers is difficult
The national health services plan is used to guide the allocation of recurrent and capital financing to provinces
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In 1999, the Ministry of Health was restructured, which resulted in the separation of the Department of Health Services from the Ministry of Health. The Director General of Health Services heads the Department and has immediate support from Deputy Directors General (DDG) of Health, each in charge of a special programme area. They have, under their jurisdiction, a number of Directors responsible for different programmes and organizations. The Divisional Director was given the responsibility of providing comprehensive promotive, preventive, curative and rehabilitative care at a primary level to the people in the division. The people and the health staff are afforded the opportunity of presenting their problems to a health manager at the divisional level, well within their reach.
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There is a shortage of nurses and paramedical personnel and concentration of medical staff in urban centres. A constraint to inter-sectoral coordination has been the weak horizontal linkages between health related ministries and the Ministry of Health, as well as the lack of appreciation of importance.
Outcomes
The improvement in health occurred simultaneously with the improvement in other states of well being and this simultaneity of progress produced intersectoral links among them ; these in turn created intersectoral synergies which were mutually supportive and advanced all the indicators together. The policies that gave equal weight to all the social goals and the simultaneity of progress that enabled people to achieve and sustain the high health indicators. Each sector simultaneously pursued its goals to improve the conditions for which it was responsible. Glimpses of Innovations in Primary Health Care in South-East Asia Primary Health Care is given priority in the activities of the network. The National Health Council has reoriented health policies towards achieving the objective of Health for All through primary health care. The NHDC has commissioned the standing committee on PHC to identify areas of action and prepare guidelines for other sub-sectoral programmes.
Learnings
The integration of services within the health sector alone is not sufficient to obtain the desired result of improving the health status of people. Alleviation of poverty, universal education, more equitable distribution of national resources, are all important factors in ensuring improved health for all. There needs to be a mechanism that allows for functional co-ordination with other sectors at all levels of governance (national, provincial and local authority/district level). Unless this happens barriers to sustainable progress are inevitable. A starting point could be placing health issues within an integrated development strategy for districts/province/country. Such a strategy needs to take a number of issues into account: first, (at provincial and district level) health and other sectoral boundaries need to be conterminous to allow for joint planning.
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There are significant potential benefits from a renewed emphasis on intersectoral action. These include an enhanced capacity to tackle and resolve complex health and social problems which have eluded individual sectors for decades; a pooling of resources, knowledge and expertise that will allow partners to address problems more effectively; reduced duplication of effort; and new ways of working together that will enable to contribute to improvements in social cohesion, increased opportunities for sustainable human development, and a more dynamic and vibrant society. Successful intersectoral initiatives are, by their nature, challenging to achieve. From the Sri Lankan experience we learn that bringing health care closer to the people at the community level either through community based health workers, and a network of health centers which have adequate staff and a reliable supply of essential drugs, even relatively poor countries can improve health of their people.
Bibliography
Country Health System Profile Srilanka. (http://www.searo.who.int/en/Section313/Section1524_10879. htm accessed on 20/7/2010) Country Cooperation strategy at a glance. (http://www.who.int/countryfocus/cooperation_strategy/CHCsbrief_lka_en.pdf accessed on 20/7/2010) Obimbo. E.M. Primary Health Care, Selective Or Comprehensive, Which Way To Go? (2003) J. East African Medical Vol. 80 No. 1 January 2003 Healthy & Shining Island in the 21st Century. Master Plan study for strengthening health system in the democratic socialist republic of Sri Lanka (2003). Pacific Consultants International (http://gwweb.jica. go.jp/km/FSubject0201.nsf/03a114c1448e2ca449256f2b003e6f57/96dbd88444f528f249257038002f554e /$FILE/03-145_Vol_I_JICA.pdf accessed on 21/7/2010) Perera, M.A.L.R.(2006) Intersectoral action for health in Sri Lanka, (http://www.who.int/social_determinants/resources/csdh_media/intersectoral_action_sri_lanka_2007_en.pdf accessed on 21/7/2010) Revitalizing Primary Health Care Country Experience: Sri Lanka. (www.searo.who.int/LinkFiles/Conference_ SRL-5-July-08.pdf accessed on 20/7/2010)
Alleviation of poverty, universal education, more equitable distribution of national resources, are all important factors in ensuring improved health for all
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Secondly, there need to be structures for joint planning at all levels of governance. Third, a useful way of monitoring development is health status, and this needs to be built into the planning process as a measure of development. All sectors have a significant role to perform to ensure that there is progress in engendering a result-orientated collaboration to development issues. However, national leadership, coordination and vision are required to ensure that a more holistic context is established for intersectoral collaboration.
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Background
The National Primary Health Care (PHC) programme was launched in Thailand in the 4th National Development Plan (1977-1981). It started with the establishment of new district hospitals and health centres and the creation of a cadre of community health workers i.e. village health communicators (VHCs) and village health volunteers (VHVs) to increase the coverage of essential primary health care and to offset the problem of shortage of health professionals. VHCs were selected and trained to serve as disseminators of health information. VHVs were then selected from the VHCs and specially trained on curative and public health issues and worked closely with the local health center staff to improve the accessibility to essential health service. The next few development plans focused on setting up of Community Primary Health Care Center in each village to facilitate the work of VHVs in delivering primary health care services, initiating village health revolving funds, improvement in quality of health services and building effective referral systems. Later the primary health care system was reinforced by the health care financing initiative under the prepaid health card scheme, to increase financial resource and improve utilization rate. With the aim to overcome the financial barrier at the point of service, the free medical service for the poor has been put into operation since 1975.
VHCs were selected and trained to serve as disseminator of health information. VHVs were then selected from the VHCs and specially trained on curative and public health issues and worked closely with the local health center staff to improve the accessibility to essential health service
Universal Coverage Scheme or 30 Baht Scheme

