INDONESIA’S COMMUNITY HEALTH WORKERS (KADERS)l

By: Katharine Shelley, Novia Afdhila, and Jon Rohde

Case Studies of Large-Scale Community Health Worker Programs was derived from the Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, edited by Henry Perry, Lauren Crigler, and Steve Hodgins.

Originally published in May 2014 by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), it was created in response to the rapid increase in and expansion of CHW programs in low- and middle-income countries over the past decade. In January 2017, a companion document was prepared to provide guidance on 13 case studies, including Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. CHW Central is serializing the case studies over time.

Summary
Background

Built on the national women’s Family Welfare Movement (PKK) movement of the 1970s, volunteers called kaders were trained to conduct health and nutrition promotion activities in each village. In the mid-1980s, the Posyandu Program was formally recognized by the MOH. The program’s goal was to decrease infant and child mortality, improve FP acceptance, improve nutrition, and empower the community through community health activities.¹

Summary
Background

Implementation

A posyandu is a health post in the community that is staffed by kaders. Kaders are almost exclusively women and are chosen by and from within the community to support services at the posyandu. Each posyandu serves approximately 100 children younger than 5 years of age or about 700 persons in the community.¹ There are an estimated 1 to 1.5 million kaders, and there are 4–5 kaders who volunteer at each posyandu. Sessions of the posyandu are held monthly, at which time mothers and infants receive services at a series of five tables for registration, weighing, result recording, advice or counseling on growth and development, and health services (such as immunization or FP).¹

Training

Kaders receive one week of training and over time accumulate the skills and equipment necessary to carry out a set of tasks, including growth monitoring and promotion, treating common illnesses such as diarrhea, and preventing disease and malnutrition.

Roles/responsibilities

Kaders conduct the posyandu sessions, where their basic roles include registration and recording on mother-infant cards, weighing, growth monitoring, providing nutrition advice, and counseling on FP. Outside of the monthly posyandu sessions, the kaders carry out follow-up visits in the community, attend community committee meetings, and update posyandu target and utilization data.² Kaders work about 8–10 hours monthly.³

Incentives

The kaders provide voluntary service without financial compensation. However, kaders may receive informal types of compensation, such as free medical treatment from higher levels in the health system.³ There is a high cultural value placed on doing something for one’s neighbors, so volunteering as a kader is highly esteemed.

Supervision

While the nearest sub-district health center (puskesmas) provides technical guidance and support, the real accountability of the kaders is to the village committee that appointed and supports them in their work. Kaders undertake to do “welfare work” for their community, and the monthly posyandu session is seen as an important function and contribution to the welfare of the community.

What is the historical context of Indonesia’s Community Health Program?

The National Nutrition Survey in 1973 highlighted the prevalence of malnutrition in Indonesia. At that time, over half of the children were undernourished.⁴ Throughout the 1970s, various program approaches were undertaken to improve nutrition at the village level. The well- established PKK organization was endorsed by the Ministry of Home Affairs and active in thousands of villages throughout Java promoting self-help activities.⁴ Working with local health departments, university departments of pediatrics, and the national FP organization (BKKBN), the PKK became the locus of a set of monthly activities, including resupply of FP commodities, weighing of children, and discussions of improving child health centered around the cooking of a common nutritious meal, all organized and carried out by volunteers, called kader gizi (nutrition workers) from the PKK. The point at which women gathered for these services came to be called a posyandu, which is an Indonesian abbreviation for post pelayanan terpadu (PosYanDu).

At the time of the posyandu session, these women were given brief training and simple health education aids and followed standard prescribed activities during their monthly meeting focused on family health and child nutrition. The KB-Gizi (FP/nutrition) Program grew dramatically during the Third Five-Year Plan (1979–1984), at which time it reached over 30,000 villages.⁵ By 1984, over 80,000 posyandus in 34,000 villages, run entirely by kaders, were providing basic nutrition and growth monitoring services.⁴ The MOH began to use these monthly gatherings as a convenient means to expand immunization coverage as well as to provide medical consultations. The MOH subsequently took over these “integrated service delivery posts” and renamed them posyandus.⁵ After only a decade, the posyandu and kader program covered 86% of villages in Indonesia with 200,000 posyandus.³

The National Nutrition Section of the MOH started the Program Gizi (UPGK). Initially it depended upon costly food supplements. Monthly weighing sessions started in response to PKK mothers asking how they would know if their children were healthy and growing well. Traditional weighing scales called dacin for market commerce were used, along with growth charts that displayed multiple green channels getting greener at the top (like rice that grows greener as it is fertilized) to demonstrate where children were located based on their weight for age and whether their weight was increasing. Finally, the sessions focused on “wisdom of mothers” (kebijkasanaan ibu) rather than on “nutrition science” (ilmu gizi) as the teaching/learning method.

