revitalizing local ownership of family planning

REVITALIZING LOCAL OWNERSHIP OF FAMILY PLANNINGA DECADE OF ADVOCACY IN INDONESIAFebruary 2021

» Secured US $17.8 million in local funding for family planning. From 2009 through 2019, AFP’s 10 focus districts and their villages allocated a total of nearly 183.1 billion Indonesian Rupiah (IDR) (US $17.8 million) to local family planning activities.

» Safeguarded family planning in national plans and protocols. When the national health insurance scheme launched in 2018, AFP ensured full coverage of family planning services. In addition, we made sure that new government guidance for districts, municipalities, and villages on funding and planning local activities included family planning.

EXECUTIVE SUMMARYIndonesia’s family planning program has undergone several transformations in its seventy-year history. By the start of the 21st century, the program—historically one of the strongest in the world—had stagnated and progress slowed. A decade of strategic advocacy has since re-energized the family planning community, enabling collaboration across government and civil society to leverage multi-sector investment, capitalize on policy change, and improve access to quality information, services, and supplies. A key catalyst: the Advance Family Planning (AFP) initiative.

At every level—from village heads to district mayors, provincial governors to national ministers—the AFP initiative has shown that advocacy can help leaders act on their promises and better meet the needs of their constituents. Local partners Yayasan Cipta and the Johns Hopkins Center for Communication Programs Indonesia (JHCCP Indonesia), in collaboration with government partners, have:

A decade of strategic advocacy has reenergized the family planning community.

Photo by Lau Rey courtesy of Flickr Creative Commons

SMART advocacy expanded to 65 districts over a decadeAFP Focus Districts

Government Expansion

» Improved quality and access across the country. AFP’s advocacy potentially reached 63 million women of reproductive age. Policy changes helped build capacity of family planning providers, supported mobile family planning services in remote areas, and improved data reporting and management.

» Reinvigorated the family planning program at the community level. From their own budgets, 611 villages in eight districts allocated a total of nearly

9.52 billion IDR (US $692,000) for their family planning activities from 2013 through 2019. AFP’s advocacy at the national level ensured that villages across the country could include dedicated family planning activities.

» Strengthened local ownership of family planning.AFP facilitated the establishment of 572 multisector advocacy working groups—16 provincial, 10 district, 31 subdistrict, and 548 village teams, involving about 6,000 participants.

■ AFP FOCUS GEOGRAPHIES■ GOVERNMENT EXPANSION

SMART advocacy expanded to 65 districts over a decade

REVITALIZING LOCAL OWNERSHIP OF FAMILY PLANNING: A DECADE OF ADVOCACY IN INDONESIA 3

“AFP’s advocacy approach has allowed all government sectors to harmoniously and effectively work together with others.”

—FAMILY PLANNING OFFICIAL, KUNINGAN

What is SMART?

Over the last half of the 20th century, Indonesia was committed to reducing fertility and harnessing the rewards of a demographic dividend—the period of accelerated economic growth that occurs when a country’s birth and death rate decline, the population’s age structure changes, and the right investments in social and economic policies are made. In the 1950s, Indonesian women had 5.5 children on average; by 1998, they had 2.5.

PRE-2009:FAMILY PLANNING FRAGMENTS AND PROGRESS STALLS

But the fertility rate has fallen only slightly since the late 1990s, to about 2.4 currently. Between the 2007 and 2017 Demographic and Health Surveys (DHS), the level of contraceptive use increased only slightly to 64% among married women of reproductive age.1,2 But as the overall contraceptive rate increased, the modern contraceptive prevalence rate decreased from 58% to 57% and unmet need for family planning remained stagnant at 11%.2

A likely contributor was the rapid decentralization of government in 2001. Suddenly, the local governments of the country’s more than 500 districts took on policy and funding roles previously fulfilled by the central government, including those for health services and supplies. Without adequate evidence and expertise to inform their decision-making, districts did not see family planning as a priority. At the same time, funding for the National Population and Family Planning Board (BKKBN) dropped, and some family planning district offices were merged with other programs. Alongside these changes, the private sector began providing family planning services with many other health services.

Photo by Yayasan Cipta

4 ADVANCE FAMILY PLANNING

With more budgetary control in local hands, sustaining and growing family planning services required buy-in from local decision-makers. Enter AFP’s Indonesian partners. In consultation with BKKBN, the initiative started small, working in Bandung and Pontianak districts in 2010 and later expanding to Bogor, Karanganyar, and Karawang districts in 2012.

