Indonesia’s Big Bang

group of women planning
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©2014 Aji Styawan, Courtesy of Photoshare

NUSA DUA, BALI—In a family-owned shop, known here as warung, the local owner wondered why I was in Bali.  When I told her I was attending the 4th International Conference on Family Planning, she smiled in approval. She wanted to grow her business to be able to provide the best for the three children she already had, she said, adding that spacing her babies and limiting their number was an important strategy for reaching that goal.

I asked when her kids were born, and learned the answer wasn’t exactly clear-cut. The 365-day Gregorian calendar differs from the Balinese pawukon calendar, a numeric calendar of 210 days per year; and that diverges from the Balinese saka calendar, based on the phases of the moon.

Whatever calendar you’re using, there’s no doubt the shopkeeper’s children were born in the era of decentralization in Indonesia.

Back in 2001, there was a “massive, rapid and drastic decentralization” of the government, explains Izhar Fihir, MD, who in 1982 earned his MPH degree at the Johns Hopkins School of Public Health.  Now a member of the Core Working Group for Family Planning in Indonesia, Fihir described the dramatic shift of authority from central to local governments as a “Big Bang” that sent family planning reeling.

In the pre-decentralization era, a vibrant and 55,000-person strong National Population and Family Planning Board (BkkbN) with the Ministry of Health built Indonesia’s family planning program to one of the best in the world. It had funding and priority. Then, when the government decentralized, family planning was relegated to 500-plus districts encompassing 82,000 villages across the more than 15,000 islands that comprise Indonesia. Decision-making landed in the laps of district leaders who didn’t always grasp the importance of investing in family planning or feel bound to uphold lofty national promises committed to by others, according to Abidin Shah Siregar of BkkbN. As a result, support dwindled for family planning. For example, the number of village-level field workers who promote and counsel about family planning plummeted from 33,000 in the 1990s to 15,000 in 2007. 

While decentralization is the main culprit behind family planning’s protracted stagnation here, there are others, such as the privatization of health services.

Now, local family planning units are small entities with low status and weak technical capacity.  Their budgets often are combined with other initiatives and subsumed by competing priorities. In fact, of the 514 sub-national districts that comprise Indonesia, only 26 have family planning offices separate and distinct from other agencies.

“There is a joke that the only office never merged into family planning is the fire department,” said Heri Haerudin, team lead of the Johns Hopkins Center for Communication Programs in Indonesia.

A champion of family planning, Haerudin doesn’t find the joke very funny. But he is optimistic.

After a decade of stubborn stagnation, during which the contraceptive prevalence rate has remained flat at 57.4 percent, with unmet need hovering around 10 percent, family planning in Indonesia has a breath of new life.

In fact, Indonesia was chosen to host the 2016 ICFP because its family planning programs are in the midst of rejuvenation. Notably, the Indonesian government, through BkkbN, in 2014 signed a memorandum of understanding to revitalize the family planning program with the Johns Hopkins Bloomberg School of Public Health, which is providing financial and technical assistance in a number of areas.

Among the sources of reinvigoration: Family planning advocacy that is diplomatic, evidence-based, flexible and strategic as well as patient but persistent. 

For the past five years, the Advance Family Planning (AFP) initiative (with lead coordinating partner the Bill & Melinda Gates Institute for Population and Reproductive Health) has been working in Indonesia as well as eight other countries, ground testing and refining a simple but powerful advocacy approach with local district working groups across this multi-cultural island nation.

Smart and targeted advocacy for family planning at every level is critical in the decentralization era, Haerudin insists. He credits three vital AFP tools for helping to pry Indonesia’s family planning program out of its decade-long slump:

  • AFP SMART - a step-by-step approach to developing a focused, collaborative advocacy strategy that leads to quick wins
  • Netmap - an interview-based mapping tool that helps working group members figure out who influences decisions so they can develop a networking plan of action
  • Family Planning Costing Projection Tool – a tool that helps estimate the cost to implement effective family planning programs at the district level

These tools enable family planning champions to target key people who influence decisions at the district level. They also facilitate discussions about the concrete costs and benefits of family planning, Haerudin said.

