Questions/Answers

The ‘healthy alleyways’ initiative aims to change community health behaviours in the city of Makassar, South Sulawesi, Indonesia. The program encompasses activities from awareness raising all the way to evaluation, and encourages residents to live healthily, such as by washing their hands before eating, making sure they take their children to health clinics, and throwing out their rubbish in the proper places. By working in alleyways – where the majority of Makassar’s residents live – the program can reach more citizens than through traditional outreach methods, where temporary health posts are established and health workers wait for patients to attend. The initiative was also established to improve health data. Residents living in alleyways tend not to access basic health facilities, even though they are provided at local community health clinics. Despite this, the poor sanitation of alleyways causes numerous illnesses and diseases amongst both adults and children. This is particularly evident in pregnant women and young children, who are can become under-nourished or suffer from infections. Because there are no outreach programs from health clinics, alleyway residents go without. Fifteen sub-districts were involved in the program in 2017. The program actively involves community health workers, community-run child health posts, community leaders, religious figures, and the family welfare movement. A number of private sector stakeholders also financially contributed to the program, such as Astra, Yamaha, and Indomaret. The program successfully improved the rate of households implementing healthy behaviours from 59.6% to 92.3%, while the number of households deemed ‘unhealthy’ fell from 8% to just 3%.

The ‘healthy alleyways’ initiative aims to change community health behaviours in Makassar, to increase health workers’ and community health volunteers’ presence in alleyways, and to improve health data of alleyway residents. This initiative began as a response to the comparatively low life expectancy of 71.49 years for Makassar residents, an overall mortality rate of 2.2 per 1,000, and an ‘unhealthy household’ rate of 8.55%. Makassar has a population of nearly 1.5 million people, and the 80% live in small alley-like streets that are only accessible by motorbike or on foot. 7,000 alleyways are taking part in the ‘healthy alleyways’ initiative. This program is community-based, and the active participation of residents is a key part of its activities. This program is listed in the mid-term plan of the Makassar government for 2014-19.

This initiative would not be successful without community participation. Residents are involved in all stages of the program, including planning, where community members joined discussions on what were the problems faced by alleyway residents, such as sanitation, healthy households, healthy lifestyles, and childbirth. The residents are actively involved in community education on topics such as the dangers of smoking and the benefits of handwashing, and provide facilities to support these activities, including smoking areas located away from houses and taps for washing hands. Community members also participate in program evaluation to ensure the initiatives are running effectively, and in fundraising efforts. Additionally, alleyway residents take part in annual development planning meetings with the local government. These meetings aim to bring together citizens and government representatives.

The ‘healthy alleyway’s initiative aims to fulfill Makassar residents’ rights to health. In order to do so, the government of Makassar has invited other stakeholders to work together in developing healthy alleyways. The initiative aims to meet SDGs 11 (sustainable cities), 3 (healthy lives), and 6 (sanitation). If the community is fully involved in developing their alleyways, public services will be better provided as the community cares more about the outcomes. Community participation is a technical process that gives community members the chance and responsibility to solve problems together.

The ‘healthy alleyways’ program is a community empowerment program that encourages the community to work with health providers. It has been able to overcome basic health problems because government health workers can more actively interact with residents. It has also improved health data, as every single household in the alleyways has been documented; this makes government expenditure more effective.

This initiative has had a positive impact on the people of Makassar, especially those who are ill, pregnant, babies, toddlers, children, elderly, and the poor. Through increased community participation, citizens of Makassar’s alleyways are receiving better healthcare from both local residents (who have been trained on providing simple care) and health workers. At the start of the program, Makassar aimed to reduce its neonatal mortality rate to 6 deaths per 1,000 live births. It achieved this by 2016, when the rate fell to just 2.58 deaths per 1,000 live births (66 deaths from 25,614 live births). Maternal mortality has remained stable, at five deaths each in 2014 and 2015, and six in 2016, while approximately 1,500 more women were assisted in childbirth by trained health workers in 2016 than were in 2014. Child nutrition has improved since the ‘healthy alleyways’ initiative began. In 2014, 2.3% of children under the age of five were under-nourished; in 2016, this fell to 2%. There were six cases of malnutrition in 2016, and all were successfully handled by health workers.

‘Healthy alleyways’ is an innovative program because it starts from the smallest of scales: alleyways. It heavily involves the community in its implementation so that together the people and the government can develop a healthy community. Communities were also unused to working this closely in cooperation with health workers and government officials; now, they are keen to do so because they see the benefits it brings. To our knowledge, no other city in Indonesia has implemented this approach.