Using a model to engage local champions in advocacy working groups, AFP helped generate consensus on local family planning needs, develop specific advocacy objectives, and build capacity to advocate for change. Working group membership included government officials, members of health professionals’ associations, and representatives of faith-based and other civil society organizations. Usually, the BKKBN district secretary or assistant served as chair for the groups. Members volunteered their time, and membership varied depending on the needs of each district. No two groups were alike.

Because of the historically low funding for family planning at the district level, advocacy

working groups initially focused on increasing those funds. They saw results almost immediately. Within the first year of AFP SMART advocacy, family planning budgets increased between 14 and 170 percent across the five districts.

This initial success coincided with an important moment: Indonesia’s commitment on a global stage at the London Summit on Family Planning in 2012. The government promised to include family planning freely throughout the country in its Universal Healthcare Coverage program; to broaden access and choice, especially in poorer regions; and to maintain its investment of US $263.7 million in family planning programs.3 This commitment and Indonesia’s subsequent inclusion in the Family Planning 2020 partnership helped rekindle commitment at the national level—and propel AFP’s expansion to an additional seven districts in four provinces over the next eight years. In total, these districts and their villages mobilized 183.1 billion IDR (US $17.8 million) over the past decade (see Figure 1).

What is SMART?

Indonesia’s advocacy working groups applied AFP’s SMART advocacy approach. The SMART (Specific, Measurable, Attainable, Relevant, and Time-Bound) approach helps advocates design, implement, and capture the results of an evidence-based, locally driven advocacy strategy.

2009–2012: LOCAL COMMITMENT TO FAMILY PLANNING GROWS


FIGURE 1:

Ten Districts Secure US $17.8 Million in Local Family Planning Funding

Bogor

Bandung

Karawang

Ambon

Kuningan

Pontianak

Karanganyar

Tual

Bengkayang

Kapuas Hulu

$4,803,000

$3,844,000

$2,668,000

$1,972,000

$1,220,000

$698,000

$606,000

$259,000

$227,000

$212,000

Source: District family planning offices, collected by Yayasan Cipta 2010-2020

Photo by Sarah Whitmarsh, Advance Family Planning


2012–2015:LOCAL PRIORITIES BETTER REFLECT COUPLES’ NEEDS As investment in family planning increased, AFP helped ensure those resources were directed to help better meet the contraceptive needs of local women. More than half of women want no more children, but only 13% used long acting and permanent methods (LAPMs) of contraception—implants, intrauterine devices (IUDs), and male and female sterilization.4 Districts now had the opportunity to invest in:

· promotion of LAPMs and referrals by community health workers,

· additional training for doctors and midwives on implant and intrauterine (IUD) insertion,

· transportation of rural women to clinics and hospitals for LAPM services, and

· provision of same-day, free LAPM services in health clinics.

During this time, the Improving Contraceptive Method Mix project found that use of LAPMs increased in six districts where AFP’s advocacy approach was applied.

A new opportunity arose in 2014 with the passage of a national law giving village leaders the power to manage their own budgets. Although village budgets are modest—usually about $28,000—family planning advocates saw a chance to further prioritize family planning at this lowest administrative level. In 2015 more than 1,000 villages in seven districts made allocations for family planning, from $75 to $500 per village. Allocations helped revive

SMART Advocacy Is Effective in Increasing Uptake of Long-Acting Methods

Improving Contraceptive Method Mix in Indonesia, an operations research project, showed that LAPM use increased in six districts where SMART advocacy took place, while there was no change in six comparison districts without advocacy. After leaders increased family planning funding and implemented supportive policies, the odds of married women using LAPMs were 1.12 times higher in three East Java districts with advocacy activities, than the odds in comparison districts. In three districts in West Nusa Tenggara, the odds were 1.31 higher.

Also, district allocations for family planning communication and community outreach in the intervention districts increased over the life of the project, from an average of about US $75,000 in 2013 to $100,000 in 2016.

The Johns Hopkins Center for Communication Programs led the research, with support from the University of Indonesia and Yayasan Cipta. Australia’s Department of Foreign Affairs and Trade and the U.S. Agency for International Development (USAID) funded the project as well as the Bill & Melinda Gates Foundation through AFP.


2016–2020:LEADERS EMBRACE, EXPAND, AND SUSTAIN ADVOCACY

community-based family planning programs and, in some cases, coordinate village team operations. For example, 124 of Karanganyar’s 162 villages formed their own village family planning teams by September 2015. Funding supported demand generation activities and capacity building for family planning cadres.

By 2016, the Indonesian government saw the potential for replicating AFP’s advocacy approach but wanted to explore how the approach would fare in more remote districts and provinces. This led to Ambon City, Kapuas Hulu, and Tual City joining the initiative in 2016. Although the districts received AFP support only briefly, they quickly scored policy and funding wins, proving that AFP’s SMART approach could work in any Indonesian context.

