NATIONAL 2 (Spotlight Weekly)]

For The People

Indonesia has shown how an integrated health system based on community participation can successfully manage a country's population

By KESHAB POUDEL in Yogyakarta Province, Indonesia

For many, the sight was extraordinary: Muslim youths performing popular scenes from the Hindu epic Ramayana. Every day a group of youths perform the Ramayana Ballet at Prambaba Area of Yogyakarta province of Indonesia, the world's largest Muslim country.

Discussion of family Planning : Learning by experience

Indonesians regard the Ramayana as one of their important legends. This may be the reason why even during the fasting month of Ramadan, Muslim youths were busy playing the roles of Rama, Laxman, Sinta (Sita), Prabhu Rahwana (Rawana), Hanuman and Janak. The influence of Sanskrit on Indonesia is not new, as the national language consists of many Sanskrit words.

Indonesians discuss matters concerning family planning (FP) and reproductive health (RH) with equal ease. Because of the people's abiding commitment and accommodative social attitudes, FP/RH programs have been successfully implemented across the country, including the Hindu-dominated province of Denpasar (Bali).

Janak's Mantili (Mithila) Kingdom and birthplace of Sita in Nepal, however, has a different story to tell. The country is grappling with the challenges presented by a rapidly expanding population.

The community's fervor in performing the Ramayana ballet provides an indication of how a liberal approach to FP/RH programs has worked in Indonesia over the decades. "We have been successful in carrying out FP and RH programs because the community accepts their importance in raising a quality family," said Dr. Jasmi Kamil, executive secretary of the International Training Program of the National Family Planning Coordination Board (BKKBN).

Hindu temple in Bali : Culture of harmony

Hindus, Buddhists and Christians have been living in harmony with Indonesia's dominant Muslim population. Cultural and religious tolerance down to the local community has been one of the hallmarks of the nation, and one of the primary reasons for the success of community-based family planning endeavors.

Under a carefully planned campaign, Indonesians population policymakers have been able to instill a sense of ownership in the community. "We are not responsible for implementing the program. There are various institutions established to carry out the works, including religious, education, health, social welfare, non-governmental organizations and institutions. FP and RH are integrated with various institutions," said Dr. Kamil.

Indonesia, which is an archipelago made up of 13,500 island, has a population of 204.39 million representing many ethnic groups and languages. The national language is Bahasa Indonesian. Eighty-seven percent of Indonesians are Muslim. About 9.7 percent of the population is Christian, 1.1 percent Buddhist and 1.8 percent Hindu.

The tradition of religious and cultural harmony is reflected in the effective implementation of family planning programs in the grass-roots level. Only one percent of the male population uses contraceptives. It is the country's women who have led the movement to make FP and RH programs successful.

Like the Ramayana, the BKKBN is a household name in Indonesia. Initiated during the 30-year rule of president Suharto, who was deposed in a 1998 uprising, the BKKBN has firmly established its popularity among the people.

Nepal and Indonesia began FP and RH programs almost at the same time. But Nepal has not been able to meet its national target of reducing the population growth rate and improving RH services. "We have been successful because our leadership has been totally committed to the program," said Dr. Masri Mudaz, director of the BKKBN's Center for International Training and Collaboration.

As a national coordinating body, the BKKBN is responsible for formulating and implementing FP/RH programs in Indonesia. The Suharto government launched the family planning policy 30 years ago when the country's population growth rate was alarmingly high. Suharto's commitment was responsible in large part for bringing Indonesia's population growth rate below 2 percent in 30 years.

As the BKKBN has implemented a vision for a prosperous and healthy family, people respect the workers of the organization. After the downfall of Suharto, the momentum of FP\RH programs gradually slowed. Since it is well accepted in the community level, the impact of the FP\RH campaign will remain undiminished.

Adolescents in public health : High participation

A decentralized approach based on community participation throughout the phases of planning, implementation and evaluation has made the FP/RH initiative successful. According to the State of World Population 2001, the average population growth rate of Indonesia is 1.2 percent, compared to 2.3

percent in Nepal. The total fertility rate is 2.27 in Indonesia and 4.48 in Nepal. Birth with attendants is 56 in Indonesia and 9 in Nepal. Indonesia's literacy rate is more than 90 percent.

