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WATCH Project, Jayawijaya (1991-2000)

Project Summary
The following Introduction is based largely on the Executive Summary and Introduction from the Project Completion Report. It is presented here for readers to gain a quick entry to the nature of the project.
Irian Jaya is one of a few provinces in Indonesia which remains comparatively undeveloped because it has an insufficient labour force and/or level of education and is geographically isolated, far away from the administrative centre of Indonesia.
The central highlands of Irian Jaya are home to 24% of the population of Irian Jaya. The vast majority of the population of Irian Jaya are engaged in subsistence agriculture and fishing. The highland districts of Paniai and Jayawijaya are a high priority for development activities, including health. The major rationale for this is their isolation as there were no land transport links to the highlands; although the roadway has now been cleared from Jayapura to Wamena, there are major shortcomings such as service and maintenance facilities.
The Jayawijaya district is an area of 52,916sq kms, 11.7 % of the area of Irian Jaya. The population of the district is over 400,000. Outside Wamena, the district centre, most people are subsistence farmers, living in small villages or hamlets and following a traditional way of life. The difficulties of transportation in the highlands and the related problem of accessible markets makes the development of new enterprises complicated.
Transport links are limited to air services and walking. Road links are being built through the highlands and these have made access to markets and communications easier and provide options to the more expensive air transport.
The level of education was not high in Jayawijaya. In 1980, only 52.8% of the total district population over 9 years of age had ever attended school and illiteracy rates were still 81.55% (versus 18.8% in the district of Fak Fak). Literacy rates for men were double those of women. The needs of women in Jayawijaya had not been specifically addressed, in part due to under-representation of women in leadership and decision making positions. Traditional economic roles and obstacles to womens education continued to be supported by the social system.
Health indices suggested that urgent attention was also required in the health sector. The infant mortality rate in Irian Jaya ranged between 70-200 per thousand, with the average being 133, compared with an early 1990s national average of 73. Maternal mortality was at least 6.5 per thousand in Jayawijaya. This compared with a rate of 4.25 in other parts of the country. The immediate causes of this high rate of maternal mortality were haemorrhage and infection and, less directly, the fact that indigenous women were traditionally assisted in childbirth only by other untrained women and there was a critical shortage of female health personnel, including trained traditional birth attendants (TBAs) in the district.
Nutritional problems were widespread in Jayawijaya due to continued dependence on sweet potato, the unavailability of continuous animal protein and a lack of knowledge about cooking methods and skills. In 1986 the Household Survey recorded over 20% moderate malnutrition and another 2.5% severe malnutrition. Other problems included access to clean water; knowledge of and resources for good sanitation were very unevenly spread.
Communicable diseases, including malaria, were emerging in the highlands. Tape worm infection, venereal disease, acute respiratory tract infection (ARI) and diarrhoea were still significant health problems. Pneumonia accounted for 26% of infant death, diarrhoea 19% and malaria 11%, but the underlying cause was malnutrition.
Jayawijaya had critical gaps in the health delivery system. There was only one hospital with 70 beds, 28 health centres and around 80 sub health centres; in 2000 only 3 puskesmas were headed by doctors. They tended to be concentrated around Wamena and other smaller urban centres. There were many pockets of poorly serviced areas in the district. Supply of cheap, good quality medicine and basic equipment was a constant problem as was the lack of cold chain equipment and supply of vaccines and sterile vaccination equipment
Lack of trained personnel was also a serious problem. There was rapid turnover of medical staff in rural areas, if they had them at all. Christian missions, which had begun operating in Jayawijaya in 1953 in very primitive conditions, filled many of the gaps. Many of the government health centres were ineffective. Apart from the absence of personnel, there were other problems such as lack of communication and transport infrastructure. Getting to a health centre was particularly difficult for women, who were less able to be away from home than men.
Low income levels in some communities made community medical financing very difficult, lack of clean water or other primary preventative measures made curative routines ineffective, supervision was very poor and most importantly, in many communities, only a few people understood the basic principles of basic health and nutrition, which led to poor compliance patterns.
The rationale of the original project in this context was to improve womens and childrens health by increasing the effectiveness of primary health care programs in the district. The project was also to integrate community development and women in development (WID) principles and activities into the project. Rather than establishing new structures, the project would strengthen and extend existing government and mission services.
This rationale was further refined to address not only the symptoms of poor health with community development tacked on but rather that some of the community development issues were in fact root causes of poor health. This resulted in a program which addressed issues such as gender imbalance, poverty and lack of community organisation. This approach formed the basis of a primary health care model that saw health care in a more comprehensive light.
There were three general areas of activity in the project:
  • Development of formal health sector resources The development of resources included infrastructure such as buildings and equipment. It also included training of personnel from health centre doctors to paramedics. It also included the development of case management protocols and a computerised health information system.
  • Community development Community development encompassed a range of things from the organisation of groups, gender awareness, income generation, agriculture, animal husbandry, small infrastructure projects and cooperative enterprises
  • Health education Health education overlapped with the development of health sector resources in the training of health personnel. Training of personnel included village cadres and members of the womens movement (PKK) who were involved in activities at integrated posts at sub village level. Education was conducted further into the schools, churches and community groups established by the project.
Establishing change in a place like Irian Jaya makes numerous assumptions about what kind of change is appropriate. Given that this project was a bilateral project, assumptions were made that the project would follow government guidelines that were inherently inappropriate to the cultural and linguistic landscape of the Irian highlands. In addition, the institutions that were part of the overall government strategy for communities in the nation were unimplementable in the highlands context. Thirdly, the level of resources, both in quantity and quality, were severely limited to ensure adequate implementation of project initiatives or ensure sustainable systems.

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