BKKBN adopts the AFP approach

BKKBN used its national platform to build on this success. It introduced the SMART approach through Kampung KB, the president’s village program, in 2016. As of September 2017, the effort had reached 346 villages in 25 districts or municipalities in six provinces. With support from the MyChoice project, a JHCCP Indonesia led initiative to reinvigorate family planning and improve contraceptive prevalence, BKKBN

“At present and in the future, advocacy becomes one of the backbones of national family planning success in Indonesia. AFP SMART, which was then adopted to BKKBN SMART, is an advocacy tool which has proven to work effectively in advocating with local government.”

— DEPUTY FOR ADVOCACY, COMMUNITY MOVEMENT, AND INFORMATION, BKKBN

Simultaneously, advocacy at the national level in 2016 with BKKBN and the Ministry of Villages led to a memorandum of understanding that made family planning a prioritized program in village budgets nationwide.


also adapted the advocacy approach as BKKBN SMART and included it in its National Advocacy Strategy in 2018 and five-year strategic plan in 2020. Under this plan, 24 of the country’s 34 provinces have formed advocacy working groups, as have 55 districts (see map on page 3).

Local advocacy continues

As BKKBN SMART took flight, AFP wanted to see whether advocacy in focus districts would continue after direct support ended. One of the first focus districts, Bandung, graduated in 2014, and the remaining nine graduated by 2017. AFP helped prepare the working groups by linking them to provincial government support and new government initiatives such as BKKBN SMART scale up. In addition, working groups asked government leaders to continue funding district working group operations after AFP assistance ended. West Kalimantan, East Java, West Nusa Tenggara, and West Java provinces allocated IDR 5.53 billion (US $471,900) between 2016 and 2018 for scaling up.

AFP decided to pilot monitoring efforts in five phased-out districts—Ambon, Kapuas Hulu, Karawang, Kuningan, and Tual. Although AFP has not provided direct assistance to working groups since December 2017, all five remain active and have annual work plans. In addition, they have been successful in advocating for increased resources for family planning and district working group operations. These districts have achieved 19 advocacy wins and allocated a total of 26.8 billion IDR (US $1.9 million) for family planning, including 838,660,000 IDR (US $59,200) for working group operations.

Each district has used its family planning allocations differently. Karawang, Kapuas Hulu, and Tual have spent most of their budgets on demand generation. Ambon has focused on improving its information system. Kuningan has emphasized both services and demand generation. Allocations for family planning continued in villages in Ambon, Karawang, and Kuningan through 2019.

Photo by Yayasan Cipta


2021 AND BEYOND: THE FUTURE OF ADVOCACY The COVID-19 pandemic has tested the strength of Indonesia’s family planning program. Clinical staff were shifted to respond to the pandemic, disrupting family planning and other essential health services. Contraceptive prevalence rates decreased between 37-40% in some provinces and around 600 private midwives stopped providing services due to their inability to procure personal protective equipment.5,6 Budget allocations for family planning and district working operations saw steep declines in three of AFP’s five monitored geographies, impacting the ability to provide services and conduct advocacy.

This setback indicates the vulnerability of the family planning advocacy and the need for continuous advocacy. But there is hope—advocates are rallying to make sure family planning remains visible and the government is invested in committing to the Family Planning 2030 partnership.

CONCLUSION When Indonesia embraced decentralization and devolution to thousands of government units across provinces, districts, and villages, it brought decision-making power closer to communities. It also made strategic advocacy for family planning a complex, multi-pronged effort. Working in partnership with national and local governments, AFP has successfully demonstrated that SMART advocacy works at all levels—even under challenging circumstances and in challenging geographies.

There is a strong infrastructure for advocacy not only to survive beyond AFP, but thrive. However, changes in government and working group members, inadequate financial support, and shifts in political priorities compromise progress and the ability to track results. High-level support, continued funding, champions to lead and hold the government accountable, and the ability to monitor progress are key to sustainability.

There is a strong infrastructure for advocacy not only to survive beyond AFP, but thrive.


REFERENCES1 Statistics Indonesia, National Family Planning

Coordinating Board, Ministry of Health, and Macro International. (2008). Indonesia Demographic and Health Survey 2007. Retrieved from https://dhsprogram.com/publications/publication-fr218-dhs-final-reports.cfm.

2 National Population and Family Planning Board, Statistics Indonesia, Ministry of Health, and ICF. (2018). Indonesia Demographic and Health Survey 2017. Retrieved from https://dhsprogram.com/publications/publication-FR342-DHS-Final-Reports.cfm.

