Sejangkung Community health center (Puskesmas Sejangkung)
Health Office sambas Regency

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Sejangkung Sub-district is one of 19 sub-districts in Sambas District. Since 2005, Sejangkung has been experiencing significant problems with malnutrition. Children under the age of five who are malnourished can be found in almost all of the sub-district’s 12 villages, and many are particularly suffering from protein-energy malnutrition (PEM), as shown in the table below: Table: Prevalence of residents with protein-energy malnutrition, Sambas District, 2010 No Sub-District Protein Deficiency 1 Sejangkung 38.38 2 Sajad 34.54 3 Sajingan Besar 34.19 … 18 Semparuk 14.07 19 Pemangkat 13.85 This data shows that Sejangkung is the sub-district with the highest rates of PEM of all 19 sub-districts in Sambas. In 2011, there were 22 recorded cases of malnutrition in Sejangkung, including one death. The issue has been a problem for a number of years, however, as far back as 2005, when the Coordinating Minister for Social Welfare, Dr. Alwi Shihab, visited Sejangkung to learn about malnutrition. Dr. Alwi visited the village with the worst levels of malnutrition in Sejangkung, and his visit caused local authorities to realise how bad the problem really was. The socio-economic groups which suffer most from malnutrition are those below the poverty line and those with low levels of health knowledge, especially about proper food preparation and nutritional requirements for children. Sejangkung Community Health Centre has long run a series of nutrition-focused programs for underweight and malnourished children under five. However, assessment of the programs by the Centre itself had led them to realise that the effect of their existing programs was minimal. Activities such as nutritional coaching for parents, regular weigh-ins for children, and hospitalization were ineffective at eradicating malnutrition in Sejangkung. So they began to look for a different solution that would help them overcome the problem at its roots.

B. Strategic Approach

 2. What was the solution?
Sejangkung Sub-district is one of 19 sub-districts in Sambas District. Since 2005, Sejangkung has been experiencing significant problems with malnutrition. Children under the age of five who are malnourished can be found in almost all of the sub-district’s 12 villages, and many are particularly suffering from protein-energy malnutrition (PEM), as shown in the table below: Table: Prevalence of residents with protein-energy malnutrition, Sambas District, 2010 No Sub-District Protein Deficiency 1 Sejangkung 38.38 2 Sajad 34.54 3 Sajingan Besar 34.19 … 18 Semparuk 14.07 19 Pemangkat 13.85 This data shows that Sejangkung is the sub-district with the highest rates of PEM of all 19 sub-districts in Sambas. In 2011, there were 22 recorded cases of malnutrition in Sejangkung, including one death. The issue has been a problem for a number of years, however, as far back as 2005, when the Coordinating Minister for Social Welfare, Dr. Alwi Shihab, visited Sejangkung to learn about malnutrition. Dr. Alwi visited the village with the worst levels of malnutrition in Sejangkung, and his visit caused local authorities to realise how bad the problem really was. The socio-economic groups which suffer most from malnutrition are those below the poverty line and those with low levels of health knowledge, especially about proper food preparation and nutritional requirements for children. Sejangkung Community Health Centre has long run a series of nutrition-focused programs for underweight and malnourished children under five. However, assessment of the programs by the Centre itself had led them to realise that the effect of their existing programs was minimal. Activities such as nutritional coaching for parents, regular weigh-ins for children, and hospitalization were ineffective at eradicating malnutrition in Sejangkung. So they began to look for a different solution that would help them overcome the problem at its roots.

