Implications of an ageing population in the Asian context.

PIP: Population aging is the increasing number and proportion of old persons aged 60 years and above in the developing countries and 65 years and above in the developed countries that exceeds 10% of the total population. In Asia, the last decade of the 20th century is marked by significant changes in the age structure due to the process of population aging. The implications of this aging population on the life of Asian countries has to be addressed since demographically the current situation is changing rapidly and there lie the future challenges that have to be answered. Due to the growing size of the elderly population, Asia will need better plans to prevent these elderly groups from turning into the socioeconomically vulnerable group of society. However, many governments are not prepared with effective policies, programs, and services that are particularly designed to care for the elderly. The provision of infrastructure and services, including education, employment, health and housing are necessary steps that need to be taken. Some of the suggested measures include: the Social Safety Net Programs; the implementation of the Association of Southeast Asian Nations Plan of Action on Rural Development and Poverty Eradication; and strengthen volunteerism and the role of private sector in human development. The role of the media in transmitting information concerning policies and programs intended to increase the welfare of the older persons is also very important.^ieng

Ready to sell our program. Anybody who is interested in learning Indonesian experience is invited to take part in the BKKBN's international training program.

PIP: The Indonesian Family Planning Program was officially launched in 1970 when President Suharto developed the National Family Planning Coordinating Board (BKKBN) to administrate the national family planning program. The inauguration of the family planning program came at the heels of a special demand by the people with very strong support of the ulama. The program was subsequently developed and expanded into remote areas in 1976. In 1992, a family-based approach to family planning was implemented in which every village family was made responsible for family planning. The program is based upon a very strong political commitment at the highest level as well as at the provincial, district, subdistrict, and village levels; it continuously innovates; every community can name its family planning program as it likes; and there is constant feedback to the community. Indonesia's family planning program strategies are as follows: it is suggested that couples in which the wife is aged 20-30 years have only two children; it is recommended that women over age 30 have no more children due to the comparatively high risks of pregnancy at that age; considerable effort is given to encourage youths to not become pregnant and bear children; numerous chairmen of small community family planning groups are appointed; and social and cultural conditions have been created in which people work for family planning activities. People interested in learning from the Indonesian experience in family planning may participate in the BKKBN's international training program.^ieng

The highest priority: how can the NAM countries continue to expand and improve the ways they learn from each other?

PIP: The author opens with a discussion of the content of population programs and the ongoing process of learning from and helping each other. Population programs used to be so narrowly defined that they were detached from important sociocultural, economic, and political realities. That definition, however, is now expanding beyond the notions of demography and family planning to accommodate the need to adjust programs to meet family needs and not vice versa. Family development is called for instead of family planning. His experience in Indonesia has shown him that simple solutions tend not to work; strong and consistent political commitment to the promotion of development is needed; bureaucrats must be honest, competent, and committed to national development; self-sustained development will not happen unless people feel they have a stake in it as both recipients and decision makers; a community-based approach is required; coercion has no place in population programs; and women are more important than men. The author also discusses how advances in science and technology initially exacerbate inequalities, the potentially positive role of governments, keys to a viable population program, making a stronger contribution, and how to pay for South-South collaboration.^ieng

Improving the quality of life.

PIP: It is encouraging that most developing countries now have population policies, but it is discouraging that some countries have been unable to implement their policies. Therefore, Indonesia believes technical cooperation should be strengthened among developing countries. International cooperation is working in 108 developing countries, but the desired impact has yet to be reached, and the quality of life in many countries is still unacceptable. For example, life expectancy at birth in developing countries is 14-17 years shorter for females and 10-13 years shorter for males as compared to developed countries which have superior health and welfare systems. The speed of population growth is also hindering efforts to help improve living conditions, and the biggest increase in growth will occur in Asia and Africa. This will increase the numbers of poor, hungry, and illiterate in developing countries and will lead to a lack of arable land, deterioration in education, and increase in unsafe sanitation. In order to slow population growth, quality family planning (FP) services must be provided to those who want them. By the year 2000, developed countries and donors should be ready to provide half of the required US$10.5 billion to FP services in developing countries. In Indonesia, population programs and policies have been governed by the National FP Coordinating Board as well as by the State Ministry for Population and the Environment, which was divided into two ministries in 1993 in order to deal with the enormity and seriousness of the two issues.^ieng

A small, happy and prosperous family.

