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Towards Health Development in the City of Yogyakarta: The Improvement of a Healthy Behavior and a Clean Enviroment towards the Prevention of Dengue Hemorrhage Fever Name organisation Department of Medical Education, Gadjah Mada Medical School City Yogyakarta Country INDONESIA Programme, project, innovation objectives 1. PROGRAM IMPLEMENTATION INDICATORS 1.1 Relevance of Health Services Delivered 1.1.1 Health promotion in community and analysis of operational organization This TUFH project emphasizes on integrated services that is based on people’s needs. Therefore to meet the criterion, we held several focused group discussions (FGD) with reference populations to obtain detailed information on people’s expectation in a program concerning the eradication of dengue hemorrhagic fever (DHF). In this section, we will describe data that had been obtained to hold relevance interventions subsequently. These FGD were held from January to February 2002 in three districts (Mergangsan, Danurejan, and Kraton) of Yogyakarta. From the three districts, we held 2 FGDs in each district. The purpose of having two focused group discussions is to gain opinions, observe level of knowledge on DHF and its prevention, and the community’s expectations on DHF eradication, from different subpopulations; the females with the usual occupation as housewives and the working male population. We had expected some differences in the point of views in the three topics discussed earlier (opinion, knowledge, and expectation). Result of the focused group discussions Level of knowledge, problems, and opinions Based on the FGDs performed in the three districts, every attending community member claimed that they had heard on what DHF is and how it is transmitted. The symptoms of DHF were familiar as well to the populations (high fever, petechiae, epistaxis, and blood vomiting). Some problems were discovered from the discussions. One of them is the length of time needed by the doctor to confirm the diagnosis of DHF. There was also a misdiagnosed typhoid fever for DHF. The community also needs more information on early detection of DHF. Participants of the FGDs stated that they know how to prevent DHF by minimizing the number of potential water collections where the Aedes aegypti mosquito can lay their egg on, insecticide fogging, and spreading soluble larvicide in water collections for daily needs. They knew these interventions from the drugstore, community health centre (CHC), and from public information program on regular public meeting (on village or neighborhood levels). This public information program usually misses one component of the community, the elderly that can not come to public program due to their physical limitations. At present, the frequency of public information program especially from the CHC has decreased. In one district, the prevention means of DHF (as stated previously) are not done by a subgroup of population, the low economic class, even when the health authorities had told them to do the means to prevent DHF. Actually, these prevention means are well known by the community theoretically, yet practically not well done. They need some kind of regular trigger for themselves to do the preventive means. The reference population knows that insecticide fogging is no longer effective. Indeed, the soluble larvicide they used to get for free from the CHC is now (in some areas) commercial. The sellers usually are from private pest control department. The community also doubt the actual content of the larvicide; they suspect that the larvicide sold were fake. To this point, dissemination of self-provided meetings and programs of preventing DHF by the community is by putting announcement on public message boards and by dissemination by some self-provided volunteers that deliver the messages from house to house. The female populations hold a major role in disseminating this kind of information. Proposed interventions by the community 1. Various attractive ways of public information program on DHF management by health authorities, women associations (PKK), and medical students. 2. Direct acts, such as mass sanitation improvement program, on-the-spot sanitation observation by authorized officer, and community services program by the students. 3. Provision of posters, illustrations, calendars, or any pamphlets for reminding on how to deal with DHF. 4. Supporting programs for the prevention of DHF, e.g. inter-villages sanitation contest, free larvicide distribution, regular house visits by health officers, mass health check-up, and collaboration with medical school. People’s expectations 1. Government and health authorities should be more actively involve in the prevention of DHF. 2. No more long bureaucracy needed in reporting DHF case or DHF outbreak. 3. Since there must be cases of DHF ever year, related institutions should pay more attention to DHF prevention programs. 4. Any public information program on DHF should be rescheduled to fit the people’s activities schedules. 