With support from United Nations Population Fund (UNFPA), 11 Nepalis joined four Bangladeshis on an observation study tour on planning and managing a community-based national family planning and reproductive health program under a decentralized approach in Jakarta, Yogyakarta Province and Denpasar Bali. During the tour, the Nepalis and Bangladeshis observed sub-village, village, sub-district and district-level campaigns implemented in Yogyakarta province.

Nepal has been implementing the policy of decentralization for more than two decades, but it has not been able to achieve its targets. Nepal has experimented successfully with community participation in the forestry sector through a decentralized approach. The country's tremendous success in mobilizing the local people in the preservation of forests has been acclaimed internationally. Nepal has shown that by making community members stake holders, the country can change the fate of development programs.

In Nepal's health sector, there are institutions working from the wards to the center, but there is a lack of mechanism for effective community participation. The government implements FP and RH programs without coordinating them with other components, including education. "We also have some very successful programs in the health sector. The problem with us is the lack of political commitment in the grass-roots level," said Tek Bahadur Dangi, senior public health administrator of the Family Health Division.

Indonesia's experience has demonstrated that FP and RH programs need to be integrated with other components in order to be successful. Yogyakarta has achieved important progress in the area of population management. According to the Indonesia Demographic Health Survey (IDHS) 1997, Total Fertility Rate of Yogyakarta is 1.70 percent while the national rate is 2.86. The province's population growth rate in 1990 was 0.58 percent while that of the nation as a whole was 1.97. The prevalence rate of contraception based on IDHS 1994 for any method is 69.5 and 59.7 percent for modern method. At the national level, it was 54.7 for any method and 52.1 for modern method.

"We have been working to formulate a long-term population management program by encouraging the local community to participate," said Purshottam Prasad Tiwari, under-secretary and division chief of IEC, Ministry of Population and Environment.

The record-keeping process in Indonesia has also played a significant role in monitoring various kinds of behaviors and reproductive health patterns of families. The integration of FP/RH programs to religion also has shown positive results. The importance of family planning and reproductive health is taught from very beginning, particularly to women.

"Recording, reporting, monitoring and evaluation are important components in implementing RH programs. We are also stressing the need to introduce such a mechanism," said Dr. Peden Pradhan, Assistant Representative of the UNFPA.

Dancers of Bali : Rich heritage

As the female literacy rate is fairly high in Java, there is a high prevalence of use of temporary FP method to delay birth. As soon as a couple decides to marry, local institutions intervene in their life, activating various mechanisms.

An eligible couple needs to take a certificate from religious officials in the sub-district level before marriage. This is the place where family planning and health officials inform them of the importance of family planning in raising a quality family.

"We also have a system to monitor activities in the district level, but what is lacking is manpower to mobilize the community. I will introduce some ideas experimented in Indonesia," said Dr. Sagar Kumar Rajbhandari, District Health Officer of Salyan in western Nepal.

Village-level volunteers have played an important role in the execution of Indonesia's FP and RH programs. These volunteers are able to contribute effectively to community development as they come from the area they are serving. To facilitate interaction, groups of acceptors, usually comprising between 15 and 60 members, are formed. Group members are brought together for social and civic reasons. The group meets each month to discuss its members' family planning status. It is used to exert a form of peer pressure on the non-acceptor part of the community.

In each sub-district level, there is an integrated service post consisting of community midwife, youth group, mother-friendly movement and IEC. These institutions help to popularize family planning programs at the grass-roots level. Along with other programs, family income-generating projects initiated and maintained by acceptor groups are vital to motivating and encouraging women.

"Nepal's family planning approach is based on a centralized concept, whereas Indonesia has followed a decentralized approach and has handed over ownership to the community," said Anita Rijal, director of the Women's Development Department. "We need to develop an approach for local-level social preparation and community involvement in an institutional manner."

Those who went on the observation tour accepted the importance of increasing the involvement of community volunteers. As Nepal has a large number of family community health volunteers, they can be mobilized in conducting more efficient outreach initiatives. The Nepalese participants of the observation tour agreed to the need to initiate family enumeration systems on a pilot basis and to establish post-clinic evaluation mechanism, activate health management committees at different levels for review and monitoring activities on a monthly basis.

As Nepal has direct experience of the centrality of a decentralized approach for local development, the Indonesian approach to FP/RH programs can easily be adopted in the country in order to manage its population. But who will take the lead?