Anna Alisjahbana

At a time when Indonesia was struggling to ensure the survival and health of its young children, Anna Alisjahbana developed new practices and technology that have changed the face of early childhood care and development throughout Indonesia.

Anna’s comprehensive approach to child development expands the roles and deepens the skills of professionals and families to extend health and education services, improve parenting, and ensure fuller, healthier lives for Indonesia's citizens. Her approach includes monitoring during pregnancy that continues through delivery and infancy, bringing together parents, health cadres, traditional birth attendants (TBAs), and village midwives. Her parenting messages help mothers and those interacting with children to craft more stimulating home environments. In 1984, Anna founded the Surya Kanti Foundation: Center for Development of Child Potential (PUSPPA: Pusat Pengembangan Potensi Anak) as a model for early detection and early treatment of child developmental disorders that provides promotive, preventive, curative and habilitative care for children up to five years in age. She focuses on those with special needs, helping kids develop into productive and confident individuals. The Surya Kanti team consists of medical professionals, psychologist, therapists, pedagogue and social workers from a wide range of disciplines, including pediatrics, neurology ophthalmology, rehabilitation ,and ENT specialist. Parents/caretakers are involved as partners in the identification and treatment management of children with developmental delays and disorders. Another of Anna’s innovations is the adjustment of the concept of Early Childhood Care and Development (ECCD for Indonesia- Asuhan Dini Tumbuh Kembang Anak (ADITUKA)), building the early detection and treatment effort into a more comprehensive “women and early childhood care” movement. Again, this adopts a holistic approach that views children as complete and complex individuals with unique talents and weaknesses. Early learning, early detection and intervention are addressed from pregnancy, delivery, and through the six year of child’s life, with parents and the community integrally involved in the process. Anna’s comprehensive approach has become common practice in both rural and urban areas in Indonesia, enabling parents, village health cadres, midwives, and pediatricians to monitor early childhood development more closely. Indonesia's Education Ministry, with a loan from the World Bank, then implemented the national adoption of Anna’s model for child development monitoring to spread throughout the country. UNICEF has implemented her model in 17 provinces, while large international COs like Save the Children and Plan International have replicated it in different provinces as well.

Despite Indonesia’s impressive success in decreasing infant mortality rates from 128 (per 1,000 live births) in 1970 to 43.50 in 2003, many children under five still suffer from malnutrition, poor health, and destabilizing home environments that hinder their cognitive, motor, and socio-emotional development. Such children are more likely to perform poorly in school and subsequently, earn lower incomes, have more children, and lack the skill and knowledge necessary to provide the best care for the children they have, thus perpetuating the cycle of poverty.

Currently, the Indonesian government still prioritizes infant survival over child health care, nutrition, and development. There is lack of interest to improve the quality of life of the child. This fact, combined with a lack of national statistics on young children’s cognitive and socio-emotional development has hidden the problem from the public. The reality of the situation, however, is that poor parenting and inadequate stimulation in the home lead to stunted development among children, and government services have failed to adopt an integrative approach to addressing these problems.

As a result, medical service providers, psychologists, therapists, educators, and village health cadres, including TBAs all lack the tools to support positive child development. Health centers and hospitals remain ill-suited to detect and properly respond to symptoms of larger medical problems. Poor coordination among government agencies further exacerbates the poor quality of child health and development in Indonesia.

Anna’s distinguished career in neonatal epidemiology led to her ground-breaking four step model. She demonstrated that early monitoring and intervention during pregnancy and the fetal period improves the odds of detecting risk factors such as low birth weight and other developmental disorders. Interested in the low birth weight prevalence in rural areas, she invented a color-specific baby scale for the mostly illiterate TBAs that enable them to detect infants with low birth weight and make referrals. This tool also circumvented communication problems caused by language barriers between TBAs and medical professionals.

When it came to infant mortality, rural TBAs typically bore the brunt of the blame for deaths outside the hospital, largely because most are illiterate. But Anna found no difference between the mortality rates of infants born under formally trained versus untrained TBAs; true to form, she wanted to know why. Anna found that the problem wasn't in their level of knowledge, but in the training method applied and difficulty in communicating with them. So she created a training regimen for them to fill the communication gap, a study which formed the basis for her PhD. The result: More knowledgeable TBAs, able to conduct early detection and make appropriate referrals. This groundbreaking new training method for TBAs was a significant reformation of outmoded communication techniques. However this result can not be seen in the decrease mortality, because cases referred to the hospital were not manage well or with other words, the referral system is not ready to provide the needed services.

In the field of Neonatal Care, in collaboration with WHO Geneva she developed the mask and tube device (a tool for birth asphyxia developed for grassroots level workers). This device is approved by PATH (Partnership for Appropriate Technology) in Seattle, and now being recommended by the Department of Health and already used by more than 10.000 community midwives. Her pilot test in a rural subdistrict in West Java showed that using this resuscitation tool it is possible to decrease birth asphyxia by 50 percent especially for normal birthweight infants). She has developed other tools using Appropriate Technology Principles, but still actively seeking funds to complete the products.

When Anna launched the Surya Kanti Foundation/PUSPPA, Indonesians were just beginning to learn about early childhood development problems like autism, learning disabilities, birth defects, and hereditary diseases, and were eager to learn more about proper screening and treatment procedures. As of 1999, PUSPPA had provided clinical services for more than 9,000 visiting patients, growing to 14,000 all over Indonesia. It developed a number of programs, including epilepsy counseling and electroencephalograph services and group and individual therapy for children with developmental delays and disorders and learning disorders.

