One Woman’s Commitment to Expanding Services for Children With Acute Malnutrition In Eastern Indonesia
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One Woman’s Commitment to Expanding Services for Children With
Acute Malnutrition In Eastern Indonesia
Blandina Rosalina Bait and Astryda Maranda
Eirene Ate is a medical doctor and head of the District Health Office in Timor Tengah Selatan District (TTS) of East Nusa Tenggara Province (NTT) in eastern Indonesia. She first learned of the Integrated Management of Acute Malnutrition (IMAM) programme when she was appointed as head of TTS District Health Office in 2018. “I accepted this new responsibility as head of TTS District Health Office fully aware that there were many challenges to face in terms of the high prevalence of stunting, high number of severe wasting cases, high percentages of maternal and child mortality, as well as drought, frequent crop failures and a high proportion of people living below the poverty line. These challenges did not dampen my enthusiasm and commitment to make positive changes for the people in TTS. I am determined to make a breakthrough and introduce innovations to help get TTS out of the vicious cycle of poverty and malnutrition,” explains Dr Eirene.
In November 2018, TTS received support from the NTT Provincial Health Office, in collaboration with UNICEF, to conduct five days of IMAM training, targeting health workers from the six community health centres (Puskesmas) that have highest number of cases of severe acute malnutrition (SAM). “During this training I got an opportunity to discuss with UNICEF and with my staff who joined the training. I learned that IMAM could be one of the innovative programmes we need to overcome the malnutrition problem in TTS,” adds Dr Eirene. Before the introduction of the IMAM programme, the TTS government had to spend around 5.5 million Indonesian rupiah, approximately US$ 400, to treat a SAM child with complications. This cost included the treatment of the child and the food of the caregiver who accompanied the child during his or her stay at an inpatient facility. “Honestly, with the high number of SAM cases in TTS, these costs were quite burdensome for the local government,” explains Dr Eirene.
Understanding the IMAM approach, she sees the benefits of its emphasis on the early identification of SAM children. When these children are found earlier, they can receive adequate and timely treatment as outpatients, which prevents their condition from becoming more severe and their needing inpatient services. It can reduce the cost and other resources required from both the health service provider and the parents when a SAM child is hospitalized. SAM children with complications are still referred to a hospital or therapeutic feeding centre to receive treatment for their medical complication, and once their condition has stabilized they can continue the treatment through outpatient services. As part of the IMAM approach, children with moderate acute malnutrition receive supplementary feeding and their parents receive feeding counselling. Dr Eirene recognizes the importance of community and religious leaders’ involvement for active case finding and treatment of SAM children. Even from the parents’ perspective, when their child is diagnosed with SAM earlier and without a medical complication that requires hospitalization, the parents can continue doing their daily work and only need to take their child to a nearby Puskesmas for weekly follow-up. “Considering all the benefits, I immediately decided to scale up IMAM to five new Puskesmas, in addition to the six Puskesmas that are supported by the Provincial Health Office,” continues Dr Eirene. As a result, by the end of 2018, 11 of the 36 Puskesmas across TTS were implementing the IMAM programme.
Furthermore, with technical support from UNICEF, TTS District Health Office developed a comprehensive and systematic road map, including a budget plan and a clear timeline to establish IMAM services across all 36 Puskesmas up to the village level in 2020. “Together, we mapped all the resources that are available at the district, Puskesmas and village levels, including village funds that could possibly be utilized to support the scale-up,” adds Dr Eirene. Based on the mapping results, she saw that there was an opportunity to recruit a nutritionist to be assigned to all Puskesmas to support the implementation of the nutrition programme, including IMAM. Her confidence was boosted when the new District Head of TTS announced during his inauguration speech in 2019 that the stunting and wasting prevention and reduction programme was one of his top priorities. He went on to confirm this commitment by issuing a policy requiring each district to support seven Puskesmas in implementing that programme and instructed that a portion of district and village funds should be allocated to funding it. With this strong political commitment from the District Head of TTS, the District Health Office has been able to scale up the IMAM programme to all 36 Puskesmas and their community health posts by June 2020, reaching the milestone set out in the road map. Ultimately, by bringing services closer to the community level, this achievement has resulted in wider access for children and their parents to SAM treatment services, which are proving even more crucial during the COVID-19 pandemic.
In response to the COVID-19 pandemic and the associated restrictions on community health post services, aimed to prevent the transmission of coronavirus, Dr Eirene initiated a proactive approach that requires health workers to conduct home visits to malnourished children. This initiative was already being implemented even before the Ministry of Health issued a circular letter in its support. Dr Eirene has also taken up the global initiative of a mother-led mid-upper arm circumference (MUAC) measurement approach, which empowers parents/caregivers to monitor their children’s nutritional status using simplified MUAC measurement independently at home, which is proving crucial during this time.
“Malnourished children are at the highest risk and I don't want to take any risks in this critical time of COVID-19,” says Dr Eirene. When asked what makes her so committed to overcoming malnutrition in TTS, she replies, “When you work in the health sector, make sure you put your feet in the shoes of the people you serve, so that whatever you do is in their best interests, not yours.”
Given that now all 36 Puskesmas and all community or village health posts have been implementing IMAM, when asked about her latest goals, Dr Eirene answers, “I will focus on improving the quality of IMAM services and strengthening reporting and monitoring systems, including strengthening linkages with other services, such as social services, on disability issues, social safety nets, birth registration and early childhood development.”
© UNICEF Indonesia/2020/Eirene Ate
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