Why health messages fail to get through in Indonesia<\/p>\n
By Santi W.E. Soekanto<\/p>\n
JAKARTA (JP): To many, statistics may be mere numbers that do
\nnot reflect human realities, whereas to more people statistics
\nare depressing because the numbers do not seem to shift much over
\nthe decades.<\/p>\n
That is, in terms of neonatal and maternal health. In 1973, a
\nnutrition survey found that more than two-thirds of Indonesia's
\n20 million children under five years old were undernourished.<\/p>\n
In August 1998, UNICEF reported some four million Indonesian
\nchildren below the age of two were severely malnourished and more
\nthan 30 percent of the country's children were at risk of failing
\nto complete primary school due to financial difficulties as a
\ndirect result of the prolonged crisis.<\/p>\n
More than two years later, in late 2000, the Indonesian
\ngovernment stated that the number of malnourished children had
\nincreased from eight million before the economic crisis to 20
\nmillion, while the infant mortality rate had doubled from 55 to
\n100 out of 1,000 live births.<\/p>\n
A different figure was given in April 2001, but the picture
\nrendered was no less bleak when Indonesian Society of
\nPediatricians chairman Jose R.L. Batubarahim said that an
\nestimated 6.8 million babies suffered from malnutrition due to
\nthe prolonged economic crisis.<\/p>\n
The current population of Indonesia is about 210 million, with
\nthe population under five years reaching 22 million.<\/p>\n
Communication expert Henny Buftheim at the John Hopkins
\nUniversity Center for Communication Programs agreed in a recent
\ninterview that although progress had been recorded in community
\ndevelopment over more than two decades, in general the situation
\nremained unchanged. Many factors can be found to be at fault,
\namong them poor communication methods which often means that
\nhealth messages do not get through.<\/p>\n
Henny, who until early this year was a staff member of the
\nJakarta office of UNICEF, believes that community empowerment is
\nvery often a case of giving people access to information. But
\nwhat kind of information?<\/p>\n
\"Good concepts do not mean anything if we don't know how to
\ncommunicate them to the selected target groups,\" she said at her
\noffice in Jakarta. \"If you want to deliver those messages in
\nscientific (jargon), forget it.\"<\/p>\n
The Jakarta office of the John Hopkins University Center for
\nCommunication Programs has experts on communication who work on
\nways to advocate human development. \"We think about ways to
\nmobilize the community, to develop support material, we discuss
\ncommunication techniques, social marketing,\" Henny said.<\/p>\n
\"We develop television and radio campaigns for health
\ndevelopment in the language the target community speaks,\" she
\nsaid. \"We go through a series of stages from formative research,
\nto the study of the characteristics of the target community, up
\nuntil developing the material that will best convey the health
\nmessages.\"<\/p>\n
The Center for Communication Programs was established in 1988
\nat the John Hopkins School of Hygiene and Public Health. It works
\nin the field of science-based communication for health promotion
\nwhich strives to, among other things, increase audience and
\nclient participation in health promotion and advocacy. It also
\naims at building capacity for strategic communication in public
\nand private institutions, nationally and locally.<\/p>\n
In addition, it aims to develop and apply new concepts and
\ntechnology to evaluate health communication and encourage
\nnational and community leaders to support health policies and
\nprograms.<\/p>\n
The center defines public policy advocacy as the effort to
\ninfluence public policy through various forms of persuasive
\ncommunication. It includes statements, policies or practices
\nimposed by those in authority to guide or control institutional,
\ncommunity and sometimes individual behavior.<\/p>\n
The center employs a six-step advocacy cycle that starts with
\nanalysis. Effective advocacy efforts must start with accurate
\ninformation and in-depth understanding of the problem, the people
\ninvolved, the policies, the implementation or nonimplementation
\nof those policies, the organizations and decisionmakers.<\/p>\n
The second step is strategy that builds upon the analysis
\nphase to direct, plan and focus on specific goals and to position
\nthe advocacy effort with clear paths to achieve the objectives.<\/p>\n
Next comes mobilization. Events, activities, messages and
\nmaterials must be designed with the objectives, audiences,
\npartnerships and resources clearly in mind. The next phase is
\naction where planned activities are carried out continuously and
\non schedule.<\/p>\n
The fifth step is evaluation in which workers must establish
\nand measure intermediate and process indicators. This step is
\nimportant because advocacy efforts must be evaluated as carefully
\nas any other communication campaign.<\/p>\n
The final element of the cycle is continuity because advocacy,
\nlike communication, is an ongoing process rather than a single
\npolicy. Workers must develop plans to sustain and reinforce
\nchange, and persevere.<\/p>\n
The John Hopkins University has a number of maternal and
\nneonatal health projects in Indonesia, among others the STARH in
\ncooperation with the National Family Planning Board (BKKBN) which
\ncampaigns for a new paradigm of family. Workers strive to
\ndisseminate the message that quality family is one that
\nprioritizes health over any other achievement.<\/p>\n
\"We try to encourage people to include health priorities as
\npart of their goals for the future such as education,\" Henny
\nsaid.<\/p>\n
One important element of the campaign is to convince the
\ncommunity, as the stakeholder, that responsibility for health
\ndevelopment is not solely the government's but theirs as well.