The major development in health financing in Thailand was the launch of the Universal Health Coverage Scheme, colloquially known as either the 30-Baht Scheme or Gold Card Scheme. The Thai government introduced the policy reform of universal coverage (UC), in
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2001 with the aim of providing access to health services for all, without financial barriers related to cost. The scheme evolved after a series of experimentation in health care financing starting from user fee with exemption, and gradually moving from out-of-pocket payment to pre-payment system. The Universal Coverage Scheme (UCS) covers those previously insured by the Public Welfare Scheme (PWS) and the Voluntary Health Card Scheme (VHS) and the uninsured (approximately 30 percent of Thai population). The UCS is financed by general tax revenue with a fixed co-payment of 30 Baht per visit or per hospitalization at the point of service, through a contract model. People joining the scheme receive a gold card which allows them to access medical services from the contracted public and private health care facilities in their district, and, if necessary, be referred for specialist treatment elsewhere regardless of their socioeconomic status. Health care providers are allowed to collect only 30 Baht for each visit of treatment aiming to prevent unnecessary utilization. The government allocates annual budget to each hospital according to the number of people registered to the hospital on capitation basis. Before 2006, the UCS provided comprehensive health care for two groups of beneficiaries: those who had to pay a co-payment of 30 baht per admission or visit, and those who were exempted from the 30 baht co-payment. In 2006, the then Public Health Minister, abolished the 30 baht co-payment and made the Universal Coverage Scheme free.
Innovative Design
The scheme is pioneering based on the ideology of equality and provides health care to all irrespective of the socioeconomic status. It is innovative as it introduced universal healthcare coverage in which all people have the equal right to access quality health care services without the constraint of health care expenditure. The scheme also ensures that the government and non-government sectors equally and evenly provide services in their respective area. The continuum care design of Universal Coverage that provides comprehensive package of preventive and promotive care along with curative care also makes it unique as it aims at improving the overall health status of the citizens and not just treating the sick.
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Key principles of the universal coverage are: Equity: An equal sharing of health care expenditure and equity of access to the same quality of health services. Efficiency: Efficient use of resources by good administrative and management practices. Choice: People have the right to choose their health services. Good health for all: Universal healthcare coverage aims to provide preventive and promotive health care along with curative care.
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The Ministry of Public Health (MOPH) plays the service provision role, where major public health facilities are under its jurisdiction while a new entity the National Health Security Office, plays a financing and purchasing role through budget allocation to its provider networks. The District health system (DHS) plays the role of service provider in the rural areas.
Objectives
The main objective of universal coverage is to provide access to health services for all, without financial barriers related to cost.
Methodology
All the citizens not enrolled in any health scheme and whose names were documented in house
The scheme is innovative as it introduced universal healthcare coverage in which all people have the equal right to access quality health care services without the constraint of health care expenditure
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registrations, were registered under the scheme. The ensured citizens receive a Gold Card, which has to be presented together with the patients national identification card every time (s)he accesses health services in the district. In case of any complication or treatment requiring higher health interventions the patients are referred to higher level health services registered under the scheme from a registered primary health centre or hospital. However emergency services can be accessed at any public health service facility. A 30 Baht co-payment as a user fee is paid for all consultations. Children under 12 years of age, seniors over 60 years of age, volunteer health workers, and the very poor are exempted from the user fee. The scheme offers comprehensive health care service package that includes most health services such as free prescription drugs, outpatient care, hospitalization, disease prevention, radiotherapy, surgery and critical care for accidents and emergencies except cosmetic care, obstetric delivery beyond two pregnancies, drug addiction treatment, hemodialysis, organ transplantation, infertility treatment, and other high cost interventions. The system is funded by the government based on capitation. The total payment per capita paid from tax revenue is 1404 Baht per year, parts of which are paid to the health care facilities, according to the number of local residents registered with the facility. The capitation includes the costs for the curative, preventive, promotional care as well as the administration. The budget for health facilities is based on the following division: 574 Baht for out-patient care 303 Baht for in-patient care 175 Baht for prevention and control of diseases. 32 Baht for high cost care 25 Baht for emergency and accident care 88 Baht for structural investment
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10% of the total package for central and regional administration, developing the information system and quality assurance 10% of the out-patient and in-patient services budget for contingency funds
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Key Strategies
The scheme was intended to integrate the existing social welfare and voluntary health card schemes, and to extend coverage to the estimated 30% of the population of mostly informal sector that remained uninsured, thereby creating a more equitable system. The policy has incorporated two main reforms reform of budget allocation, payment methods and strengthening primary care. One of the key elements of the program is capitated-based reimbursement of public hospitals based on populations enrolled in the hospitals. The capitation contract model has been adopted to purchase ambulatory and hospital care, preventive and promotive care, including reproductive health services, from public and private service providers. Universal Coverage capitation is geographically structured so hospitals have fixed revenues based on the local population and financial viability depends on an ability to control costs. The scheme improved access to health care by expanding public health facilities nationwide through centralized health care coverage plan. It helped to overcome physical barriers to cover the entire population. The MoPH established a hierarchy health service system using administrative areas as the main approach for investment in the health care infrastructure. Initially, general hospitals were built in Bangkok and extended to every other province. After achieving provincial coverage, the coverage plans to build small hospitals for districts and health centers for sub-districts were accordingly carried out using the same approach. Universal coverage introduced the integrated Continuum of Care design. The preventive health services were linked to curative health services. Therefore the health examination was implemented as a risk identification tool. The goal of this screening and evaluation program was to prevent the disease or to diagnose an existing disease. For example,
The scheme improved access to health care by expanding public health facilities nationwide through centralized health care coverage plan
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measurement of blood pressure is intended to detect hypertension so as to initiate treatment and prevent subsequent morbidity (e.g., stroke or renal failure) or mortality. A further goal of the periodic health examination is to educate patients about risk behaviors or environmental exposures that pose risks for future diseases. The risk groups are informed and encouraged to join the risk modification program and to undergo appropriate treatment.
Highlights
The Universal Coverage Scheme covers almost 76 % of the Thai population.
Challenges
The current user fee exemption mechanism fails to distinguish the poor from the poorest. It also fails to exempt all those over 60 years of age an exemption that should be automatic and easy to administer as all patients have to present the Gold Card and their Thai identity card whenever they seek health care at a registered facility. This suggests that there is either a system failure, or that patients are not sufficiently well-informed about how to obtain the exemption. Despite the apparent success of the scheme in decreasing direct health care costs, indirect costs such as loss of income are still a problem. The card is issued at the municipality district of residence and can only be used at a designated primary care unit and hospital. Anyone moving to a different district cannot utilize health services there without going through a re-application procedure. There are also opportunity costs to be considered, such as cost and availability of transport or loss of earnings. The service hours of health facilities and also loss of income restrict the access. Loss of income and inconvenient service hours pose a great problem for those who have to pay the user fee. Considerations such as service quality and geographical access also need to be taken into account when trying to improve access to health services for the poor.
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Health facilities in areas with sparse population face financial difficulty. Further development of this scheme to make it financially affordable within the economy of the country while able to maintain the quality of care and the motivation of health staffs remain a great challenge. The private sector is not well developed only a few individual private practitioners are available, and they are not able to provide a comprehensive range of services Thus, geographical monopoly inhibits selective contracting, especially in rural settings. Purchaser provider splits between Ministry of Public Health (MoPH) and National Health Security Office (NHSO) is confronted with challenges due to implementation system and overlap of responsibilities between NHSO and MoPH Long waiting hours and lack of confidence in service quality is also an issue faced by the beneficiaries. Change in provider payment method to capitation payment makes providers face difficulty in adapting themselves because of unequal distribution of human resources among regions and among urban and rural areas The monitoring system to ensure quality of care and quality control aspect of Universal Coverage needs to be strengthened Outcomes Expanded health-care coverage has resulted in an increase in the use of both outpatient and inpatient services by the poor. The introduction of the policy apparently extended coverage to 18.5 million previously uninsured Thais. Other estimates suggest insurance coverage increased from 71.0% of the national population in 2001 to 94.3% by 2004. Not only did the 30-Baht Scheme expand the coverage, it also successfully maintained it for those previously covered by other types of health insurance. The scheme turned out to be the most popular government policy, as judged from repeated opinion polls. However, the scheme was not popular among health care
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providers because of the increased workloads, inadequate health budget, lack of new investment funds, and inflexibility for the public health care facility to collect user charges from patients who are able to pay. Studies indicate that since the introduction of the 30-Baht Scheme the poor have a very low burden of health care costs and that Thailands poor receive more benefits than the non-poor in outpatient care. It has been reported that the proportion of households who were impoverished following medical treatment declined by about two thirds between 1992 and 2002 with at least some of these reductions attributed to the 30-Baht Scheme. Overall, satisfaction with the scheme was found to be high General tax was the most progressive source of finance. Because this source dominates total financing, the overall outcome was progressive, with the rich contributing a greater share of their income than the poor. Glimpses of Innovations in Primary Health Care in South-East Asia The scheme has led to a more equitable and more efficient health system.
Learnings
The Thai experience shows that Universal Coverage or near-Universal Coverage is achievable in a lower-middle income country using pluralistic approaches. The multiple approach of using health financing reforms accompanied by nationwide extension of primary health care coverage, mandatory rural health service by new graduates, and systems redesign, especially the introduction of a contracting model and closed-ended provider payment methods have led the Thai government to achieve an equitable and efficient health system . Therefore, it proves that infrastructure for health care, adequate qualified health professional and technocrats, experience on health care financing systems are mandatory for successful planning and implementation of universal coverage for health. Evidences suggest that strong political commitment, strong civic /public support and support from Government, reformists, and policy researchers are the three facilitating factors needed in order for the health care reform to be successful. One of the significant learning from the success of universal coverage in Thailand is universal coverage cannot
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Quality improvement program and measurements to improve equity are the next step after achievement of the universal coverage. Existing literature, suggests that removing financial barriers to health services may not be sufficient to provide access for the poor if other factors, for example the quality of services, is deemed insufficient. The experience in Thailand showed that its strategy towards human resource distribution into rural area that made 3 years rural services mandatory for new graduate doctors, nurses, dentists, and pharmacists is a positive step towards ensuring quality services along with universal coverage even in the rural areas.
Bibliography
Cronberg. S.C, Laohasiriwong. W and Gericke, C.A.( 2007).Health care utilisation under the 30-Baht Scheme among the urban poor in Mitrapap slum, Khon Kaen, Thailand: a cross-sectional study. J. International Journal for Equity in Health 2007. http://www.unescap.org/aphen/thailand_universal_coverage.htm accessed on 15/7/2010 Somkotra T and Lagrada. L.P. (2009) Which Households Are At Risk Of Catastrophic Health Spending: Experience In Thailand After Universal Coverage. J. Health Affairs, Vol 28, no. 3 (2009) Tangcharoensathien V, Tantivess S, Teerawattananon Y, Auamkul N and Jongudoumsuk P( 2002 ) Universal Coverage and Its Impact on Reproductive Health Services in Thailand. J. Reproductive Health Matters, Vol. 10,No. 20, (Nov., 2002) Thailand: Universal care coverage through pluralistic approach. Series: Social security extension Initatives in East Asia. ILO Subregional Office for East Asia Thailand: health care for all, at a price. (www.who.int/bulletin/volumes/88/2/10-010210/en/index.html accessed on 16/7/2010) Universal coverage in the land of smiles: lessons from Thailands 30 baht health reforms (2007). J. Health Affairs, 26, no. 4 (2007)
The Thai experience shows that Universal Coverage or nearUniversal Coverage is achievable in a lower-middle income country using pluralistic approaches
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just be achieved by changing in one go. It needs long term planning and continuous effort to go further step by step. Distribution of health care infrastructure nationwide should be the first step before arrangement of health care financing for universal coverage. Investment in healthcare infrastructure especially in the rural area is essential for the implementation of Universal Coverage. The access to health care facilities can be improved through network of health facilities at subdistricts, districts, province/ state level.
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Strategic Route Map (SRM)
Background
Primary health care in Thailand has a long history of development, even before Alma Alta Declaration in 1978, from demonstration projects in several provinces to the adopted primary health care program with village health communicators and village health volunteers to healthy Thailand, all of which were intended to be community-based development utilizing primary health care concept and strategies. Primary health care was initially designed as a service program in delivering simple medical care by village health volunteers who were intended to work with local health workers in disseminating health related news, coordinating and assisting in public health care delivery, and act as good role models. The organization and financing aspects were virtually taken care of by the government. Due to the persistent problems of inequity in health, the transition from communicable to non-communicable diseases causing double burden, the decentralization of the administration and the availability of health funds to the community, real community participation and the shift from service oriented to development oriented are required to achieve sustainable development. The Strategic Route Map was developed and verified to serve this purpose in 2005 by Dr. Amorn Nondasuta, with the support of the National Health Security Office (NHSO) and the Public Health Support Division, Department of Health Service Support, Ministry of Public Health
Strategic Route Map (SRM)