PIP: Despite crop failures, epidemics, and wars during the 1st 1/2 of the 20th century, Indonesia's population grew steadily from 37 million in 1905 to 60.1 million in 1930 to 97 million by 1961. Between 1961 and 1971, the population was growing at an annual rate of 2.07% reaching 119 million in 1971. It grew even faster at an annual rate of 2.32% during 1971-80 attaining 147 million in 1980. Then the growth rate fell to 1.97% during 1980 and 1990 primarily attributable to the effect of the National Family Planning (FP) Program launched in 1969 as an integral part of the National Development Plan. As a result of the government population control approach the total fertility rate (TFR) fell from 5.6 in 1967-70 to 3.0 in 1989-91. The fertility rate of women aged 15-19 dropped from 155 during 1967-70 to 67 during 1989-91. The population growth rate has been reduced from a potentially insupportable level of over 2.32% during 1971-80 to 1.97% during 1980-90. The Indonesian FP Program and the National Family Planning Coordinating Board's (BKKBN) activities are determined by the policies of the People's Consultative Assembly (MPR), the supreme legislative body representing the people. The achievements of the 22-year old National FP Program are attributed to effective information, education, and motivational campaigns, institutional development, wide availability of contraceptives and large coverage of village-based health care. The program is based on the concept of the small, happy, and prosperous family adopted in 1974. Volunteer workers at health service posts register mothers, weigh babies, and provide education on nutrition, oral rehydration, immunization, and FP. Self-reliant FP expanded form under 5% of total acceptors in 1987 to 22% by 191. 26.3% of nonacceptors of FP were young couples wanting a child in 1991, while 69.3% of married couples have used contraception.^ieng

Breast-feeding and the family planning sector's initiative in Indonesia.

PIP: Breastfeeding (BF) averts an average of 28% of the total potential fertility (fecundity) per woman of reproductive age in Indonesia. Contraception adds another 35% and age at marriage and other factors inhibit 15% more of total fecundity. Only around 22% of the total fecundity is realized in actual births. This is a total fertility rate of around 3.4 per woman in 1987. BF protects infants from illness and weight loss. Bottle fed infants are supposed to be 5 to 8 times more likely to have respiratory diseases than breast fed infants. Malnutrition has been found to be higher among bottle fed babies. Improved preparation of infant formulas and management may be some of the reasons for this. Breast milk is also very economical. Most rural Indonesian women breastfeed for a long time; however, in urban areas this is generally shortened. During the 1980s, there seems to have been a revival of BF in Jakarta. This has occurred among mothers of lower socioeconomic status, but not higher socioeconomic status. More promotion efforts should be aimed at high socioeconomic status mothers. Support for "rooming-in" (where mothers can breast feed their babies on demand) is strong, but many misconceptions exist among administrators and health care providers. Many who wish to breastfeed lack information. Others do not seek advice. Most women giving birth at hospitals do not know about rooming-in. The Indonesian government is promoting BF by addressing it in development plans. Nongovernmental agencies are also interested. One of these is BK-PP-ASI. It has been set up as the national coordinating body for promoting BF. International agencies also support BF. In 1989, the National Family Planning Coordinating Board (BKKBN) developed an explicit policy to promote BF by integrating it into the national family planning program. The complementary relationship between BF and contraception will be focused on.^ieng

BKKBN and the expanding role of private sector FP services and commercial contraceptive sales in Indonesia.