 3. How did the initiative solve the problem and improve people’s lives?
Sejangkung’s initiative began with an examination of existing nutrition programs. The first was a routine coaching event for parents on good nutrition. Carried out by health volunteers, parents were instructed on healthy eating, child health, and healthy lifestyles. However, during assessment, it became apparent that the coaching was not having a significant effect on reducing rates of malnutrition. The case was the same for the Centre’s nutritious food program, which provided additional food for underweight and malnourished children under five. Monitoring indicated that the program was not only expensive to run, the food was actually being eaten by people other than the children it was intended for. Another of the Centre’s existing programs, weighing children at an Integrated Services Post, was also deemed to be ineffective, as not all parents took their toddlers to the post, so many cases of malnutrition went undetected. Outpatient care for toddlers who were malnourished but not displaying clinical symptoms was not effective, either, as the Centre was too far from patients’ houses and the treatment was too expensive. In-patient care at the Sambas District General Hospital was more intensive and brought positive outcomes, but parents often refused to participate because of financial and geographic constraints. Sejangkung Community Health Centre decided to try something new. Focusing on how to cut the problem of malnutrition at its roots, the Centre established a number of Child Nutrition Post where parents and community members can work together to combat children’s nutritional problems. The key activity at the posts is a monthly 10-day activity for parents and others to cook together, eat together, and learn about good nutrition. Healthy, nutritionally-dense food is the centrepiece of the activity. Based on principles of community empowerment and ‘gotong royong’ or mutual help, the post accepts donations of foodstuffs (such as rice, vegetables, fruit, tofu/tempeh, spices, and oil) and once a month invites parents with malnourished children to cook and eat together. The event is thus from, by, and for the community, and has strong support from the village governments and local NGOs. In addition to cooking and eating together, the Child Nutrition Post teach parents and children how to wash their hands properly using soap; how to live healthily and cleanly; how to look after young children; what sort of food is appropriate for different age groups; and how to properly prepare food. Food menus are based on what foodstuffs are easily available locally (based on input from poor families with well-nourished children) and refer to nutrition standards for child growth. Menus are developed on a five-day cycle so that families have many options to choose from. The Child Nutrition Post have dramatically improved child nutrition in Sejangkung. The first two posts were opened in 2013 in the villages of Sulung and Piantus, where prevalence of PEM were 26.92 and 32.33 respectively. After three years of implementing the posts, the prevalence had fallen to 21.28 in Sulung and 16.04 in Piantus. In 2014, posts were opened in Penakalan and Senujuh; by 2016, prevalences of PEM in Penakalan had fallen from 27.78 to 18.03, and in Senujuh from 30.77 to 28.07. In 2015, another post was opened in Setalik, where PEM fell from 28.40 to 20.69 after just one year of implementation. With nine posts in six villages, overall, the prevalence of PEM in Sejangkung District has fallen from 27.60 in 2012 to 20.86 in 2016, and no cases of malnutrition were identified in 2015 or 2016, compared to 11 cases in 2012. This shows a clear positive impact on the children of Sejangkung.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The Child Nutrition Post involve the community in a way that no other nutrition programs have in Sambas District. Generally-speaking, the community is not actively involved and is treated as an ‘object’ to receive information on health and nutrition. Community members are especially not involved in problem identification and problem solving processes, leading to low knowledge and low interest. Sejangkung Community Health Centre, having previously established a community forum to assist the Centre in its work, decided to explore more participatory and empowering nutrition programs, and came up with the idea for the Child Nutrition Post. The posts are: a. Easily and quickly implemented Posts do not require special facilities, and health volunteers come from the community themselves. b. Cheap Posts are cheaper to implement than creating therapeiutic feeding center (TFC). c. Participatory Community members and parents are actively involved in obtaining donations, cooking, and eating. d. Sustainable As the posts empower the community and use community food donations, they can be continued by community members without the support of the Health Centre. e. Locally-based principles Posts are based on the founding Indonesian principles of ‘gotong royong’ (mutual help) and empathy for others. f. Culturally-acceptable Culturally, the posts are acceptable because they use local food traditions.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The initiative was implemented by Sejangkung Community Health Centre after they took part in an event run by Dompet Dhuafa, a social welfare-focused NGO. Dompet Dhuafa’s event trained health volunteers on nutrition and how to run nutrition programs focusing on children. This training inspired the volunteers to establish a nutrition post of their own, and incorporate locally-appropriate solutions into overcoming child malnutrition. By 2016, nine Child Nutrition Post were running on a monthly basis in six of the 12 villages in Sejangkung Sub-District. These six villages were chosen because they were ranked as the worst for child malnutrition in 2012. Each post runs for 10 days per month and the routine child health post is run on the 11th day. 589 malnourished children under the age of five took part in the program over the four years it has run so far (2013-2016), averaging 150 children per year. No cases of malnutrition in children under five have been identified since 2015.