It’s been game changing when district leaders learn how little family planning programs will cost their districts compared to the projected costs of immunizing babies and educating children. Decision makers who want connect their actions and investments to the development of their districts have had “Aha” moments—and changes of heart when it comes to investing in family planning programs—after advocates share cold, hard quantitative data about family planning’s payoffs instead of vague qualitative promises. 

As of 2014, the Indonesian government issued a law allowing village leaders to manage their own village budgets. As a result, family planning advocates here are concentrating on not only districts, but also villages to improve access to family planning information, services, and supplies. In 2015, the first year the funds were available, more than 1,000 villages in seven districts allocated funds for family planning.

“The consequences of decentralization in Indonesia have been profound, but not unique,” said Duff Gillespie, PhD, director of AFP, and a professor in Population, Family and Reproductive Health at the Bloomberg School.

During  a 4-day pre-ICFP workshop hosted by AFP, advocates from Indonesia, Tanzania, Kenya and the Democratic Republic of the Congo worked together with 22 participants from 14 countries, including Pakistan, Burkina Faso, Madagascar, to learn and adapt the AFP advocacy framework to various cultures and countries, some of which are experiencing their own versions of decentralization of decision-making. 

Kenya, for instance, had its own “big bang” devolution in 2013. Sharing his country’s successes and challenges—many of which mirror Indonesia’s experiences—was Sam Mulyanga, a senior advocacy advisor for Jhpiego Kenya.

While Kenya’s county-level technocrats might not be moved by emotional pleas to fund family planning services for the sake of women and children, they can be swayed by data that show substantial cost savings, Mulyanga said. When he shares a tool devised by the Guttmacher Institute with local leaders, they see for themselves that every local dollar invested in family planning has a return of $4- to $7. The numbers reveal that family planning isn’t just a women’s issue, or a health issue, he says: It’s a development issue.  

Smart advocacy techniques like this employed in Kenya have resulted in four counties, for the first time ever, allocating $250,000 (total) toward family planning in their 2015-2016 budgets, Mulyanga said.

Still, decentralization remains a sobering stumbling block in the way of many countries reaching their Family Planning 2020 (FP2020) commitments—and their broader Sustainable Development Goals, Gillespie emphasized during an ICFP 2016 panel discussion (Fulfilling the Promise of Family Planning Through Decentralization) that he moderated Tuesday. Getting all levels of decision-makers on board with family planning is key to achieving the FP2020 goal of reaching an additional 120 million women and girls (by the year 2020) with family planning information, services and supplies.

AFP Indonesia has come a long way since being piloted in 2010. As a result of AFP expanding across Indonesia and ramping up around the globe, the estimated number of people impacted by the advocacy approach has increased from 7.3 million in 2014 to 22 million in 2015, and is projected to impact 92 million by 2018, according to Gillespie.

“Family planning is not only contraception,” explained Dini Haryati of Yayasan Cipta Cara Padu, team lead of AFP Indonesia. “It is way beyond that, and related to (all people’s) quality of life.

“Family planning belongs to all of us.”

AFP is one of the fruits of a 40-year partnership between Johns Hopkins University and Indonesia. A new brief, released during ICFP 2016, documents this sustained collaboration, a four-decade-long case study of public health in action.  

Advance Family Planning (AFP) is an evidence-based advocacy initiative of the Bill and Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health. It is supported by the Bill & Melinda Gates Foundation, the David & Lucile Packard Foundation, and The William and Flora Hewlett Foundation.

Ed note: Global Health NOW correspondent Maryalice Yakutchik, with support from the Bill and Melinda Gates Institute for Population and Reproductive Health, is among the journalists reporting from Indonesia at the 2016 ICFP. Check back every day this week for exclusives from the conference.

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