Policy Innovations Digital Magazine (2006-2016): Innovations: From the Forest to the Health Clinic

For Pak Manto, the cost of his wife's emergency cesarean section was equal to the amount of money he received for cutting down 60 rain forest trees.

In 2007, communities like Pak Manto's in West Kalimantan (one of five provinces in Kalimantan, the Indonesian part of Borneo) were crying out for affordable health care. The right to health is not new—it was first articulated in the 1946 Constitution of the World Health Organization (WHO)—but access to basic health services has remained elusive for the world's poor in general and for West Kalimantan's communities in particular. Compounding the lack of access is affordability. Since the people of western Borneo make only $23 a month on average, even the most basic health care is too expensive.

In West Kalimantan, the inability to pay for health care expenses or basic services has led many into the lucrative business of illegal logging. Today, Borneo is experiencing one of the most rapid deforestation rates on the planet, and the UN estimates that between 1985 and 2001 it lost "56 percent of the protected tropical lowland forests."

In this context, it is crucial to analyze and address the intricate relationship between poverty, logging, and health care affordability.

Earth-Human Health Partnership

In 2005, after spending several years in the region, Dr. Kinari Webb founded Health In Harmony to start thinking of ways to create a viable earth/human health partnership. At the time, surveys documented that approximately 1,300 loggers were working out of the communities that share a border with the Gunung Palung National Park. Legendary behemoth trees with a life span of up to 1,000 years, like the Borneo Ironwoods, were being illegally cut down and sold to local sawmills, timber companies, etc. by community members, who could not afford to pay for health care services, school for their kids, or other services.

So Dr. Webb and her colleagues engaged in conversations with hundreds of people from the villages surrounding Gunung Palung National Park to try to find a holistic solution to the health, economic, and environmental problems that afflicted the communities in the region. After several weeks the need to connect health care with forest care became apparent.

In 2007, Health In Harmony launched Alam Sehat Lestari (ASRI) with the goal of engaging local communities in integrating high-quality, affordable health care with strategies to protect biodiversity and natural resources.

Since its inception, the program has put health care within reach for the 60,000 community members of the Gunung Palung watershed; and today, the patients from villages that do not participate in illegal logging receive a major discount at the ASRI Clinic. "We try to save lives and livelihoods," explains Dr. Webb. "In a country with few safety nets—where a family's $10 shortfall can keep a child out of school, where some people can't make it to the clinic because they can't afford to rent a motorbike—costs must be borne in mind."

ASRI uses a village color-coding system for patient bills to create incentives for eliminating logging. ASRI's Forest Guardians conduct rigorous quarterly verification in each village and post updates at the clinic for all patients to see and refer to. Green villages have no logging and receive a 70 percent discount on their care at the clinic. Yellow villages are those which have dramatically reduced their logging and are clearly making efforts to reduce it further. They receive a 50 percent discount. Red villages have evidence of illegal logging, but still receive a 30 percent discount for agreeing to work with ASRI to attempt to reduce it. This system of incentivizing conservation has made an impact. After five years, the number of loggers in the communities around the Park went from 1,300 to 450, and more than half the villages are now either green or yellow.

To further increase access to care, patients have six months to pay their bills. If they don't have cash, they can pay in seedlings for ASRI's reforestation sites; manure and compost for sustainable farming operations; vegetables, fruit, and rice; and/or handwoven mats, baskets, rice scoops, and hats.

Ibu Ema recently paid her bill with manure. She was an early participant in ASRI's Goats for Widows program, which provides goats to the area's most disadvantaged households—specifically, widows who are often raising families alone and have limited means of a steady income. Goat manure helps improve the quality of the soil, which is very poor due to deforestation and loss of the organic layer from the rain forest.

The results of Health In Harmony's five-year survey showed a remarkable impact. Common disease symptoms in the communities have declined dramatically across the board by as much as 68 percent. Infant mortality decreased significantly from 0.6 per 100 households to 0.4 per 100 households, and there was an increase in midwives present at births. Additionally, ASRI patients were less likely to defecate in rivers, more likely to use a restroom, and more likely to use birth control than non-ASRI patients. Importantly, ASRI appears to be lowering barriers to care. While ASRI patients' incomes are not statistically different from non-patients, ASRI patients were significantly less worried about being able to afford health care (57 percent vs. 73 percent) and accessing health care (57 percent vs. 70 percent) than non-patients, and it was significantly less likely that patients who had been to ASRI would have to choose between food and medicine.

The logging-poverty cycle can and has been broken by the Health In Harmony model. Pak Busni is a nearly toothless 56-year-old grandfather. Today, his health-insurance policy consists of about two dozen tree seedlings sprouting from black plastic bags behind his home. Three such plants have just paid for his medical exam. "I've collected seeds for my whole family," he beamed, before hoisting a seedling into the back of the pickup truck. The seeds were Borneo Ironwoods.