Strategic Route Map (SRM) is a strategic management tool which helps put into focus the goal, destination and direction of an organization. It is a technique that elaborates various strategic objectives and transforms them into plans and programmes that answer
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In other word, SRM is a tool or technique to be used for project planning and management. It is a process-based in trying to understand root causes of the problems so that vision, destination, missions and strategies to achieve the destination can be effectively defined. The formulated strategy must be integrated, comprehensive and relevant. SRM links strategy formulation to strategy execution. Plan of actions incorporate both technical and social interventions with clear indicators for monitoring and evaluation. The technique places an emphasis on three inputs, namely, organization, manpower, and funds. The heart of this technique is the belief in communitys capacity to take care of themselves and their environment. This requires the changes of the attitudes of health professionals and local people from service-oriented to development oriented. Four perspectives need to be focused when developing SRM: The People: What role should the people, their family and their community assume to make changes in health behaviors, community health and development, and social determinants of health development. The Partner (Stakeholder): Who are the partners in development? What are their roles and involvement? The Process: What are the areas of managerial process which are needed to bring about the effective roles and relationship of the people and the partner? The Foundation: There are at least three components to be identified at this level. They are: a) Attributes of the human resource e.g. competency, capability etc.; b) Attributes of the information systems e.g. accuracy, relevance etc.; c) Attributes of the organization e.g. organization, culture etc.
SRM is a tool or techniques to be used for project planning and management. It is a process-based in trying to understand root causes of the problems so that vision, destination, missions and strategies to achieve the destination can be effectively defined
the vision and goal of the organization. It systematically and continuously monitors the progress of the plans and programmes by using appropriate key performance indicators (KPI), therefore allows mid-term corrections and revision in case of looming debacle. Finally, it is also a communication tool which helps align all parties and individuals concerned to work toward the same destination.
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Innovative Design
This strategic innovation recognizes synergistic effects of the three variables of organization, finance and manpower, and takes into account the complementarities between technical and social interventions. The tool focuses on the development-oriented approach to ensure PHC sustainability. The focus is shifted to the community and people are empowered to play an active role in health promotion, based on the vision: People play a role in caring for their own health as well as their families, communities, environment and society in a sustainable manner with determination, willingness, good conscience, and faith. It uses human as well as other resources including communitys opportunity and wisdom to the maximum extent. This approach provides the opportunity for the community to examine its potentials, in terms of assets and wisdom, and use them as a basis for development. For sustainability, it is important to change the attitudes of the people, from leaving their health in health staffs hand to actively taking care of their own health and environment; and of health staff in trusting the ability of the people in planning and managing their own health and environment. This has been done through a training programme in which both health staff and local people participated.
Objectives
To strengthen peoples capability to decide, plan and take action in health promotion and disease prevention.
Stakeholders currently joined SRM project were health, municipality, Tambon Administration Organization committee members (TAO), religious leaders, civic groups in the community such as house wife, elderly, youth, etc) and community leaders. To secure the cooperation from these stakeholders, the following methods have been used: Through existing network Start from problems they currently had
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Talked to people repeatedly Show them the results of SRM applications Assign roles and responsibilities to involve them Ask for their help, especially those who are respected by community people (champion) Roles currently taken by stakeholders are: Advocacy and moving SRM forward Management of the project Defining vision Implementation and evaluation of the project Capacity building and SRM training Financial supports
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Methodology
There are seven steps of SRM construction which consists of community assessment; destination statements; SRM development; strategic linkage model development; definitions of strategic objectives; defining performance indicators, key performance indicators, identification of issues to be focused; action plans, and strategic team. Fundamental concept of SRM lies on the relationships among four components, namely, community people, stakeholders, process, and foundation factors. Based on the results of community asset assessment, destinations, basically health related, are set at the community people level, actions to be taken by community people and supporting activities carried out by stakeholders to help people achieve desired actions, the process to secure the participation from stakeholders and information, skills and capacity of both human resource and institution needed to support such process are identified and verified for systematic linkage.
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SRM development Before developing SRM, three questions need to be answered: Where are we now in the development process? This is the entry point to context and situation analysis. Where are we going to (our aspiration)? This leads to destination statements. How do we get to where we want to go? This leads to the development of SRM. After the above questions have been answered, there are two more steps in the SRM development process to be addressed: SRM objective verification Constructing a Strategic Linkage Model (SLM) Steps in SRM construction Glimpses of Innovations in Primary Health Care in South-East Asia 1. Context and situation analysis using positive approach Analyzing the context and situation using positive approach leads to the internationalization on the part of the analyzer. It in turn leads to inspiration and eventually triggers innovation. Hence, positive approach is strongly recommended. Mind Mapping, a very powerful tool for brainstorming, is used. It groups various ideas and provides discernible links among them. The statement of aspiration in the mind map forms the basis for the identification of destinations in the next step. Setting Destination The basic of the destination setting is to compile or reconcile the aspirations derived from the four perspectives of the mind map. With this technique, the relationship between thoughts and destination is clear. Constructing SRM Constructing SRM, analogous to drawing a community map, gives an overall view of how various strategic objectives relate to one another. It has important characteristics as follow:
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It has zones in the form of the four perspectives. It has important landmarks in the form of strategic objectives. It shows the linkage between strategic objectives with arrows. The objective from where the arrow starts is the cause while the objective that the arrow points to is the effect. 4. Constructing SLM A strategic Linkage Model (SLM) identifies the final destination and the most appropriate routes to reach it. It is a combination of chosen strategies to be implemented in a shorter time frame (2 years). 5. Define critical success factor and the indicators for monitoring and evaluation. 6. Defining strategic objectives This step comes after developing issue-based SLM. The process is basically to define each of the objectives in various perspectives. 7. Constructing Mini-SLM This is a 1-year activity-linkage model or action plan.
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Key Strategies
Systematic and evidence-based approach has been used in SRM. The project starts off with community and health staff preparation through an attitude training programme to make them ready for their new roles. Situation analysis has been done to identify current situations of all four perspectives, on which goal, objectives, strategies and activities are based. Ownership has been built through the delegation of authority and responsibility. Monitoring and evaluation of the project has been objectively carried out through Key Performance Indicators (KPI) identified by local people making them aware of changes taking place due to the project, and consequently, the sustainability and expansion of the project will follow.
Constructing SRM, analogous to drawing a community map, gives an overall view of how various strategic objectives relate to one another
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The focus of health care services has shifted to the capacity building of the community members by empowering people to manage their own health, mutually develop social measures for behavior changes in appropriate and sustainable ways.
Managing the Strategy with SRM