 6. How was the strategy implemented and what resources were mobilized?
The Child Nutrition Post were established in Sejangkung as follows: 1. Sejangkung Community Health Centre staff approached village heads with the proposal to establish a Child Nutrition Post in their village. 2. Sejangkung Community Health Centre staff trained health volunteers for four to six days on how to run the program. 3. Sejangkung Community Health Centre staff gained the commitment of village figures and the community through Village Community Discussion Forums. 4. Sejangkung Community Health Centre staff and health volunteers researched existing good practices to learn what they could replicate in Sejangkung. To begin with, staff visited the homes of local residents with healthy, well-nourished children, to examine eating habits and conduct interviews. They documented this information and used it as the basis of developing the Child Nutrition Post strategy, covering topics such as choosing what to eat, preparing food, cooking food, serving food, and feeding children. The volunteers also incorporated new knowledge about local good practices on cleanliness and health into the strategy. 5. Sejangkung Community Health Centre staff and health volunteers established the first two posts in 2013, one in each of the two villages with the highest rates of child malnutrition. At the posts, held over a 10-day period once a month, volunteers and parents with malnourished children cook and eat together between 10am and 3pm. The posts continue until all children ‘graduate’ and there are no more malnourished children in the village. Food menus are based on what foodstuffs are easily available locally (based on input from poor families with well-nourished children) and refer to nutrition standards for child growth. Menus are developed on a five-day cycle so that families have many options to choose from. 6. Monitoring is conducted during every 10-day Child Nutrition Post session, and focuses on children’s attendance and their ability to finish the food served to them. Children who finish are congratulated. Parents’ food preparation skills are also monitored to ensure they are learning from the post. 7. The Child Nutrition Post are currently being replicated throughout Sejangkung Sub-district. From the original two posts in 2013, two more were added in 2014, and another two in 2015. Seventh, eighth, and ninth posts were established in 2016. The Sambas District Health Office has also shared information on this good practice at the provincial level in 2014 and national level in 2015. The finances required to develop and implement the Child Nutrition Post in Sejangkung are as follows: 1. Sejangkung Community Health Centre operational funds (2013): IDR 29,843,800 (US$2,250) to contribute to food for the posts and to cover transportation costs for health volunteers and Sejangkung Community Health Centre staff. 2. Sejangkung Community Health Centre operational funds (2014): IDR 21,485,000 (US$1,615). 3. Sejangkung Community Health Centre operational funds (2015): IDR 38,956,600 (US$2,928). 4. Sejangkung Community Health Centre operational funds (2016): IDR 31,355,600 (US$2,357). Many donations of rice are provided to the Child Nutrition Post by community members who own rice milling factories or by shop owners. Other community members also frequently donated foodstuffs or money, as do the parents of children enrolled in the program. Villages with Child Nutrition Post contribute to the activities by providing a building that can be used. This is usually a pre-existing multi-use building. Village heads have also allocated money from village budgets to ensure the sustainability of the programs into the future. Donations of vegetable seeds were also given to the posts by the Sub-District’s Centre for Agriculture, Fisheries, Livestock, and Forestry.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
a. Sambas District Health Office (DHO) One of the Sambas DHO’s priority areas for 2012-2016 was speeding up the elimination of malnutrition. The DHO contributed to the Child Nutrition Post through their funding of Sejangkung Community Health Centre, and by taking part in replication efforts. b. Sejangkung Sub-District Office The Sejangkung Sub-District Office facilitated the establishment of the Child Nutrition Post by coordinating between stakeholders. The Office also conducted awareness raising and monitoring through cross-sectoral mini-workshops at the Sub-District level. c. Sejangkung Community Health Centre The Sejangkung Community Health Centre trained and provided health workers and volunteers to run the posts, and financially supported their activities. d. Village Heads Village Heads issued circular letters, allocated funds via the village budget, and permitted the use of the multi-purpose building. e. Community Community members donated foodstuffs to the posts, and members even became health volunteers themselves to assist with the activities, especially in contributing their knowledge of healthy cooking. Community members also contributed kitchen utensils and fuel.

