Why health messages fail to get through in Indonesia

By Santi W.E. Soekanto

JAKARTA (JP): To many, statistics may be mere numbers that do not reflect human realities, whereas to more people statistics are depressing because the numbers do not seem to shift much over the decades.

That is, in terms of neonatal and maternal health. In 1973, a nutrition survey found that more than two-thirds of Indonesia's 20 million children under five years old were undernourished.

In August 1998, UNICEF reported some four million Indonesian children below the age of two were severely malnourished and more than 30 percent of the country's children were at risk of failing to complete primary school due to financial difficulties as a direct result of the prolonged crisis.

More than two years later, in late 2000, the Indonesian government stated that the number of malnourished children had increased from eight million before the economic crisis to 20 million, while the infant mortality rate had doubled from 55 to 100 out of 1,000 live births.

A different figure was given in April 2001, but the picture rendered was no less bleak when Indonesian Society of Pediatricians chairman Jose R.L. Batubarahim said that an estimated 6.8 million babies suffered from malnutrition due to the prolonged economic crisis.

The current population of Indonesia is about 210 million, with the population under five years reaching 22 million.

Communication expert Henny Buftheim at the John Hopkins University Center for Communication Programs agreed in a recent interview that although progress had been recorded in community development over more than two decades, in general the situation remained unchanged. Many factors can be found to be at fault, among them poor communication methods which often means that health messages do not get through.

Henny, who until early this year was a staff member of the Jakarta office of UNICEF, believes that community empowerment is very often a case of giving people access to information. But what kind of information?

"Good concepts do not mean anything if we don't know how to communicate them to the selected target groups," she said at her office in Jakarta. "If you want to deliver those messages in scientific (jargon), forget it."

The Jakarta office of the John Hopkins University Center for Communication Programs has experts on communication who work on ways to advocate human development. "We think about ways to mobilize the community, to develop support material, we discuss communication techniques, social marketing," Henny said.

"We develop television and radio campaigns for health development in the language the target community speaks," she said. "We go through a series of stages from formative research, to the study of the characteristics of the target community, up until developing the material that will best convey the health messages."

The Center for Communication Programs was established in 1988 at the John Hopkins School of Hygiene and Public Health. It works in the field of science-based communication for health promotion which strives to, among other things, increase audience and client participation in health promotion and advocacy. It also aims at building capacity for strategic communication in public and private institutions, nationally and locally.

In addition, it aims to develop and apply new concepts and technology to evaluate health communication and encourage national and community leaders to support health policies and programs.

The center defines public policy advocacy as the effort to influence public policy through various forms of persuasive communication. It includes statements, policies or practices imposed by those in authority to guide or control institutional, community and sometimes individual behavior.

The center employs a six-step advocacy cycle that starts with analysis. Effective advocacy efforts must start with accurate information and in-depth understanding of the problem, the people involved, the policies, the implementation or nonimplementation of those policies, the organizations and decisionmakers.

The second step is strategy that builds upon the analysis phase to direct, plan and focus on specific goals and to position the advocacy effort with clear paths to achieve the objectives.

Next comes mobilization. Events, activities, messages and materials must be designed with the objectives, audiences, partnerships and resources clearly in mind. The next phase is action where planned activities are carried out continuously and on schedule.

The fifth step is evaluation in which workers must establish and measure intermediate and process indicators. This step is important because advocacy efforts must be evaluated as carefully as any other communication campaign.

The final element of the cycle is continuity because advocacy, like communication, is an ongoing process rather than a single policy. Workers must develop plans to sustain and reinforce change, and persevere.

The John Hopkins University has a number of maternal and neonatal health projects in Indonesia, among others the STARH in cooperation with the National Family Planning Board (BKKBN) which campaigns for a new paradigm of family. Workers strive to disseminate the message that quality family is one that prioritizes health over any other achievement.

"We try to encourage people to include health priorities as part of their goals for the future such as education," Henny said.

One important element of the campaign is to convince the community, as the stakeholder, that responsibility for health development is not solely the government's but theirs as well. Everyone is invited to contribute whatever they can to the process.

Another concept is community empowerment, Henny said, where people are asked to identify their own potential and count the cost and benefits of their action. "For instance, a community without a latrine is asked to weigh the cost and benefits of building one," Henny said. "Not to have one means the spread of disease. To build one, they would need to fork out at least Rp 40,000 in material. The choice is theirs."

In West Java, where the maternal mortality rate is quite high, it has been found that many majelis taklim (Koranic study circles whose members are usually women) have raised significant amounts of money among themselves.

"They have money but also high number of women who die during childbirth ... we assembled them and told them that it was their responsibility to care for every pregnant woman in the village. With the money, some study circles then bought ambulances so there wouldn't be a lack of transportation for women in labor," Henny said.

"They identified potential blood donors. So, all stages for the saving of a mother's life is being managed by the community itself," Henny said.

In the 1980s when she worked for a Canadian funding agency in an Irian Java village, Henny found how the locals had to walk kilometers in order to fetch clean water. Rather than giving them money, the agency asked the locals to identify what they had available and what they did not have.

"They needed water. They said, 'We have sand and stones but we don't have pipes.' So we provided them with pipes, and they provided the manpower," Henny said. "In no time, they had a water supply and water taps. They no longer had to walk far for water. Which meant they had more time on their hands.

"Next, we asked them to identify what resources they had in abundance in their region. Nutmeg, they decided. They could make sweet boiled nutmeg, but they did not how to market their product. We then sent out two villagers to study food processing and marketing in Yogyakarta -- they were to teach the others upon their return.

"They had water, and an income generating activity from processing nutmeg. The next thing they wanted was to establish a cooperative," Henny said. "When I visited the village two years later, I almost couldn't recognize the place, so changed it was."

The prerequisite of leaving the choices to the community, however, is access to information.

Henny described how another thing that had yet to change over the decades was the relation between non-governmental organizations (NGOs) and the government, which remains imbalanced at best.

"I have been working with NGOs such as ELSAM (the Institute for Policy Research and Advocacy) and Walhi (Indonesian Forum for the Environment) for a very long time, and they are all development oriented," Henny said. The NGOs focus on concepts such as accountability, and the importance of teaching people not only how to fish but also helping them identify the spots where there are fish, Henny said. Unlike government agencies, however, NGOs can only move in scaled down space and time.

"Even then, their performance is good enough to make them a role model, and yet the government remains suspicious of the NGOs," Henny said. Some things never change, she said.

In the 1980s, no matter how good an NGO was, the government would never make it a partner in community development programs. At best, it was made into a subcontractor while the government continued to hold the purse strings.

"Now, many government agencies say yes to reform, but only conceptually while continuing in the same mode for their day-to- day operations," she said.

As a consequence, today's NGO activists have the same complaints as their predecessors did in the 1980s. "They still speak about the lack of equal partnership, complain about how donor agencies want to dictate their agenda, how the agencies use expatriate consultants despite the presence of equally skilled domestic consultants and this causes high overhead costs," she said.

Henny blamed the lack of progress in this particular area to the absence of social integrity. "There is no honesty to ourselves or the public. People are suffering out there but here we dispute about whose jurisdiction a program should be under. And no program means no money."

Henny cited how a number of agencies agree to launch an "integrated" program but quarrel over who should do what. If one agency develops support material for the campaign, the other agencies insist on developing their own (and wasting money in the process) rather than using the same material.

"Twenty years of working on problems which are basically the same, with people who are basically the same, wreaks havoc with my metabolism," Henny joked.

"But it is high time this wasteful practice is stopped. We need real integrated collaboration, for the sake of the people."