PIP: The Indonesian family planning program is an internationally recognized success. Launched in 1970, the program, coordinated by the National Family Planning Coordinating Board (BKKBN), now enrolls an average of 20,000 new acceptors each day. About 60% of eligible couples participate in the program. The key factors in the BKKBN's strategy are 1) a firm commitment from all government leaders, 2) a positive relationship with religious and other leaders, 3) decentralization and flexibility, 4) a shift from a traditional clinic-based to a community-based program, and 5) the integration of the program with health, family welfare, and other development activities. The next phase of the program emphasizes self-support or self-reliance in family planning. This means taking responsibility for one's own family planning, but it also means that those who are financially able to do so should pay for services and supplies. New projects have begun with the private sector. BKKBN has been working with professional doctors' and midwives' associations to promote private initiatives for family planning. The Kondom Dua Lima, a social marketing project with a private company, distributes and sells condoms in the commercial retail sales market. The Blue Circle Contraceptive Social Marketing Project provides low-cost but high-quality contraceptive supplies to fill the gap between free BKKBN supplies and the expensive contraceptives available through commercial pharmacies. BKKBN is working with the private sector to encourage its participation in the Indonesian goal of institutionalizing the small, happy, and prosperous family norm.^ieng

The strategies, experiences and future challenges of the information component in the Indonesian Family Planning Programme.

PIP: In 1957, the Indonesian Planned Parenthood Federation was established. In 1970, the National Family Planning Board (BKKBN) was created. The current contraceptive prevalence rate is 45-50%. The family planning program began with a health-oriented approach. To promote acceptance, religious leaders were asked to provide legitimacy to the program. Through their efforts, it became possible to include all the means and medication used for family planning services within the program. In developing an IEC strategy to encourage couples to accept family planning, 3 main factors were studied: 1) the types of innovations that were to be introduced, 2) the characteristics of the Indonesian community, and 3) the need for an IEC strategy to convey the programs messages the community and make the community itself the agent of the innovation being introduced. The elements of the strategy were introduced stage by stage to avoid unnecessary debate. Another strategic step was the introduction of family planning using a community approach. A 3rd strategic step was a shift from couples as family planning acceptors to the introduction of the norm of a small, happy, and prosperous family. The 1st stage, expansion of program coverage, 1) promoted the need for and desirability of family planning to make the small and happy family the norm and 2) supplied contraceptives and information about contraceptives throughout Indonesia. The 2nd stage, the program maintenance approach, included 1) an increase in the frequency of visits to villages by mobile family planning teams, 2) the integration of family planning activities with other health-related activities, and 3) giving people a wider choice of methods and helping them to choose the most suitable method for them. The 3rd stage made family planning a community activity, integrated within the economic and social fabric of community life. The general strategy of the IEC program is to make the various target groups full family planning participants, who will in turn, help to draw nonacceptors into the program. Social marketing is being used to 1) reach those as yet uninformed about family planning, 2) promote the quality of various information and motivation activities so that they will become behaviorally oriented, and 3) provide an opportunity for the private sector to participate in the program professionally.^ieng

East and Southeast Asia assessment.

PIP: The people of East and Southeast Asia, despite societal differences and varied economic successes, share 1 cultural value, i.e., the love of children and the importance of family. The small family norms espoused by family planning programs, the goal in some nations of 1- or 2-child families, the concept that 2 children are enough regardless of their sex -- all these ideas contradict the basic cultural appreciation for children in most countries and the preference for sons in many. Yet, demographic realities give Asia no alternative. It is necessary to work against cultural values to increase the opportunities for individuals, their families, their countries, and the region as a whole. All the countries of this region have had family planning programs since at least the 1970s, and some have been very successful. It may be well into the 21st century before the populations of most East and Southeast countries stabilize. Stabilization will take longer for those countries which are without successful family planning policies and programs. Each national family planning program requires the full and positive political and financial commitment of its government. Programs also need the freedom to try all new approaches. The appropriateness and acceptability of a particular mehtod should be decided by program managers and personnel in consultation with potential users, rather than by politicians. Future family planning programs will need to be even more innovative. Family planning service delivery must be brought closer to the client so it will be available in all communities and work places and at all potential public and private places. Other basic services such as nutrition, income-generating schemes, and general and maternal/child health must be integrated into the programs. The responsibility for managing programs must be assumed by the community in order to create a very strong and broad base of national commitment.^ieng

Indonesia. B. The building of a successful population-family planning programme.