5. If needed, a health crises centre will be very useful. Subsequent inter-stakeholders workshop results Following the FGDs, an inter-stakeholders workshop was held in February 7th, 2002. The workshop was attended by representatives of community, local government, academic (Gadjah Mada Medical School), and non-governmental organization (The Coalition for Healthy Indonesia). The stakeholders where divided into two groups, the first group consisting of the districts of Kraton and Mergangsan, and the second group are the representatives of Danurejan. The two groups during the workshop have discussed various topics on the anticipation of DHF, such as the prevention, the repression, and the curative measures for DHF. The first group discussed: 1. Prevention - The 3M method throughout the neighborhood - Mass counseling (formal and informal guidance) - Mass neighborhood cleaning programs 2. Repression - Formation of DHF workgroups (public & public figures) at city, district, and village levels - Fund raising and cross-subsidizing for continuous measures on DHF eradication 3. Curative - Primary care: early diagnosis, First aid - Referrals - Patient referrals to private and public hospital - Optimizing private medical practices The second group discussed: 1. The more effective and accurate mass counseling 2. Fund raising to reinforce anti-DHF measures, e.g. fogging 3. The making of motion picture on how the DHF happens in human body 4. Formation of a supervising team on district level 5. Possibility to collaborate with Rotary Club Yogyakarta in DHF eradication The final conclusions of the workshop are: 1. Both groups agree that DHF has become a very troublesome and irritating disease in community. 2. Both groups agreed upon total dedication and commitment towards the eradication of DHF. 3. Both groups agree to increase their knowledge and awareness towards DHF. 4. Both groups agreed to cooperate and collaborate with the various stakeholders involved in this project. 5. Both groups agreed that action and intervention must be appropriate for the inhabitants of each community. 1. 1. 2 The High Risk Communities The target communities of Mergangsan, Danurejan, and Kraton are considered to be high-risk DHF communities due to various factors. One factor is due to the dense living space since these three districts are considered to the oldest areas in the city of Yogyakarta. This means, old buildings and houses are established close together with new buildings and houses, making this area a potential breeding ground for the Aedes Aegypti mosquito, which is the vector for DHF. Also, the population in these three communities is the highest in Yogyakarta. According to the latest census, the population of the Kraton District is about 29,037 people, the Mergangsan District 40,947 people, and the Danurejan District 30,159 people; hence the total reference population from the targeted areas is about 100,143 people. With a large population, the risk of social problems increases and a major social problem is littering, pollution, and the lack of environmental responsibility. Due to this, the amount of Aedes Aegypti mosquitoes has increased during the past few years, followed with the increase of DHF occurrences. So these three districts were specifically selected for this project because of the high occurrences and outbreaks of DHF, which is still a major health concern in Yogyakarta, as well as in Indonesia. 1.2 Quality of Health Service Delivered Quality of health promotion activities As taken from the TUFH working paper, quality can be viewed from the angle of the users and service providers. We try to go in the corridor of quality aspect of this project by addressing all possible interventions to the needs of the community. Since our program specifically addresses the eradication of DHF, the most important intervention that will hopefully effective is by preventing through a continuous effort of maintaining healthy and clean behavior of the reference population. We are to maintain this alteration in healthy life style by keeping in touch with the local community, health care providers, and local governments by doing continuous observation and process evaluation throughout the length of this project. Hopefully by collaboration with other parties such as Rotary Club we will be able to perform similar measures for a longer time and try to sustain the measures by expanding the possibility of wider cooperation amongst the stakeholders of community health. Since proposed interventions gained from the first workshop will be done, yet not performed until this report is made, only preliminary proposed interventions as mentioned earlier are reported. 1.3 Equity of Health Services Delivered Equity within the Community Project This project was designed to promote equity through the participation of the various stakeholders involved. The five points of the pentagon are involved as much as possible. These points include the local health center (health managers), the local government (provincial, municipal, and district), health professionals (the local Indonesian Doctors' Association and the Indonesian Nursing Association), Gadjah Mada Medical School (educational institution), and most importantly the inhabitants of the Kraton, Mergangsan, and Danurejan communities. During the focused groups’ discussions and the workshop, all of the stakeholders were invited to participate. Especially for the representatives of the three communities, they were invited without discrimination of gender, social status, economic/financial status, and educational background. Since the beginning of the project, equity between the five stakeholders (Gadjah Mada Medical School, Local Governments, Local Health Centers, Health Professionals, and the Community) has been encouraged and promoted. Especially, during the following implementation of the project, we expect to cover all the elements of the pentagon in the districts of Kraton, Mergangsan, and Danurejan without prejudice. Amazingly, from the three communities a proactive reaction came from the neighborhood wives society (PKK), they demanded a leading role in future campaigns for the eradication of DHF in their respective communities. Since the population of female inhabitants surpasses the male population (3 : 1) in all three districts, a majority of the campaigns will be targeted towards the female population. Also, during the preliminary meetings it showed that the female populations were more interested in health prevention and intervention. The