What to change? Strategy = Change SRM Strategic Route Map (4 years) How to change ? Glimpses of Innovations in Primary Health Care in South-East Asia Strategic Objective Tactic Plan of Action (1 year) Task (Social) Indicator SLM Strategic Linkage Model (2 years)
Activity
Task (technical)
SRM tool is being used for process linkage between strategic management or what the people need to be changed to respond to changing situations and environments. It helps to align the development process in the same directions and destinations, monitor the progress systematically, develop communication systems, and raise mutual understanding among all persons concerned. SRM is used as a tool for directing and changing working directions, by three fundamentals, consisting of: adjusting projects and process, developing budgetary plan and identifying responsibilities, duties, and capacity building for human resources.
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The technical measures delivered by health workers and social measures are integrated to tackle health problems.
SRM tool is being used for process linkage between strategic management or what the people need to be changed to respond to changing situations and environments
There are three forms of SRM with different functions: (1) the strategic route map (SRM): generally unchanged during a given time frame (4-5 years); (2) the strategic-linkage model (SLM): a combination of chosen strategies to be implemented in a shorter time frame (2 years); and 3) the plan of action: a 1-year activity-linkage model. Basically, a triad of main strategies to influence behavioral change is needed. These are complemented by a set of four sub-strategies.
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A Strategic Route Map Design
An SRM designed to reach MDGs