PIP: Indonesia's population and family planning program is one of the most successful in the world, but much work must be done to meet the reduction in fertility targets set by the government. The goal is a birthrate of 22/1000 by the year 1990, a 50% decrease from the 1970 birthrate. With eligible couples entering the program at a rate of 600,000-750,000, a hard job lies ahead. The basic tenets which have made the Indonesia program strong will be used to meet the goals for 1990. The first of these is political commitment, meaning that all government leaders, from the President to the village chief, back the program and work actively for its success. Along with political commitment is the use of cultural values. The javanese society is feudal, in the sense that people try to respect elders, both leaders in the village and beyond. Thus, when the President speaks in favor of family planning, it carries considerable weight and significance. The village chief speaks favorably of family planning and that means the villagers are receptive to trying it. Another important cultural tenet is that of mutual help, or what is termed "gotong royong." This system goes back for centuries and forms the basis of village interaction. It is simply that people help each other for the common good. The National Family Planning Coordinating Board (BKKBN), with the help of the formal and informal leaders, has defined family planning as something which is for the mutual benefit of the entire community. A 3rd tenet of the program is flexibility. The BKKBN has continually experimented with various approaches. With flexibility comes some risk. The BKKBN has managed to maintain a system whereby it is possible to take risks, and this element of flexibility has benefitted the program greatly. Ownership is another important tenet of the program. The community feels that the program is theirs and that they can decide the activities of the acceptor groups and that they are responsible for maintaining and sustaining one another. The final tenet, which has aided in the development of a successful program, is that the BKKBN is the sole coordinator of the program, responsible for all family planning activities in both the public and private sector. These tenets and others will be used in the future in an effort to meet the 1990 targets.^ieng

Family planning attitudes in urban Indonesia: findings from focus group research.

PIP: Although the Indonesian national family planning program achieved high acceptance and continuation rates in rural areas, the urban program was lagging, especially in major cities. To investigate the family planning attitudes and behavior of urban residents, 20 focus group sessions were conducted in Jakarta among 10 categories of respondents: 3 groups of married women with children, and 3 groups of men (current users, former users, and never users); married women without children; unmarried women; women about to be married; and older women. Groups were conducted at 2 educational levels for each of the 10 categories: those with 6 years or less of education, and those educated beyond the 6 year level. Attitudes and feelings on 8 subjects (marriage, early childbearing, family size, the concept of family planning, contraceptive decision making, awareness of birth control, and attitudes toward various specific methods) as well as the general awareness of family planning facilities and information sources about family planning, are reported.^ieng

Continuation of contraception on Java-Bali: preliminary results from the quarterly acceptor survey.

PIP: Review of recently tabulated contraceptive continuation and pregnancy rates for Java-Bali and the constituent provinces. It was found that IUD continuation rates are higher than those for pill or condom, although considerable variation between provinces occurs. East Java and Bali seem to be recording the most and Jakarta and Yogyakarta least success in use continuation. Older, higher parity acceptors tend to use for longer periods, irrespective of method. Similarly, age and parity do not seem to affect the relationship between pill, IUD and condom continuation rates. Pill acceptors are more likely to terminate for physical, emotional, or health reasons than condom or IUD acceptors. Younger and lower parity groups show a greater likelihood of termination in order to have another child. Sources of bias in the rates were also examined. Using a rough adjustment procedure it was found that women lost to follow-up are not a serious bias in the 1st round results, with the exception of differential response by province. As subsequent rounds of the survey are completed, however, the lost-to-follow-up bias is likely to be a more important source of error in reported continuation rates. Factors to adjust acceptor statistics for women who denied ever using family planning were also presented.^ieng

[A project for small and healthy families]. / El proyecto para una familia pequena y sana.