3 Family Planning 2020. (2013). London Summit on Family Planning Summaries of Commitment. Retrieved from http://familyplanning2020.org/sites/default/files/London_Summit_Commitments_12-2-2013_13.pdf.

4 National Population and Family Planning Board, Statistics Indonesia, Ministry of Health, and ICF. (2018). Indonesia Demographic and Health Survey 2017. Retrieved from https://dhsprogram.com/publications/publication-FR342-DHS-Final-Reports.cfm.

5 Indonesian Midwives Association. (2020). Challenges Encountered and Efforts Made by Midwives in Providing Access to Family Planning and Reproductive Health Services and Information during and after COVID-19 Pandemic [PowerPoint slides].

6 Listyawardani, Dwi. Ir. (2020). Situational Mapping, Plans and Strategic / Innovative Measures for the Provision of Access to Family Planning Services and Information during and post-COVID-19 Pandemic [PowerPoint slides].

ABOUT USAdvance Family Planning is an initiative of the Bill & Melinda Gates Institute for Population and Reproductive Health within the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health. It is supported by the Bill & Melinda Gates Foundation, The David and Lucile Packard Foundation, and the William and Flora Hewlett Foundation. The AFP initiative was implemented by two organizations working in partnership with the Government of Indonesia: Yayasan Cipta and the Johns Hopkins Center for Communication Programs Indonesia.

Photo by Sarah Whitmarsh, Advance Family Planning


https://dhsprogram.com/publications/publication-fr218-dhs-final-reports.cf

https://dhsprogram.com/publications/publication-fr218-dhs-final-reports.cf

https://dhsprogram.com/publications/publication-FR342-DHS-Final-Reports.cfm


http://familyplanning2020.org/sites/default/files/London_Summit_Commitments_12-2-2013_13.pdf

http://familyplanning2020.org/sites/default/files/London_Summit_Commitments_12-2-2013_13.pdf



AFP and its partners in Indonesia acknowledge the contributions of the National Population and Family Planning Board (BKKBN) at both National and Provincial levels, especially West Java, West Kalimantan, Central Java, and Maluku Provinces; Dinas Pengendalian Penduduk, Pemberdayaan Perempuan, Perlindungan Anak dan Keluarga Berencana (DP2P3AKB) – Office of Population Control, Women Empowerment, Child Protection and Family Planning of Pontianak City; Health, Population Control, and Family Planning Office of Bengkayang District; Dinas Sosial dan Pemberdayaan Perempuan, Perlindungan Anak, Pengendalian Penduduk dan Keluarga Berencana (Dinsos P3AP2KB) – Office of Social Affairs, Women Empowerment, Child Protection, Population Control and Family Planning of Kapuas Hulu District; Dinas Pengendalian Penduduk dan Keluarga Berencana (DPPKB) – Office of Population Control and Family Planning of Ambon City; Dinas Pemberdayaan Perempuan, Perlindungan Anak, Pengendalian Penduduk dan Keluarga Berencana (DP3AP2KB) – Office of Women Empowerment, Child Protection, Population Control and Family Planning of Tual City; Dinas Pengendalian Penduduk dan Keluarga Berencana (DPPKB) – Office of Population Control and Family Planning of Kuningan District; Dinas Pengendalian Penduduk dan Keluarga Berencana (DPPKB) – Office of Population Control and Family Planning of Karawang District; Dinas Pemberdayaan Perempuan, Perlindungan Anak, Pengendalian Penduduk dan Keluarga Berencana (DP3AP2KB) Office of Women Empowerment, Child Protection, Population Control and Family Planning of Karanganyar District; Dinas Pengendalian Penduduk, Pemberdayaan Perempuan, Perlindungan Anak dan Keluarga Berencana (DP2P3AKB) – Office of Population Control, Women Empowerment, Child Protection and Family Planning of Bandung District; Dinas Pemberdayaan Perempuan, Perlindungan Anak, Pengendalian Penduduk dan Keluarga Berencana (DP3AP2KB) Office of Women Empowerment, Child Protection, Population Control and Family Planning of Bogor District; Members of District Working Groups (DWG) of Bandung, Bogor, Kuningan, Karawang, Karanganyar, Pontianak City, Kapuas Hulu, Bengkayang, Tual City, and Ambon City.

INDONESIAJohns Hopkins Center for Communication ProgramsEddy Hasmi: [email protected]

Yayasan Cipta Dini Haryati: [email protected]

UNITED STATESBill & Melinda Gates Institute for Population and Reproductive Health

Johns Hopkins Bloomberg School of Public HealthMervyn Christian: [email protected]

ACKNOWLEDGMENTS

revitalizing local ownership of family planning

Documents