\nEveryone is invited to contribute whatever they can to the
\nprocess.<\/p>\n
Another concept is community empowerment, Henny said, where
\npeople are asked to identify their own potential and count the
\ncost and benefits of their action. \"For instance, a community
\nwithout a latrine is asked to weigh the cost and benefits of
\nbuilding one,\" Henny said. \"Not to have one means the spread of
\ndisease. To build one, they would need to fork out at least Rp
\n40,000 in material. The choice is theirs.\"<\/p>\n
In West Java, where the maternal mortality rate is quite high,
\nit has been found that many majelis taklim (Koranic study circles
\nwhose members are usually women) have raised significant amounts
\nof money among themselves.<\/p>\n
\"They have money but also high number of women who die during
\nchildbirth ... we assembled them and told them that it was their
\nresponsibility to care for every pregnant woman in the village.
\nWith the money, some study circles then bought ambulances so
\nthere wouldn't be a lack of transportation for women in labor,\"
\nHenny said.<\/p>\n
\"They identified potential blood donors. So, all stages for
\nthe saving of a mother's life is being managed by the community
\nitself,\" Henny said.<\/p>\n
In the 1980s when she worked for a Canadian funding agency in
\nan Irian Java village, Henny found how the locals had to walk
\nkilometers in order to fetch clean water. Rather than giving them
\nmoney, the agency asked the locals to identify what they had
\navailable and what they did not have.<\/p>\n
\"They needed water. They said, 'We have sand and stones but we
\ndon't have pipes.' So we provided them with pipes, and they
\nprovided the manpower,\" Henny said. \"In no time, they had a water
\nsupply and water taps. They no longer had to walk far for water.
\nWhich meant they had more time on their hands.<\/p>\n
\"Next, we asked them to identify what resources they had in
\nabundance in their region. Nutmeg, they decided. They could make
\nsweet boiled nutmeg, but they did not how to market their
\nproduct. We then sent out two villagers to study food processing
\nand marketing in Yogyakarta -- they were to teach the others upon
\ntheir return.<\/p>\n
\"They had water, and an income generating activity from
\nprocessing nutmeg. The next thing they wanted was to establish a
\ncooperative,\" Henny said. \"When I visited the village two years
\nlater, I almost couldn't recognize the place, so changed it was.\"<\/p>\n
The prerequisite of leaving the choices to the community,
\nhowever, is access to information.<\/p>\n
Henny described how another thing that had yet to change over
\nthe decades was the relation between non-governmental
\norganizations (NGOs) and the government, which remains imbalanced
\nat best.<\/p>\n
\"I have been working with NGOs such as ELSAM (the Institute
\nfor Policy Research and Advocacy) and Walhi (Indonesian Forum for
\nthe Environment) for a very long time, and they are all
\ndevelopment oriented,\" Henny said. The NGOs focus on concepts
\nsuch as accountability, and the importance of teaching people not
\nonly how to fish but also helping them identify the spots where
\nthere are fish, Henny said. Unlike government agencies, however,
\nNGOs can only move in scaled down space and time.<\/p>\n
\"Even then, their performance is good enough to make them a
\nrole model, and yet the government remains suspicious of the
\nNGOs,\" Henny said. Some things never change, she said.<\/p>\n
In the 1980s, no matter how good an NGO was, the government
\nwould never make it a partner in community development programs.
\nAt best, it was made into a subcontractor while the government
\ncontinued to hold the purse strings.<\/p>\n
\"Now, many government agencies say yes to reform, but only
\nconceptually while continuing in the same mode for their day-to-
\nday operations,\" she said.<\/p>\n
As a consequence, today's NGO activists have the same
\ncomplaints as their predecessors did in the 1980s. \"They still
\nspeak about the lack of equal partnership, complain about how
\ndonor agencies want to dictate their agenda, how the agencies use
\nexpatriate consultants despite the presence of equally skilled
\ndomestic consultants and this causes high overhead costs,\" she
\nsaid.<\/p>\n
Henny blamed the lack of progress in this particular area to
\nthe absence of social integrity. \"There is no honesty to
\nourselves or the public. People are suffering out there but here
\nwe dispute about whose jurisdiction a program should be under.
\nAnd no program means no money.\"<\/p>\n
Henny cited how a number of agencies agree to launch an
\n\"integrated\" program but quarrel over who should do what. If one
\nagency develops support material for the campaign, the other
\nagencies insist on developing their own (and wasting money in the
\nprocess) rather than using the same material.<\/p>\n
\"Twenty years of working on problems which are basically the
\nsame, with people who are basically the same, wreaks havoc with
\nmy metabolism,\" Henny joked.<\/p>\n
\"But it is high time this wasteful practice is stopped. We
\nneed real integrated collaboration, for the sake of the people.\"<\/p>",
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