Road Map of Phase 1 Peoples Health Behavioral Change Communitys Effective Surveillance System Community-based Health Program
People
Delegate authority to local leaders / CHWS
MOU between Health Authority and Local Administration Local Administration Involvement in Programming and Support Government Organizations Strong Support Advocating Organizations Playing Effective Role
Stakeholder
In-country workshop to produce context-specific SRM Efficient IEC Efficient Managerial Process Effective Innovation Management
Process
Foundation
Relevant, up-to-date Data/ Information
Conducive Organizational Atmosphere Adequate Capability of Manpower SRM Training Start Here
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Highlights
The Ministry of Public Health encourages all levels of its agencies to employ the Strategic Route Map in support of the peoples health development activities at the local or community level. The MOPHs Office of Inspectors-General use Strategic Route Map as one of the monitoring indicators. The National Health Security Office (NHSO) requires that each subdistrict (tambon) health security fund uses the Strategic Route Map to guide its work. At present, all provinces in Thailand have adopted the technique.
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Challenges
The technique is time consuming and affecting family and work life Drop outs of members Resistance from some health staff and local people considering it as un-necessary process Health fund committee members had limited knowledge about SRM making it difficult to get the local fund Difficult to secure cooperation from others in the community Complaints that too much emphasis on health aspects Interfere with routine work of local health staff
Outcomes
In Thailand, SRM technique has been applied to pilot areas around the country since 2005. Monitoring and evaluation of SRM implementation in those areas has confirmed its effectiveness as a tool to tackle community health problems through innovations. In the process, the community could compare the degree of success of SRM implementation against a benchmark area and apply knowledge and experience gained in subsequent development at local administrative level.
SRM promotes bottom up planning with the full participation of the community, intersectoral collaboration and appropriate technology
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SRM promotes bottom up planning with the full participation of the community, intersectoral collaboration and appropriate technology. The community members realize that SRM is an effective tool used to secure community participation and community mobilization. It has lead to integration of community work and increased protection of human rights among the community. The community members recognize that the success of the community participation requires mutual responsibility, sharing information and communication, community rules or social measures set by the community members themselves. The SRM promotes self-actualization and pride of community members who undertake role and responsibility that result in a sustainable development at the community level. The SRM tool provides a platform that makes possible continuous knowledge-sharing and lesson- learning among community members. Strong networks within and outside community have taken place. Glimpses of Innovations in Primary Health Care in South-East Asia People are aware of their own responsibility for their health and take action accordingly. Village health volunteers are better recognized and empowered. Economy of the community were improved due to SRM site visits. Community leadership was enhanced. Peoples health behaviors have been improved. Relationships among community people and overall atmosphere have been improved.
Learnings
To strike a balance between services and development in primary healthcare a strategic change is required to shift towards health system development. Although there are many challenges for sustainable health system development, motivating people to take care of their own health depends on three key components: service providers (including networks of service providers), managers, and the people themselves. In attaining healthy communities, the critical success factor is peoples behaviours. The critical success factors
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of behavioural changes, in turn, are social measures and a community surveillance system. Strengthening community empowerment using SRM as a tool for change, acts as a catalyst for reaching the goal of behavioural change. Individuals and the community need to be empowered to achieve people-centered health care or for health care to adopt a developmental approach rather than the service approach. Literacy/education combined with income generation play a crucial role in community empowerment. Thailands experience with the Strategic Route Map (SRM) illustrates this approach, moving from health for all to quality of life. If people are properly empowered, they will be able to effectively take care of their health and environment. The Strategic Route Map- SRM is essentially a tool for change management. It is an instrument to link or bond strategies of all agencies toward empowering communities and societies through the development of peoples quality of life, thus becoming thinking and learning society.
Bibliography
Meeting Report Lessons Learned and Knowledge Management on Development and Utilization of Strategic Route Map (SRM) at the Community Level, as Part of Primary Health Care in WHO/SEARO: Setting up of Institute for Primary Health Care Innovation (IPI), (2009). Department of Health Service Support, Ministry of Public Health and The Foundation for Quality of Life (S. Sithigarn) Office of the Institute for Primary Health Care Innovation (IPI). Strategic Route Map Manual (2009). Primary Health Care Division, Department of Health Service Support, Ministry of Public Health and Institute for Primary Health Care Innovation (IPI) Thailand. Primary Health Care Innovation: Development and Implementation of Strategic Route Map (SRM), Mueang Mai Subdistrct, Amphawa District, Samut Songkhram Province, Thailand SRM Curriculum for Refresher, Manual (2010). As part of Primary Health Care in WHO/SEARO: Setting up of Institute for Primary Health Care Innovation (IPI) Phase 1. Unpublished paper. The Foundation for Quality of Life (S. Sithigarn). WHO (2009).Teaching of Public Health in medical schools, Report of regional meeting Bangkok..
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Timor-leste Servisu Integrado Saude Communitaire (Integrated Community Health Services)
SISCa
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Background
Timor-Leste was a Portuguese colony between the 18th century and 1975. In 1999, the Timorese people voted for independence, which was followed by retaliation from the Indonesian military and Timorese militias that destroyed most of the countrys infrastructure, including health facilities. After three years as a UN protectorate, TimorLeste became an independent nation in May 2002. The country has been faced with the daunting task of rebuilding an entire infrastructure, including the health system. In Timor-Leste, the Ministry of Health (MoH) came into being in September 2001 with the following objectives: Reduce levels of maternal and infant mortality Reduce the incidence of illness and death due to preventable communicable and noncommunicable diseases, including HIV/AIDS Improve the nutritional status of mothers and children Improve reproductive health in Timor-Leste Ensure that all people have access to health services Ensure the delivery of a minimum healthcare package at all levels of services Collaborate with all stakeholders in the health sector to achieve national goals for health Ensure that sufficient and adequate training for health professionals is undertaken to meet national requirements Regulate the employment of all health professionals to ensure minimum standards of professional practice Increase womans access, both to health information and to quality health services Increase the availability of mental and dental heath services.
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The Ministry of Health of Timor-Leste realising the socio economic determinants of the health status has assumed from its inception a vision that implies a broad definition of health - Healthy Timor-Leste people in a healthy Timor-Leste. With this vision, the Ministry of Health envisages a community enjoying optimal level of health that will allow them to develop to their full potential in a healthy environment. The fact that the vision implies a healthy Timor-Leste means that sectors other than health should contribute to reach the peak that this vision foresees (i.e., a multi-sectoral approach to health). The mission of the Ministry of Health strives to ensure the availability, accessibility, and affordability of health services to all the people of Timor-Leste; to regulate the health sector; and to promote community and stakeholders participation (including those from other sectors). Ministry of Health aims to provide quality healthcare to the people by establishing and developing a cost-effective and need based health system which will specially address the health issues and problems of women, children, and other vulnerable groups, particularly the poor, and the approach is based entirely on peoples participation.
Servisu Integrado Saude Communitaire (SISCa)