preliminary meetings also showed that almost every social group from the three targeted districts were represented. Each group showed much enthusiasm in implementing this project, especially in holding anti-DHF campaigns such as the 5M Campaign. Equity within the High Risk Approach The target high-risk population are primary the young, elderly, and the underprivileged of the three communities. When implementing the project towards the high-risk population, it is important to concentrate especially on this group without discrimination. This group has been identified to be a liability, so clearly inequity for this group must be avoided. As stated above, the special attention areas are divided into two categories. The first are public buildings and facilities and the second are areas, which are inhabited by large groups of people with low educational levels and income. One of the main and important focuses for equity is towards the second category of the special attention areas. These underprivileged citizens have little knowledge and information towards Dengue Hemorrhage Fever. It is usual that they do not care enough on health promotion and disease intervention, until they themselves suffer from a disease. This becomes a challenge for health professionals because once they suffer from a disease the therapy becomes difficult due to the lack of finance, especially in purchasing drugs and medication. Therefore, during campaigns, these areas are likely to be a strong focus for health promotion and intervention. To further educate these people, Gadjah Mada Medical School will plan on holding workshops or meetings and distribute publication on the matter of disease prevention by having a healthy behavior. The Local Health Center will also give counseling and guidance on this topic. The first category will also be focused on, but the health promotion and intervention programs will be emphasized on the physical structure of these public buildings and facilities. These buildings tend to be dark, humid, and dirty, hence they are very attractive towards the Aedes aegypti mosquito. The 5M campaigns will be a suitable program for this category. 1.4 Cost-effectiveness Evaluation This TUFH project in Yogyakarta gain its cost-effectiveness by addressing only to what is needed by the community and by trying to elaborate as many stakeholders potentialities as possible to achieve the optimal results from the limited financial supports of this project. According to local governments’ information, the Rotary Foundation through Rotary Club in Yogyakarta is also doing similar project in eradicating DHF through mass action in eradication of larvae of Aedes aegypti. Since they have similar goals with the TUFH project and their project is well funded (about US$ 220.000), we both decided to collaborate in a way that TUFH project personnel are to observe the Rotary’s project implementation while helping in guiding the people in implementing the Rotary’s objectives. Meanwhile, the TUFH projects collaborate with local government and health care providers in increasing the public knowledge in early detection of DHF. The Ministry of Health should fund this. 3. Partnership Indicators The indicators that were selected to determine the quality of partnerships are: 1the types and model of collaboration between stakeholders, 2the management efforts to promote and sustain collaboration, and 3the prospect of sustainability. 3.1 Collaboration between Stakeholders Assurance on the quality of collaboration between stakeholders can be seen in their attendance during the informal information exchange meetings. The representatives from each stakeholder show enthusiasm and an eagerness to cooperate for the common cause of eradication of DHF in the districts of Kraton, Mergangsan, and Danurejan. The local provincial government (legislative and executive) also shows a strong eagerness to cooperate; they are willing to formally implement the results of each meeting and to allocate funding to sustain this project continuously. The joining of this project with their major current project can see the support from the local government: Yogyakarta Healthy 2005. The basic objective of this project is to eradicate major and troublesome diseases, such as DHF, TBC, and malaria, from the province of Yogyakarta. The expected elimination for such diseases is the year 2005. Also, in recent developments several domestic and international non-government organizations (NGO’s) have shown interest in this project. Two major NGO’s now participating in this project is the Indonesian Rotary Club and the Coalition of a Healthy Yogyakarta (CHY). The Indonesian Rotary Club this year has also started to establish a program to eradicate DHF from various cities in Indonesia, especially in Yogyakarta. Rather than acting independently, they find that cooperating and integrating their program with the TUFH project to be effective and efficient. They have also showed great interest in becoming a significant stakeholder in the effort to eradicate DHF. The Coalition of a Healthy Yogyakarta (CHY) is an alliance of various NGO’s dedicated in making the city of Yogyakarta and its inhabitants healthier, both physically and mentally. When approached to become a stakeholder in this project, they where very enthusiastic and have become a supportive stakeholder. The communities in the three target districts also have shown an eagerness to cooperate and aid each and every stakeholder involved in the project. As an example, when Gadjah Mada Medical School requests information on the cleanliness habits pattern of the population in the three target districts, they where more than happy to search and provide it. 3. 