In 1999, Anna’s ECCD Program was implemented through the Tanjung Sari Demonstration Project in 14 of the 28 villages in the Tanjungsari subdistrict in Sumedang, West Java. The project provides integrated services in health, nutrition, and psychosocial development for children less than six years of age. The four step ECCD model includes:

1) Parental Education.

2) Early child education through a neighborhood playgroup meeting two to three times a week that provides three to five year-old children with experiences in socialization, gross and fine motor skills and language development.

3) Early detection and intervention through a partnership between community midwives and village health cadres to assist mothers through safe pregnancy and childbirth, and growth monitoring by health cadres.

4) Community empowerment through activities organized by trained community volunteers, with parents contributing to the maintenance of the activities, including transport costs with the main purpose of sustainability of the program.

Through Taman Posyandu she built in her ECCD model into government’s Posyandu (Pos pelayanan terpadu - integrated health service posts), which have spread throughout the country but typically focuses primarily on MCH activities (family planning, maternity care, baby weighing, and immunization, and nutrition monitoring.. In almost two years of field testing, the 14 Taman Posyandus reached over 700 children between the ages of two and six.

In Surya Kanti Foundation, Anna has also worked to establish a special school for the purpose of early socialization that gives special needs children the opportunity to be with other children, and helps integrate these kids into the normal school system in a process known as mainstreaming. They avoid rigid classification by “disability,” preferring instead to treat a range of conditions through interdisciplinary methods. The center also conducts research in a variety of disciplines, working across cultural barriers in assessment and evaluation methods for young children with developmental delays, as well as engineering research to design and manufacture tools, like wheel chairs for youth.

Another innovation is the design of the “home based developmental milestones” (or deteksi dini tumbuh kembang Anak = DDTK). The purpose is that mothers and cadres (grassroots level workers) can monitor child development easily. The DDTK is therefore design in a pictorial form. This pictorial milestone must be used in combination with the growth chart (or KMS terpadu). By using it together mothers and local village cadres can easily recognized when the child is deficient in growth and development with is quite often the case in rural areas. (In Indonesia, although literacy rate is increasing for women, their perception and comprehension of what they read is still low).The DDTK is now planned by the Department of National Education as a tool to monitor child growth and development throughout Indonesia. However since she is basically a researcher herself, she is not satisfied because there is lack of funding to evaluate and analyse the sensitivity and specificity of this developmental test (DDTK tool).

Since Anna’s program’s inception, the eastern provinces of Papua, West Nusa Tenggara and East Nusa Tenggara have requested support for similar initiatives. Additionally, Plan International and Save the Children have replicated it in seven provinces in East Indonesia, as well as in post-tsunami Banda Aceh. UNICEF also has succeeded in promoting the program to the Department of National Education, leading to its adaptation for Early Childhood Education Program (PAUD – Pendidikan Anak Usia Dini).

In 2003, Anna and her colleagues also established a research institution called Frontiers for Health (F2H), which focuses on community empowerment in improving child development, including design and dissemination of appropriate technologies. In the future, Anna plans to create a school for developmental therapists and continue to develop various tools using appropriate technologies and training methods to help meet the needs of children in Indonesia.

Anna was born in Jakarta in 1931, the seventh of nine children. Her father served as “bupati,” or district head, but after Japanese forces put him in prison during the Indonesian revolution, her family was unable to pay for her high school education. Realizing she would have to earn her own keep, she started working as a typist.

In her final year of high school, she decided to pursue her interests in biology and genetics by applying to medical school, whose acceptance rate was a mere ten percent. Ultimately accepted, Anna was the only woman to finish in her class, in addition to being the only member of her family to attend university. As a student assistant, she paid her way doing research, but after three years, the lack of contact with patients left her looking for more.

After completing her degree in Jakarta, Anna moved to Bandung with her husband to work in pediatrics at the medical school. She continued to cultivate her interest in babies, and began to study in neonatology with special interest in birth defects. After studying abroad for a few years, Anna returned to Indonesia in the late 1973, and opened the neonatal unit at the General Hospital Hasan Sadikin. Questioning the wisdom of only working with hospital-born infants when 90 percent of newborns were born outside of the hospital, Anna soon took on a research project in rural Indonesia. In short order, she invented new appropriate technology, including a resuscitation kit for midwives and TBAs, and, drawing on the expertise of professionals from a wide range of disciplines, devised a new approach for treating children with developmental problems.

Anna has won a number of awards, including the Aktion Sonnenschein Medaille from Aktion Sonnenschein International Congress of German Social Pediatric Association for outstanding work in the prevention of handicapped by initiating and founding the Surya Kanti Foundation (1991). Her latest innovation is another new profession in Indonesia, that of a child developmental therapist, for which she is establishing a training school. Between 1992 and 2003, Anna also served as Director for the World Health Organization’s Collaborative Center for Perinatal Care, Maternal and Child Health (WHOCC-PMC) in Bandung. Under her leadership, it became a dynamic, socio-culturally competent research institution for grassroots community-based health research.

The monitoring of growth and development has, over time, become a norm in Indonesia, and Anna’s methods are now used in more than 17 provinces. A life-time serial entrepreneur, Anna continues to develop solutions to tackle new problems.