In Timor-Leste, about three-fourth of the population live in rural areas with little access to a health facility. In order to take primary health services and health promotion information to the community who otherwise have little contact with the formal health system, the Timorese Ministry of Health has initiated a program in March 2008 called Servisu Integrado Saude Communitaire (SISCa), which means Integrated Health Services at the Community Level in the local Tetum language. A community-based initiative to enable primary health
services to reach the village level.
SISCa (Integrated Community Health Service) seeks to create more opportunities for reaching local communities, particularly through the use of local health volunteers. Under the SISCa model, the MoH expects development partners to provide technical support to the districts and sub-districts that make up the public health system of the country.
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Implementation of SISCa requires that health staff, in partnership with members of village councils, chiefs of villages, chiefs of hamlets, youth organizations, women groups, and others leaders, work to mobilize resources and provide health care to the community. Health volunteers are chosen directly from the community and are trained to provide health assistance, together with the health staff.
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The programme is novel as it is an effort to connect the government health system with rural communities, and to give communities responsibility for assuring that care is available and accessible. The programme has been built up on the little available resources and aims to improve the health status of the community through small interventions. The concept of SISCa aims at a sustainable health programme through public private partnership and partnerships between the health sector and other sectors to create a healthier environment by solving health and related problems within the community through community participation. The keywords for SISCa are: the Basic Service Package, Good and Healthy Behaviors and community participation.
Objectives
To improve the health status of the community through small interventions as under: Allow easy and nearby access of integrated health assistance based on Basic Service Package to the community level. Improve population data collection, children, pregnant mothers in order to facilitate them to receive proper health intervention. Expand health promotion and education efforts on how to change behaviors. Increase the community members participation in the areas of community health.
The concept of SISCa aims at a sustainable health programme through public private partnership and partnerships between the health sector and other sectors to create a healthier environment by solving health and related problems within the community through community participation.
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Role of stakeholders
The principle of SISCa shows that it belongs to the community itself. Hence, community leaders (suco chiefs, Aldeia chief and members of suco councils) such as sub-district council members and chiefs, hamlet chiefs, together with the youth organizations, churches, womens networks and other community leaders take the lead and organize themselves to mobilize available resources in the community and work together with health sector and the community to provide health assistance that is necessary. SISCa is formed by communities as a place for all community members to gather in order to have access to basic integrated health activities. Communities themselves, through suco and aldeia chiefs, with their own initiative mobilize pregnant women, children under five, youth and the elderly to get access to health services at the village level using available resources while waiting for the arrival of health workers who come from the Community Health Center to provide health assistance. With initiatives from SISCa, health workers coming from much higher structure come together and meet with the community from the field level in a Post that is intended for SISCa. The health staff at the community health centre (CHC) and Health Post identifies, make diagnosis and provides treatment and counseling for common diseases at community level and to high risk pregnant women visiting SISCa. They orient and provide motivation to volunteers and manage all SISCa activities. Volunteers are selected from the communities and registered with the Ministry of Health. The volunteers are trained by ministry of health and work together with health workers to provide health services such as distributing ORS, vitamin A, iron tablets, DOTs treatment and first aid. The volunteers are not allowed to make diagnosis for diseases and give treatment on their own. The volunteers mobilize the community along with the suco chiefs to participate in SISCa, they act as a social agent helping the community to change their beliefs, behaviours and day to day practices so that the families and community members can improve their health status. The volunteers also work as health educators teaching families and community members to improve their health status and prevent communicable diseases, especially those that are endemic.
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The suco chiefs play an important role in planning and implementation of SISCa. The suco chief together with suco councils, aldeia chiefs, women and youth groups, church officials, elderly speakers decide the SISCa date, venue and determine people responsible for community mobilization. The suco chief dominates all aspects in his / her area that can help support SISCa. This includes population data and all potential human, natural and other resources available to support the implementation of SISCa. Suco councils support suco chief through new initiatives, contributing ideas and providing solutions to problems that may arise in the implementation of SISCa. The aldeia chiefs along with volunteers mobilize the beneficiaries (target group /community) and submit all the health related data from their aldeia to suco chief every month. The wives of suco chiefs and aldeia chiefs also have an important role in mobilizing the community and in motivating pregnant mothers to visit the SISCa post to get health assistance. They also initiate, motivate and contribute to some of the SISCa activities such as: participate in cooking demonstrations, games, singing and other activities. Ministry of health allocates some funds to support the implementation and execution of SISCa. Utilization of funds is directed by the community health centre. Ministry of health also supports the programme through training the volunteers and deputing health workers and doctors for SISCa activities and providing technical guidance in form of formulating implementation guidelines , designing and providing formats for data collection.
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Methodology
SISCa events revolve around a Six Table Assistance System consisting of 1) population registration, 2) nutrition assistance, 3) maternal and child health, 4) personal hygiene and sanitation, 5) health care services, and 6) health education. Families come to the event and have the chance to visit these six stations and get health services in a familiar setting. Table 1-Registering Basic Data: Registry is the first part in SISCas activities. During registration at table 1 the volunteer
Health workers coming from much higher structure come together and meet with the community from the field level in a Post that is intended for SISCa
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registers beneficiaries based on the target group. The children under five years are registered in registration book for children, later at table 2 their height and weight are also recorded in the book. This helps volunteers and health workers to assess the growth and health status of children. Based on childs condition, the health workers can provide timely health assistance. The registration book for pregnant mothers is used to register pregnant women who come for check up at SISCa. This registration book serves as a record for health parameters of the pregnant woman, also for all the health services given to her and what needs to be given. Volunteers register all other community members or patients who come for checkups or undergo treatment in registration book for patient. The book serves as a reference to know the type of diseases which is common in the suco or aldeia so that the volunteers and health workers are able to control it with maximal intervention and treatment. After the registration the beneficiaries are given a slip of paper with their names written in bold, they are sent to the next table (table 2) / booth 2. Later, after the SISCa activity is over, based on the data from registration books, volunteers together with health workers create a health map of every suco that has a SISCa. The information of the beneficiaries such as pregnant women, high risk pregnant women, children under five, cases of tuberculosis etc. The map serves as a guide for volunteers and health workers to know the actual situation of the patients and the general situation of the suco to facilitate health workers and volunteers to visit houses and provide health assistance and health education at the same time. The suco chiefs, aldeia and volunteers are instructed by the health workers to collect data in the forms prepared by the health workers. The basic data on total population, population distribution- under five years & elderly, pregnant and disabled from each suco and aldeia is collected two weeks prior to the SISCa activity. This data is submitted by the suco/ aldeia chief to the person responsible for registration when implementing SISCa to
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facilitate and confirm the collected data with the number of people visiting SISCa. Table 2-Nutrition Assistance In the second Table in SISCa, nutrition activities are carried. The pregnant women and children under five are weighed, measured and the data is noted in the registration slip provided at table 1.The purpose is to monitor the growth of children, pregnant women and identify cases of malnutrition. Table 3-Health Assistance for pregnant mothers and children Activities in Table 3 focus on maternal and child health. The volunteers complete the LISIO (registration book) based on weighing and measuring results. The childs condition and growth chart is then explained to the parents and condition of pregnant women to their husbands by the volunteers. If the growth chart classifies the child as malnourished or there is indication of poor health, the child is referred to table 5 for diagnosis and treatment. The trained health workers in Table 3 also provide antenatal care to pregnant women, post natal care, family planning methods & counseling, treatment to sick children under five according to IMCI guidelines, immunization to children and pregnant women. The patients that cannot be treated by health workers during SISCa are referred or sent to the nearest community health centre or hospital immediately. Table 4-Personal Hygiene and Sanitation Table 4 focuses on environmental health. Volunteers together with official from sanitation department provide information to the patients about personal hygiene like hand washing, bathing, cutting nails etc; sanitation to keep surroundings clean, waste disposal and on improving sanitary condition within the house.