The initiative is an original one, developed and initiated by the Makassar government in collaboration with residents of the city’s alleyways. The Mayor’s slogan – ‘twice as good’ – aligns with his vision for alleyway-based development.

The initiative is run by the health workers of 46 community health centres spread across Makassar. Initially, the ‘healthy alleyways’ program was run alongside complementary programs on healthy lifestyles and behaviours. Beginning in 2015, the program was funded as its own program by the Makassar District Health Office. IDR 260 million (US$18,200) was allocated for the initiative’s activities in 2015; IR 400 million (US$28,000) in 2016; and IDR 610 million (US$42,700) in 2017. The most key human resources are Makassar’s community health volunteers, who help health workers provide services to the community. The volunteers weigh babies at the monthly health posts, eradicate mosquito larvae at houses, record health data of residents, and report back to the health centre if there are citizens who have not been reached by health services.

Yes

Since ‘healthy alleyways’ began implementation in Makassar in 2015, 22 cities and districts have visited to learn about the program. All have indicated their interest in replicating the initiative in their own areas. Within Makassar itself, after seeing the success of ‘healthy alleyway’s, other government offices have implemented alleyway-based activities, such as ‘garden alleyways’, ‘family planning alleyways’, and ‘family welfare alleyways’. This has had a significant positive impact on the residents of Makassar.

One community health centre is responsible for a number of alleyways. To increase the sustainability of each alleyways’ programs, local regulations have been developed in the form of circular letters from the heads of local neighbourhoods. The letters instruct community health volunteers and residents to be actively involved in the healthy alleyways initiative, even if the city gains a new mayor in future elections. Community participation is an important part of shared responsibility. To motivate health workers, volunteers, and residents, awards and competitions are regularly held. Awareness raising events are also frequently run, to ensure that all stakeholders – including religious and community leaders – are aware of the initiative’s activities.

Healthy alleyways are an indicator of a healthy city. Each alleyway now has its own coordinator, and all coordinators meet regularly with local residents to discuss and monitor the program. Coordinators also report back to the Makassar District Health Office.

Yes

The initiative is regularly monitored and evaluated by the government of Makassar. All health workers must send daily, monthly, and annual activity reports to their supervisors at the community health centres, who share them with the Makassar District Health Office. This information is used to assess whether the program is running effectively. The District Health Office itself also goes into the field to directly observe the progress of the healthy alleyways.

Healthy behavior has increased from 59.5% to 92.3% in Makassar since the initiative began. The number of households deemed unhealthy has also fallen from 8% to just 3%.

The initiative was evaluated through the 10 healthy behaviour indicators and the 12 healthy family indicators. Both sets of indicators were developed by the Indonesian Ministry of Health. The healthy behaviour indicators are: childbirth assisted by a health worker; exclusive breastfeeding; baby weighing once a month at the child health post; handwashing with clean water and soap; using healthy toilets; eradicating mosquito larvae at home; eating fruit and vegetables every day; doing physical activity every day; and not smoking at home. The healthy family indicators are: the family understands family planning; the mother follows standards for antenatal checkups; toddlers are fully vaccinated; children are exclusively breastfeed up until 6 months of age; children’s development is observed; people with hypertension follow medication routines; active TB patients follow standard treatment; no one in the family smokes; the whole family is part of the National Health Insurance program; the family has access to clean water; the family uses a healthy toilet; and the family can access mental health services.

The ‘healthy alleyways’ program is primarily funded by the local government, but also receives CSR (Corporate Social Responsibility) support from companies such as Indonesia Medical Association, Healthy City Forum, Pertamina, Astra, Yamaha, and Indomaret. This shows strong cooperation between private and public stakeholders. Private sector partners have funded the renovation of and purchase of equipment for child health posts, as well as financially supporting the purchase of items such as paint, pots, and plants for Makassar’s alleyways. Community health workers are a key part of this program, but the initiative is also implemented by community leaders, religious leaders, the family welfare movement, children’s groups, and others. The Mayor and Deputy Mayor themselves also keep a close eye on the program. They regularly go down to the alleyways to oversee the activities and to ensure all is running well, as well as making regulations to support the initiatve.

One of the most important things that the Makassar government learned from this program is that meeting community needs is not necessarily complicated. Communities generally simply want to see that the local government is present and helps them when they face problems, such as when they are ill. The people do not need extraordinary services that are beyond the reach of the government. Through ‘healthy alleyways’, the government and its health workers also learned that persuasive approaches can be effectively used by health volunteers to encourage residents to be seen to by health professionals. A useful way into this is to conduct go house to house to update health data at the beginning of the program.