2 The Management Efforts to Promote and Sustain Collaboration Gadjah Mada Medical School has arranged routine meetings between the stakeholders. During these meetings each stakeholder has an opportunity to discuss with other stakeholders their opinions on the implementation of the DHF eradication program. Also in these meetings stakeholders are given a chance to coordinate each and every step of the program with other stakeholders to ensure the successful implementation of the program. One of the most important result of the discussions during the meetings where the formation of a Task Force Group or POKJANAL, with the responsibilities of promoting cleanliness and DHF knowledge in each respective district, thus preventing DHF infection. A workshop was held on the early February 2002, to re-coordinate the stakeholders. The amount of participants in this workshop where two times more than the routine meetings, thus ensuring a more effective transfer of information. With the support of the local government (provincial and municipal) the coordination and the management of the program has become uncomplicated and more effective. The various departments, especially the local health department, under the local government are in continuous contact with the other stakeholders, hopefully ensuring the success of this program. 3.3 The Prospect of Sustainability The various stakeholders have shown an eagerness and willingness to cooperate with one another for the success of this program. This is due to the problem being addressed, which is DHF, which has become a troublesome and annoying disease in Indonesia, especially in Yogyakarta. With the support of major stakeholders, such as, the local government, the Indonesian Rotary Club, and the Coalition of a Healthy Yogyakarta it is expected that this program will have continuing financial and administrative support. Also not to forget the enthusiasm of the targeted communities in eradicating DHF, which has been a very annoying to them. Hopefully, with the support and aid of the various stakeholders this program to eradicate DHF in Yogyakarta, epecially in the districts of Kraton, Mergangsan, and Danurejan, will succeed. 4. Dissemination To this point, we have experienced an incredible amount of support from the various stakeholders, especially the community. The stakeholders currently cooperating with us are the Local Government (Provincial, Municipal, Neighborhood/ Community), Non-Government Organizations (The Rotary Club, The Coalition for a Healthy Yogyakarta), Professional Oganizations (The Indonesian Doctors Association/ IDI, The Indonesian Nurse’s Association), the Local Community Health Centers in the three-targeted districts, and most importantly the community of the targeted districts. Gadjah Mada Medical School has become a facilitator and coordinator for the various stakeholders in this project. The stakeholders, especially the community, have taken a proactive approach in eradicating DHF in the targeted districts. There will be intervention from the medical school, but the ideas of intervention come directly from the community and the other stakeholders. Up to now, the pattern of WHO’s Pentagon is falling into place in this project, hopefully with the success of this project the possibilities for the eradication of other health problems are endless. Also, if this project is successful it can be used as an example for a national health campaign project of various health problems, not just DHF. Funding sources There are many measures that can be taken to prevent DHF. One of them is by eradicating the larvae of Aedes aegypti. This measure is now also being performed by the community and is funded by the Rotary Foundation. In accordance with the TUFH project, we have reached an agreement to cooperate. The TUFH project team acts as a controller in the three districts of the continuity and consistency of the program Rotary funded. All funding are derived from the foundation and since we do not allocating any budget on this intervention whilst still be able to involve in as a controller, this act should meet the challenging value of cost-effectiveness. Other sources of funding are also going to be optimized by the communities themselves. They are willing to do that as long as the continuity of the DHF eradication program is maintained. Stakeholders 1 STAKEHOLDERS INVOLVEMENT INDICATORS Active Participation At first, Gadjah Mada Medical School acted more a coordinator stakeholder than a partner in the beginning of this project. As the project progresses, local government begin to understand how important it is to optimize the already available sources and to elaborate them synchronously in order to minimize the incidence of DHF. The local government, at least in one district (Danurejan) has the initiative in inviting us to a health volunteers meeting on larvae eradication in order to let us know more closely the health volunteers and the foundation that funded the larvae eradication project, Rotary Foundation. In the meeting, we also had an opportunity to study how the local health center as a health manager performs one of its activities in health promotion/disease prevention. The communities of all sample populations show their enthusiasm in preventing DHF by generously contribute their opinion and ideas on how we should altogether act against this community health problem. Many of them even willing to leave their jobs at times when we invited them to a focused group discussions. This situation gives a good prospective on the upcoming intervention by GMMS based on public needs. Last name Sastrowijoto First name Soenarto Title Prof. Affiliation Faculty of Medicine Gadjah Mada University Contact information E-mail address guefkugm@hotmail.com Telephone 62-274-560300 Fax number 62-274-561196 PO box or address SPP Building, Jl Farmako, Seki Zipcode 55284 City Yogyakarta Country INDONESIA