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The health workers and volunteers visit the identified houses along with suco / aldeia chiefs to inspect the condition and give information about hygiene and environmental health. Table 5-Health Assistance The health workers in Table 5 provide treatment based on the diagnosis to the patients. Apart from treatment for simple diseases, the services for diagnosis and treatment of tuberculosis, malaria and worms are also provided in Table 5. Assistance for immunization for children and pregnant women, distribution of vitamin A, deworming tablets, consultations and simple treatments are provided by health workers and curative treatments are provided by doctors. Table 6-Health promotion and Education The volunteers and health workers in Table 6, offer health education through participatory learning methods. The objective is to bring about change in the attitudes, behavior and practices of the community to achieve optimum level of health. Glimpses of Innovations in Primary Health Care in South-East Asia Apart from health promotion and education activities at table 6 there are other activities such as cooking demonstrations using local foods, screening films on health issues, games, music, simulation and focused group discussion focusing on health related issues. A family health promoter (community health worker) then gives a short reminder of the key messages and conducts a question and answer session. The flow of activities for 6 Table Assistance System 2 Nutrition Assistance
1 Registration
3 Assistance for pregnant women and children 4 Hygiene and sanitation
6 Health education
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5 Health Assistance
Key Strategies
SISCa or Integrated Community Health Services stands on the principle of From, With and To the Community, which signifies that it is the community who would help conduct the activity, mobilize people; together with all health workers to work side by side to give assistance, protect and improve the state of community health in the country. The programme provides assistance in the areas of health promotion, prevention of diseases, treatment for sickness and rehabilitation as well as health interventions such as combating against infectious diseases, family planning, nutrition, maternal and child health and environmental health through community participation The programme covers all the sub-districts (sucos) in all the 13 districts in the country targeting general community, infants, children under five years of age, pregnant mothers, adolescents/reproductive age group, elderly and disabled irrespective of the gender, religion, social and economic status. Community members and local leaders in each suco select one location that is designated for SISCa to receive health care assistance. Post for SISCa are located at any place such
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SISCa or Integrated Community Health Services stands on the principle of From, With and To the Community
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as the village community center, hamlet community center, community members homes, schools, churches or any place other than near the community health center and/or health post to fulfill the objectives of SISCa services of improving access to health services at the suco level. The location for SISCa is established based on community consensus, so that everyone can have an equal and easy access. Community members that live closer to SISCa posts in neighboring sucos than their own, are encouraged to frequent whatever SISCa location is the most convenient. SISCa activities are carried out once a month at SISCa posts to ensure sustainability. Head of Community Health Centers, Suco Administration, Aldeia and Suco Councils guarantee the continuation of SISCa activities. The activities at SISCa last for a minimum of four hours, to ensure that communities will have time and the opportunity to participate. The schedule of SISCa is decided together amongst community members. Scheme of Integrated Health Assistance in SISCa based on target groups Glimpses of Innovations in Primary Health Care in South-East Asia
General Community Children under five Pregnant Women
Health Assistance
Weighing Fill out LISIO Personal Hygiene Health Assistance
Registration
Counseling
Finish
Weighing Health Assistance
Highlights
The Ministry of Health has designed and implemented a number of health promotion and health education interventions aimed at improving indicators in maternal and child health, nutrition, family planning, and infectious diseases. The design and implementation of BCC strategies represents a qualitative leap as the
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design process has shifted from a focus on the development of communication products and materials, which until now characterized health communication activities, to a more strategic approach that draws upon behavior change theories, existing evidence, and data from formative assessments. Integration of Community-based Management of Acute Malnutrition (CMAM) into health system (from lowest level SISCa where the identification takes place to highest level of health system referral hospital) has been piloted in one (1) district in 2008.
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Challenges
Assessment of weight-for-age is problematic as it requires knowledge of the actual age and ability to calculate the Weight-for-Age Index. This level of complexity is difficult for some health staff and volunteers. Furthermore it is time consuming, distracts them from other duties, and focuses on growth monitoring which is ineffective against chronic undernutrition. Limited access to health services is the significant obstacle to reducing maternal and infant mortality and improving maternal and child malnutrition. Data collection and quality of data are weak, and local authorities and community health volunteers do not yet coordinate and share data successfully. Substantial resources are needed to establish the health infrastructure, especially in remote areas. Considerable resources are also needed for development of human resources. There is a scarcity of human resources for health including health managers, doctors, nurses, midwives and paramedical staff. Further, rural health staff members are often away for training and are unable to attend SISCa. This places a heavy burden on the Community Health Volunteers who are under compensated and undertrained for the services that they are expected to provide. More local health personnel are needed to provide quality service.
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Linking the community to health services through local health workers has been highly effective in improving healthcare coverage
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Lack of trained human resources in the public health system is a major constraint in reducing health problems including maternal and underfive mortalities, in preventing and controlling communicable and non communicable diseases and risk factors and in increasing awareness of health problems, particularly among women, adolescents and young people. Essential drugs and adequate equipment are short in health facilities. No special health services address the adolescents special needs, where there are a significant percentage of young people. The capacity of laboratories is limited, both at the peripheral and central levels. There are gaps in community awareness of services available. There is low participation in some districts. The communities are not always formally educated, so thats why some understand the programme and some dont. Some communities do not take the ownership. SISCa program has no infrastructure investment. SISCa post consists only of temporary space in a village home or more commonly outside (e.g. under a tree, in a field). There is no trained cadre of community volunteers for Family Planning The monitoring and evaluation of the programme is weak In some districts there is lack of coordinated planning
Outcomes
The SISCa covers all the districts. Each of Timor Lestes 442 villages has a SISCa post. There has been an increase in rural access to health services. Linking the community to health services through local health workers has been highly effective in improving healthcare coverage. There has been a greater access and delivery of quality maternal and child health care.
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Learnings
The SISCa programme has paved way for the developing countries with higher percentage of population residing in rural areas and where taking primary health care to the people is a challenge. It has proved that the access to and utilization of essential primary health care services can be increased through active community participation. The programme also demonstrates the significance of addressing the determinants of health to improve the overall health status. SISCas integrated approach of service delivery through decentralized planning and management involving all relevant actors in the community with technical back-up from MoH staff has demonstrated that the community can plan and manage health services for the community. The evidences also suggest that even a community with low literacy levels, little resources if trained and encouraged can play an important role in transforming the health scenario of the country. It also suggests that a programme is sustainable only when the community takes the ownership and participates actively.
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Bibliography
Country Team Action Plan, Timor Leste. (www.esdproj.org/.../Timor_Leste_Presentation_Reconvening_ Bangkok_2010_nopic.ppt? accessed on13/7/2010) Strengthen Communities in the area of Health through SISCa Servisu Integradu da Sade Communitria (Integrated Community Health Services). Ministry of Health Democratic Republic of Timor Leste. (www.basics.org/documents/13-SISCa-Guidelines.pdf accessed on 13/7/2010) The Timor Leste NGO Forum. Statement by NGOs Timor-Leste Development Partners Meeting. (http://www.laohamutuk.org/econ/10TLDPM/FongtilEn.pdf accessed on 14/7/2010) WHO Country Cooperation Strategy 2009-2013 Timor Leste. (http://www.tls.searo.who.int/EN/Section3_101. htm accessed on 14/7/2010)
SISCas integrated approach of service delivery through decentralized planning and management involving all relevant actors in the community with technical back-up from MoH staff has demonstrated that the community can plan and manage health services for the community
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The South-East Asia region is home to nearly a quarter of the worlds population and accounts for nearly 30% of the global disease burden. Governments in the region are making concerted efforts for reducing the disease burden and improving the health of their people and the countries have adopted the primary health care approach for health development. This document gives a brief overview of some of the experiences in the delivery of primary health care in the Member States of the WHO South-East Asia region. The innovative and coordinated efforts of government, civil society and communities have made a significant impact. The document showcases some of the important projects, programmes and groundbreaking innovations in Primary Health Care currently being implemented in Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor Leste. It is an attempt to share successful models and practices from various SouthEast Asian settings with policy makers, international agencies, researchers, social activists, programme personnel and civil society for wider learning, experience sharing and forging the way ahead.
ISBN 978-92-9022-386-3
World Health Organization World Health House Mahatma Gandhi Marg New Delhi 110002, India Website: www.searo.who.int/hsd