 8. What were the most successful outputs and why was the initiative effective?
1. Decision Letter from the Head of the Sejangkung Sub-District to establish a team to eliminate malnutrition (issued in 2013). 2. Decision Letters from four village heads (the first issued in 2013) to establish Child Nutrition Post in their respective villages. 3. Establishment of nine Child Nutrition Posts in six villages between 2013 and 2016. 4. Monthly programming over 10 days at each post. 5. Tens of health volunteers trained on child nutrition, healthy eating, and healthy lifestyles.

 9. What were the main obstacles encountered and how were they overcome?
a. The timing of Child Nutrition Post events was difficult to make appropriate for all parents of malnourished children. Most work as rice or rubber tree farmers, and generally work 6-11am and 1-4pm. These hours clash with post operating hours, meaning some parents were unable to attend. The problem was overcome by reminding parents that they could delegate another family member to attend instead, such as grandparents. The running hours of the posts were then discussed with all members to ensure the most appropriate timing. b. Funding for the posts was limited, especially during the first year. The sole source of funding in the initial stages was from Sejangkung Community Health Centre operational funds. This was overcome by establishing posts over time, village by village, as funds allowed, and by encouraging villages to contribute funds from their own budgets. c. The third challenge was the low level of understanding of parents about child nutrition. A number of parents with malnourished children did not thoroughly incorporate what they learned at the posts into their daily lives, so the children’s bodyweights did not increase at first. This meant that health workers needed to conduct house visits and frequent monitoring. d. Some parents initially misunderstood the aim of the program, and thought that the food provided at the posts should be the main meal of the children’s days. In actual fact, this nutrition-rich food was intended to be an extra meal. This was overcome through explanation from the health volunteers. e. Finally, some parents/guardians did not make their children eat everything because they became frustrated. This was dealt with through further explanation on the importance of good nutrition, and through adding a competition element – all children who grew to their ideal weight and ‘graduated’ from the program won bath equipment.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
a. Improved child nutrition. Using the ‘Heading towards Health’ card, underweight and malnourished children were weighed and their weight recorded until they reached an ideal weight. Children were deemed to ‘graduate’ from the program when their weight fell in the green section of the card (improved from red or yellow). The Child Nutrition Post have dramatically improved child nutrition in Sejangkung. The first two posts were opened in 2013 in the villages of Sulung and Piantus, where prevalence of PEM were 26.92 and 32.33 respectively. After three years of implementing the posts, the prevalence had fallen to 21.28 in Sulung and 16.04 in Piantus. In 2014, posts were opened in Penakalan and Senujuh; by 2016, rates of PEM in Penakalan had fallen from 27.78 to 18.03, and in Senujuh from 30.77 to 28.07. In 2015, another post was opened in Setalik, where PEM fell from 28.4 to 20.69 after just one year of implementation. Overall, the rate of PEM in Sejangkung District dropped from 27.6 in 20012 to 20.86 in 2016, and no cases of malnutrition were identified in 2015 or 2016, compared to 11 cases in 2012. This shows a clear positive impact on the children of Sejangkung. Overall PEM in children in Sejangkung fell from 27.60 in 2012 to 20.86 in 2016 after four years of Child Nutrition Post activities in six of the sub-district’s villages. After just one 10-day session, on average children put on 200 grams. Eventually, all graduated from the program. Additionally, no cases of malnutrition in children under five have been found in Sejangkung in 2015 or 2016. b. Increased parental knowledge on child nutrition. Nutritional problems in Indonesia are caused by a number of factors, including lack of knowledge, tradition and habit, food preparation, and food myths. For example, many parents believe that if their child is full, then their nutritional needs have been met. The Child Nutrition Post worked to overcome such problems by educating parents and other family members on proper child nutrition and helping them solve the problems they face. Parents now report having a good understanding of what a healthy diet looks like for children. c. Increased cross-sector co-operation on child nutrition. Child nutrition cannot be solved from a medical or health viewpoint alone. The Child Nutrition Post in Sejangkung were successful because they brought local governments such as villages and the sub-district.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The nine Child Nutrition Post in Sejangkung are transparent and accountable in their work. Community members and health volunteers run the programs, and all information is available to those involved. The principles of honesty, consistency, openness, caring, and hard work are prioritised by the Head of Sejangkung Community Health Centre, and he ensures his staff incorporate these principles into their daily activities. The Posts have clear targets on overcoming child malnutrition, and those in charge make their patients’ satisfaction a priority. If patients put forward a complaint or suggestion, they are handled straight away to ensure that services improve. The posts’ activities are reported back to the Sejangkung Community Health Centre every month via village midwives, and results are discussed and assessed in the quarterly cross-sectoral mini workshop that is attended by community representatives. This ensures that the community is well-aware of the program, its resources, and its results.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Special focus was placed on ensuring that poor families were aware of the program and encouraged to take part. Health volunteers frequently visited the houses of poor parents with malnourished children to give them advice and information, and to motivate them to attend the posts with their children. Volunteers also ensured that the posts’ activities were relevant to poor families’ needs and capabilities, such as through focusing on locally-available, affordable and accessible foodstuffs when deciding their menus.

Contact Information

Institution Name:   Health Office sambas Regency
Institution Type:   Local Government  
Contact Person:   Muslimin Muslimin
Title:   Head office  
Telephone/ Fax:   +6285245355569
Institution's / Project's Website:  
E-mail:   pkm_sejangkung@yahoo.co.id  
Address:   Jl. H.M Syarie Dahlan No. 35 Sejangkung
Postal Code:   79463
City:   Sambas
State/Province:   West Borneo
Country:  

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