The Posyandu Program thrived during the 14-year period from 1984 to 1998 under President Suharto’s rule,⁶ expanding to more than 65,000 villages with some 250,000 posyandus run by over 1 million kaders. Initial skepticism around volunteerism and worry about attrition of kaders gave way to pride and recognition for the important community service they provided.

Women wishing to retire from their role recruited and trained their replacements, thereby developing a self-perpetuating system of local health and nutrition care. However, the economic crisis during 1997 significantly impacted posyandu performance. Some reports indicated that up to 70% of the posyandus stopped functioning.⁷

In 2001, the Indonesian Ministry of Home Affairs, through a ministerial letter, called for a revitalization of the Posyandu Program. It requested that the government (1) ensure the sustainability of regular posyandu activities; (2) ensure the empowerment of local leaders and kaders through advocacy, orientation, and training; and (3) institutionalize the posyandus by maintaining them both as a physical structure and as a sociopolitical structure within the village system that is accountable to the community. Due to limited resources, the revitalization effort has focused on inactive posyandus and those in low-income communities.²

What are Indonesia’s health needs?

The kader program was primarily developed as a response to addressing malnutrition, which was identified as the greatest threat to Indonesian children in the 1970s.⁴ Over the next two decades, with regular attention to monthly monitoring of child growth and use of locally grown foods and recipes, malnutrition was halved without food supplementation programs, so popular at that time in many other countries.⁴ Today, malnutrition remains a significant health challenge in Indonesia, but it is far less severe: among under-5 children, 18% are undernourished and 36% are stunted.⁸ Indonesia has recorded steadily declining rates of infant mortality over the last 40 years, from 142 deaths per 1,000 live births in 1967, to 68 deaths per 1,000 live births in 1990, to 32 deaths per 1,000 live births in 2012.⁹ While in the 1970s, diarrhea was the most prevalent cause of child deaths, the availability of oral rehydration at the posyandu and the monthly attention to nutrition and hygiene along with early rehydration in the home for diarrhea cases reduced diarrhea to the 4th or 5th leading cause of death. Now one- third of infant deaths occur within the first month of life, an indication that increased quality of delivery and PNC is needed. Acute respiratory infections, perinatal complications, and diarrhea remain important to address, especially in rural settings.¹⁰

What is the existing health infrastructure?

Indonesia’s public health system includes facilities at the central, provincial, district, sub- district, and village levels, largely managed through a decentralized system responsible to the provincial and district levels of government. Indonesia underwent government decentralization in 1999–2000, at which time most health functions and budgets were transferred to the districts, with the national and provincial levels largely setting norms and providing guidance.¹¹ Referral hospitals are located in the larger cities and provincial centers. District hospitals are present in each of the 580 districts, and community health centers (puskesmas) each cover a catchment of approximately 30,000 people. Below the puskesmas, at the village level, there is a network of low-level facilities, including pustus (sub-health centers), polindes (village midwife clinics), and posyandus (health posts) (see Figure 1).^11,12

Figure 1. The health care system in Indonesia, including the posyandu (health post) at the community level.¹²

What type of program has been implemented?

Community health activities are carried out at the posyandu, which is an integrated health post staffed by various community health kaders. The posyandu links people at the village level with the formal health center and the health care system.³ Each posyandu serves approximately 100 under-5 children or about 700 persons in the community.¹ There are an estimated 1 to 1.5 million kaders in Indonesia, based on four to five kaders stationed at each posyandu. The various types of community health kaders include: the gizi kader (who works in nutrition); the kesehatan kader (who works in health); the KB kader (who works in FP); the first aid kader; the non-communicable/chronic disease kader; and the mental health kader. The original idea was to have one kader for every 10–20 families.³ By 2009 there were more than 250,000 posyandus, and an average of 3.6 posyandus per village.^2,13

Posyandu sessions are conducted on at least a monthly basis by the five or more kaders present at each session.² Kaders typically work about 8–10 hours monthly.³ At the posyandu session, four tables are set up with at least one kader stationed per table. The first table is for registration, the second for weighing of children, the third for marking the growth card graph with the weight outcomes; at the fourth table, the mother is given advice based on the weighing and growth monitoring data. A fifth table was later added to provide immunizations and curative services.