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Glimpses of Innovations in Primary Health Care in South-East Asia

Foreword Introduction Bangladesh

Integrating Traditional Medicine in Primary Health Care

Universal Free Medical Care System

ASHA - Accredited Social Health Activist Project Arunoday 72

Village Midwives Programme Health Insurance for the Poor

Healthy Villingili Island Programme 104

Healthy Mother Project

Female Community Health Volunteers

Sri Lanka Thailand

National Health Development Network 134

Universal Coverage Scheme Strategic Route Map (SRM)

SISCa (Integrated Community Health Services)

Glimpses of Innovations in Primary Health Care in South-East Asia

Demand Side Financing for Maternal Health : (DSF)

Glimpses of Innovations in Primary Health Care in South-East Asia

Demand Side Financing for Maternal Health : (DSF)

Glimpses of Innovations in Primary Health Care in South-East Asia

Lack of trained Medical Officers (Gyn-Obs. & Anaesthesia)

Empowerment of Women and Decision Making gains Foothold

Glimpses of Innovations in Primary Health Care in South-East Asia

Bangladesh Community Health Clinics

Glimpses of Innovations in Primary Health Care in South-East Asia

Community Health Clinics

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South East Asia South-East

Bhutan Integrating Traditional Medicine in Primary Health Care

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South East Asia South-East

Democratic Peoples Republic of Korea

Universal Free Medical Care System

Universal Free Medical Care System

Household (HH) Doctor System

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South-East Asia

2000 81 91.5 98.3 81.5

2006 82.2 96.9 99.8 99.8

2008 91.7 99.2 99.3 96.9

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South East Asia South-East

India ASHA - Accredited Social Health Activist

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South-East Asia

Comparing the progress in VHAI-managed PHCs & CHC

No. of Specialists providing services in Deomali CHC

Summary Statistics: Indicators and achievements of VHAI-managed PHCs:

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South East Asia South-East

Village Midwives Programme

Glimpses of Innovations in Primary Health Care in South-East Asia

Health Insurance for the Poor

Glimpses of Innovations in Primary Health Care in South-East Asia

Health Insurance for the Poor the Askeskin/Jamkesmas Initiative

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South-East Asia

Glimpses of Innovations in Primary Health Care in South-East Asia

Outcomes and Highlights

Glimpses of Innovations in Primary Health Care in South-East Asia