An epidemiological approach to health planning and problem-solving in Indonesia

Daerah Istimewa Aceh, with a population of 2.9 million, is locatedin northern Sumatra and is one of 27 provinces in Indonesia.Since 1982 a USAID-funded project (CHIPPS) has supported anexperiment in Aceh involving decentralized health planning andproblem-solving. Instead of following the usual Indonesian practiceof rigidly adhering to strict health programme guidelines sentfrom Jakarta, Acehnese health officials tried to use an epidemiologicalapproach in defining their most important health problems andin selecting the most appropriate interventions to solve thoseproblems. The fundamental approaches of the project were to provide trainingin applied epidemiology for health officials at province, districtand sub-district levels, to carry out province-wide or district-widesurveys designed to identify the major preventable causes ofdeath and to develop a population-based information system concerningbirths, deaths and cause-of-death. Provincial health officialscarried out several major surveys which demonstrated that thepattern of morbidity and mortality in Aceh differed markedlyfrom national estimates and that the provincial health departmentneeded to develop specific disease control strategies tailoredto fit the situation in Aceh. For example, a province-wide neonataltetanus mortality survey found that 2.1 per cent of all infantsborn in Aceh died of tetanus, that neonatal tetanus mortalityrates in some districts were 10 times higher than in other districtsand that babies delivered by trained village midwives were nearlyas likely to die from tetanus as babies delivered by untrainedvillage midwives. Surveys like this had major implications forhealth planning and priority-setting in Aceh. The CHIPPS projectin Aceh has demonstrated that province-level health officers,with training in epidemiology and with limited financial resources,can develop a simple but sound information base, determine theirown local priorities and implement effective interventions,even when these priorities and interventions differ markedlyfrom national norms.