Synergies from transdisciplinary research Dr Bronwyn Myers, Mr Rohan Fisher, Mr Nelson, Dr Suzanne Belton, Ms Frederika Rambu Ngana Hamel
MODIS IMAGE
• Long way from capital city • Environmental legislation comes from distant national capital – need for increased regional capacity • Many isolated rural communities dependent on natural resources
• History of our research in NTT • Health mapping projects in NTT – – – –
Why decentralise health mapping? Appropriate tools and systems for NTT Keys to successful uptake New project more accurate and efficient health reporting
• Impacts – Research teaching – Sustained uptake & improved services?
• Barriers to accessing maternal health care – Menzies-RIEL-UNDANA collaboration
• Started with Natural Resource Management focus – Savanna fire management (1999 + 2002-2005) – Capacity building in NRM (2006-2008) • Reviewed GIS as basis for better resource management and service delivery (2009) – Conference at UNDANA; Book published • GIS/Mapping has been a tool for integrating research across disciplines.
Projects funded by AusAID’s PSLP (2008-2013) 1. Mapping Health Indicators 2. Field Data collection 3. Access Modelling 4. SMS health reporting
• Reliable health data are essential for health service delivery. • Through decentralisation, there has been a devolution of budgeting and planning power to the Kabupaten level without a corresponding provision of skills for required for good decision making.
Data collection and analysis at the local level can increase data understanding and data quality.
‘The experts’
Ad vo ca cy
Data Collection
Data Analysis Understanding Data
Action
Goal
Empower local health professionals to analyse and understand the data they collect to guide better (more accurate) data collection to inform service delivery and program development at the local and national level.
Three components – Integration of existing data for spatial visualisation
Three components – Integration of existing data for spatial visualisation – Field Data collection for: • Updating health infrastructure data
Three components – Integration of existing data for spatial visualisation – Field Data collection for: • Updating health infrastructure data
– Service Availability Mapping • Modeling travel time to health services
Grabysch and Campbell from‘Composite Maternal and Infant Health’
SERVICE SERVICEAVAILABILITY AVAILABILITYMAPPING MAPPING(SAM) (SAM)
Travel Time Puskesmas
16
• Decentralised/contextualised training • Real issues • Local data
• Appropriate tools/Methods • Long term engagement with key partners
• Free open source tools • No Internet • Tool Convergence
• A need for more timely and accurate reporting of health data – Near real time mapping of health indicators
• Current use of SMS for reporting and service requests – Ad-hoc SMS reporting systems
• SMS tools for health monitoring and surveillance in eastern Indonesia
Using Frontline SMS • No Internet requirement • Free • Customisable • Able to send forms to simple/cheap java enabled phones
• Text messages can save lives • Reporting data from the field – Maternal health indicators – Disease out-breaks – Medicine stock
• Sending reminders – Maternal check-ups
• Information Requests
– Undergraduate Teaching • Flinders Biomedical school • CDU Pharmacy • CDU Introduction to GIS
– PG Students • Yulius (UGM) • Frederika (CDU) • Afrona (CDU)
– Ongoing on-ground teaching • Amarylis – Building capacity in NGO’s across indonesia • CARE • University Hasanuddin
Health indicator mapping
Map : Malaria deaths in reported from clinics in 2010
Analysis and advocacy for health infrastructure funding
• Small pilot study → larger study planned • Mixed methods and interdisciplinary • GIS spatially visualised data • Qualitative data • Quantitative data • Novel approach to understand complexity
Participants
Cause and perceptions of maternal death interview topics
Family Members
Social demographics; reproductive history; condition of infant; process of death; perceptions on the cause of death; access to health services, choice of birth place and assistants; preparation for birth; use of emergency services and responsiveness of the health system
Village Leaders
Social determinants of health interview topics Condition of the roads; access to clean water; economic activity; nutritional security; access to school; availability of electricity; mobile phone coverage or public phone; ethnic diversity and religion, languages; ‘normal’ birth practices; availability of health insurance; access to health facilities; presence of a midwife and ambulance service.
Case
Month of death
Characteristics
1
Feb
Married women, age unknown age. Five living children, attended antenatal care. Gave birth to unexpected twins at home with family. There was no midwife in the village, and the nurse was called but woman died at home after waiting two days for transportation. Died in wet season. Both infants survived birth and one died later.
2
June
Married to health cadre, age unknown. Three living children. Complained of chest pains during antenatal care. Gave birth at home with family assistance. Infant survived one hour and mother perceived as unwell and taken to hospital. She was discharged to home and died.
3
Jan
29 year old married farmer having first child, attended formal antenatal care, gave birth at home with her family’s assistance. Died in wet season. Died after five days. Infant survived until two months dying of failure to thrive.
4
Feb
27 year old married died on fourth day with fever , family took her to midwife infant survived
5
April
24 year old farmer, separated from her husband, died giving birth to second child. Rapid hemorrhage with retained placenta. Cadre, traditional midwife and family present. Midwife called only after cadre felt it was late enough in the morning by which time she was dead. Infant survived birth.
6
May
28 year old, unmarried servant with first pregnancy who did not seek antenatal care due to social stigma. Gave birth at home with family. Died after 24 hours. Infant survived
7
Sept
20 year old, unmarried farmer with first pregnancy who did not seek antenatal care due to social stigma. Gave birth at home with family and traditional birth attendant. Retained placenta died within 24 hours of birth. Infant survived.
8
Sept
Married woman with three living girl children, post partum haemorrhage, retained placenta, infant survived, difficulty getting the midwife to attend.
• • • • •
Remoteness Poverty Traditional customs Health system dysfunction Fatalism
General Topography
PONED no barriers Dry Season
PONED River barriers Wet Season
Road conditions
Access to health care?
Traditional customs
Dead women can’t talk • One brother recounted his sister’s words: Brother: She left if all up to God, after she gave birth, to let her die. Interviewer: Why did she say that? Brother: She did not have a husband, so she felt that she had humiliated everyone. She said she would rather die than make more problems for her parents who had struggled so much. • These two families delayed seeking help and both women took at least one day to die, probably from blood loss. Both families suggested it was the woman’s wish, however dead women cannot tell their own stories.
Fatalism • God’s will that women die “Interviewer: So, what did the clinic staff say? Husband: They did not say anything. When things like this happen we always think; well God has called back my wife.” • Lack of personal belief to be able to change circumstances
1. Based on real problems (wicked) required a transdisciplinary approach 2. Multiple levels of engagement 3. Impacts & sustained uptake 4. Unforseen spin-offs – Range of applications – Research – teaching nexus
References • Fisher R, Myers B, Sanam M, Tarus V (eds) (2009) GIS applications GIS Applications for Sustainable Development and Good Governance in Eastern Indonesia & Timor Leste. CDU Press, Darwin. • Fisher R, Myers B (2011) GIS can be free and easy: An example of decentralised public health mapping in eastern Indonesia. International Journal of Health Geographics.10:15 • Rambu Ngana, F, Myers B, Belton S (2011) Health reporting system in two subdistricts in eastern Indonesia: highlighting the role of village midwives. Midwifery doi:10.1016/j.midw.2011.09.005 • Belton, S, Myers, B, Rambu Ngana, F (2012) The Social and Geographical Topography of Maternal Deaths in Eastern Indonesia: A pilot study (CDU, UNDANA) (English and Bahasa Indonesia)