PIP: Since its beginnings in 1969 the National Indonesian Family Planning Program has helped more than 50% of married women in the country. The planned Project for Small and Healthy Families wants to go beyond the scope of contraception, and help the community in matters of nutrition, education, general health, women's status, and jobs. The project will have the community as its base, and responsibility for the project will stay with the community itself. Particular importance will be given to infants and children below 3, with the purpose of lowering infant and child mortality. Reduction of fecundity will be one of the long-term results of the project. Health services will be distributed by community workers, and serious cases referred to hospitals outside the community, with reimbursement of costs to the family. The project also contemplates setting up courses in nutrition and health education.^ieng

The Indonesian family planning program: its strategy for the future.

PIP: This paper discusses the strategy of the Indonesian national family planning program for the coming 5-10 years, in which communities will be given greater responsibility for their own fertility limitation programs and a stronger alliance with other government programs will be sought in order to assure the long-term success of both family planning and development activities. The article explains why more vigorous fertility limitation efforts will be required in the future despite encouraging results so far, and describes the structure of the Indonesian national family planning program. The rationale behind the move away from clinics as depensers of family planning services is examined, and the community family planning approach in Bali is described and compared to that in Java. The differing approach to service delivery in the Outer Islands is then discussed. The relationship between development and the small family norm is discussed, and efforts underway to maximize cooperation between the family planning and development sector projects are described.^ieng

Contraceptive use-effectiveness in Mojokerot Regency, Indonesia: a comparison of regular program and special drive acceptors.

PIP: A follow-up survey of family planning acceptors between April 1971 a nd March 1973 in Mojokerto, the last 4 months of which period marked the initiation of highly productive special acceptor drives in 2/3 of Indonesia, indicates that: 1) IUD acceptors in the regular program and the special drives are highly persistent and successful contraceptors, 2) pill acceptors are less successful than are IUD acceptors, and 3) special drive pill acceptors are significantly less successful than regular program acceptors of the pill. The figures for all-method continuation rates 1 year after acceptance are approximately 90% for IUD acceptors in both regular and special drive programs, 66% for regular program pill acceptors, and 53% for special drive pill acceptors. Pregnancy rates were, conversely, 6% for regular IUD and 8% for special drive IUD acceptors, 16% for regular pill and 25% for special drive pill acceptors. Controlling for demographic factors (number of living children and age at acceptance) and for secular trends did not alter the findings. The differences between regular program and special drive acceptors while not great suggest that special drives recruit acceptors who are more difficult to motivate and might not accept in the regular program. A relatively low percentage of special drive acceptors was lost to follow-up which suggests reported acceptances were in fact real. Sampling was done on a systematic random basis and the Tietze short-form questionnaire was used for data collection. Validity checks were made with indications that response error was low. The performance statistics of IUD acceptors in both types of program compare favorably with median international experience, while regular program pill acceptor performance approximates median international experience, and special program pill acceptance is below the median, though well within the range of international experience.^ieng

[The Indonesian experience)]. / L'experience indonesienne.

PIP: Indonesia, the fifth most populous contry in the world, has doubled since 1930 to 121 million persons, and in 1971 had a growth rate of 2.08-2.67%. The population density ranges from 9 persons/square km on the island of Kalimantan to 565/km on Madura and Bali. In Java and Bali 84% of the population is under 15 years of age. The government has acted by creating the Indonesian Family Planning Association in 1957, the National Institute for family Planning in 1969, and the Committee for Coordination of Family Planning in January 1970. Indonesia's effort is hampered by universal and early marriage with pressure for children, especially sons, but fortunately no organized group or religion opposes contraception. The short term public education plan includes mass media and local campaigns. In the long term people will be taught a life style integrating health, education and qualtiy of family life. Family planning will be taught in literacy classes. In Maduar and Bali, 2067 free clinics offer individual choice of contraceptives. Since 1969 3 million couples have used these facilities, 58% taking pills and 35% chosing IUDs. A 1972 survey showed that 54% of new acceptors are under 30, 87% have received less than elementary education, 38% are illiterate, and 57% are peasants.^ieng