Outside of the posyandu sessions, kaders are responsible for (1) updating a register with names of pregnant women, postpartum and breastfeeding mothers, infants, and under-5 children); (2) updating the statistics describing posyandu session utilization; (3) carrying out follow-up visits to houses of absent participants and participants who need further health education; and (4) attending community committee meetings.² Growth monitoring, FP, mental health counseling, general MCH care, guidance on the prevention of diarrhea, and immunization are all provided at the posyandu sessions.¹³ Infant health care includes immunizations, promotion of early stimulation, growth monitoring, disease detection, and basic curative care. In 2010, coverage of infant health care was 84%, and the monthly posyandu session is considered a key reason why the coverage level is high. The posyandu is an important access point for families to bring their infants for routine care.¹³

Posyandu activities are divided into core and optional activities. By offering additional optional activities, a posyandu becomes designated as an integrated posyandu.²

Core activities carried out by kaders and their posyandu:

MCH care
Family planning
Immunization
Nutrition
Diarrhea prevention and treatment

Optional additional activities:

Bina Keluarga Balita (empowerment of families with children younger than 5 years of age)
Tanaman Obat Keluarga (family herbal farm)
Bina Keluarga Lansia (program for the elderly)
Pregnancy savings (encouraging women to save in preparation for delivery and for the newborn’s needs)

What about the community’s role?

The posyandu and its kaders serve as a community empowerment unit on health-related issues that is supervised institutionally by a village committee. Medical and technical supervision is provided by the clinical staff at the puskesmas, where a physician, 5–8 nurses, and several midwives work.² The selection of the supervising village committee and kaders is based on consensus reached within a village-level meeting conducted by staff from the puskesmas and attended by village leaders, other respected people in the village, and selected members of committee.²

How does Indonesia select, train, and retain kaders?

The community plays an integral role in selection of kaders. Selection criteria include the following:

Able to read and write
Social in spirit and willing to work voluntarily
Knowledgeable about the customs and habits of local people
Willing to commit the time required
Residing in the village
Friendly and sympathetic
Accepted by the local community

Training of kaders lasts less than one week, meaning that only a few technical skills can be learned during that short duration of training.³ Kaders are taught to do very few things, but importantly, the training focuses on learning one task at a time. Kaders are given the skills and equipment needed to carry out that task, and two or three months later they may be trained on the next skill. Many of the skills can be passed on from one kader to another, such as preparing and using ORS and zinc, vitamin A distribution, and folic acid and iron distribution for pregnant women.

Evaluations conducted in the 1980s estimated that the annual dropout rate for kaders was 20%, and the average length of service for each kader was 3–5 years.³ As kaders drop out, new ones are selected and begin to work even if they have not been formally trained.³ A kader who drops out is sometimes responsible for finding and training her replacement.

How does Indonesia supervise the kaders and posyandus?

The posyandu is a community-driven health service managed and run from, by, for, and with the community. It also receives technical supervision from the staff at puskesmas.²Each puskesmas has at least one general doctor alongside nurses and midwives. At least one puskesmas is located in each sub-district, and someone from the puskesmas staff makes a visit to each posyandu session. Supervision of the kaders is minimal. Health facility staff members who attend posyandu sessions are not expected to supervise kaders. Rather, they attend the posyandu session as respected colleagues, and they incorporate statistics of services provided at the posyandu session as the first layer of data used in the district health information system.

How is the program financed?

There is almost no finance requirement after it gets started. Any money is a bonus and used to do what the committee decides on. Financing for the program serves to fund operational activities, nutritional foods for children under 5, kader transportation costs, start-up capital for posyandu commercial activities, and costs for transport for patients requiring referral. The program is financed through a variety of sources, including:

Community members, attendee donations, community health savings, donations from community members, and donations from social or religious groups;
Private commercial sources, such as some companies that adopt a posyandu and provide sponsorship;
Commercial activities undertaken by the posyandu itself (such as selling herbal medicine); and
Government sources (mainly for the early stage of posyandu development, particularly for establishing facilities and infrastructure).²

What are the program’s demonstrated impact and continuing challenges?

The community-level monitoring system is called SKDN and is used in some posyandus, depending on the initiative of the local committee, in order to monitor progress. It consists of four indicators which were designed to be simple and easy enough to use for community-level feedback and tracking of progress, but also to provide useful coverage information for the formal health care system.³ The simple monitoring system was designed to be used at the community level by the people who are collecting the data. The initials SKDN are used to represent the key data points: S for “all”—the number of under-5 children; K for “growth charts”—the number enrolled in weighing; D for the number of children “weighed” during the month; and N for the number of children who “gained weight” during the month. Key indicators are (1) the proportion of children reached (e.g., given growth cards) (K/S); (2) the proportion of children with growth cards who were weighed (D/K); and the proportion of children weighed who gained weight (N/D). A wall chart is then constructed at the community level to track a village’s progress.³

Measuring impact through these SKDN indicators requires an accurate estimate of the total number of children in the target age group, which is often difficult to ascertain. The latest 2010 figures from the Indonesia MOH indicate that 68% of under-5 children were weighed.¹³ The MOH has stated that the decrease in maternal and child mortality as well as the increase in life expectancy in Indonesia are partly attributable to the work of the posyandus and kaders in the community.²

Lack of funding, political support, and new volunteers have been cited as challenges. Some critics say that over half of the posyandus are inactive, but others claim this is overstated. The head of the Demographic Institute at the University of Indonesia in Jakarta says, “Times have changed. People no longer take pride in being posyandu volunteers [kaders]. People also prefer to go to clinics [more] than [to a] posyandu.”¹⁴ In spite of these vulnerabilities, the posyandu system in Indonesia, run by volunteer women for more than 30 years, is probably the largest and longest continuous community-based volunteer health and nutrition program in the world. Driven by women who honestly want to know, “How is my child doing?” and are willing to serve their neighbors by devoting one day a month to a common welfare activity, the kader gizi (and other kaders) have brought a level of universal health and nutrition care to a huge and diverse population in one of the poorest countries of the world. The posyandu and its kaders provide a foundation for health in modern Indonesia.

The quality, coverage, and impact of posyandus varies by region. The quality of FP services provided at the posyandu is heavily dependent on the midwife from the puskesmas being present for the posyandu session. If she is not able to attend, then women who need replenishment of supplies or an injection will be without protection.¹⁵

The trend for increased utilization at the puskesmas will continue, particularly since a national health insurance scheme went into effect in early 2014 and over the next 5 years will cover everyone in the country. However, the need for the posyandu will continue—for growth monitoring of children, for attention to mental health issues, for chronic disease management, and for many other services that can be effectively provided at that level.

References

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Ministry of Health Indonesia. Pedoman Umum Pengelolaan Posyandu (Posyandu General Guide). Jakarta, Indonesia; 2011.
Berman P. Community-based health programmes in Indonesia: the challenge of supporting national expansion. In: Frankel S, ed. The Community Health Worker: Effective Programmes for Developing Countries. England: Oxford University Press; 1992:62-87.
Rohde J. Indonesia’s posyandus: accomplishments and future challenges. In: Rohde J, Chatterjee M, Morley D, eds. Reaching Health for All. England: Oxford University Press; 1993:135-57.
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Abdullah A, Hort K, Abidin AZ, Amin FM. How much does it cost to achieve coverage targets for primary healthcare services? A costing model from Aceh, Indonesia. Int J Health Plann Manage. 2012; 27(3): 226-45. doi:10.1002/hpm.2099.
WHO. Indonesia Country Profile. 2003. Available at: http://www.who.int/disasters/repo/9062.pdf.
Ministry of Health Indonesia. Indonesia Health Profile 2010. 2011. Available at: http://www.depkes.go.id/downloads/Indonesia Health Profile 2010.pdf.
IRIN. Indonesia: bid to revitalize community-based healthcare. IRIN News. February 24, 2012. Available at: http://www.irinnews.org/report/94946/indonesia-bid-to-revitalize- community-based-healthcare.
Mize L. The Paradox of Posyandu: Challenges for Community Health Services in Indonesia; Literature Review. AusAID HRF; 2012.

^lThis case study was written by Katharine Shelley, Novia Afdhila, and Jon Rohde. Ms. Shelley and Ms. Afdhila are students in the Johns Hopkins Bloomberg School of Public Health; Ms. Afdhila is from Indonesia and has worked with the CHW program. Dr. Rohde was instrumental in the formation of the Indonesia CHW program in the 1970s.