›This is the third post in a series profiling the process of building political commitment in countries whose governments have made strong investments in family planning. Previous posts have profiled Rwanda and Iran.
While the two other countries profiled in this series, Rwanda and Iran, have only reinvigorated their family planning programs within the past 20 years, Indonesia’s story begins in the 1960s. In this respect, the world’s fourth most populous country is classified among the pioneers of family planning in the developing world and has been described as a “world leader” and “one of the developing world’s best.” An extensive community outreach program combined with a centralized government that made family planning a priority were key to Indonesia’s success story.
Jakarta Pilot and Religious Support Motivates National Scale-up
For a decade and a half after the struggle for independence from the Dutch ended in 1949, the government of President Sukarno ruled out any government support for family planning. According to a Demographic and Health Survey (DHS) report, the rate of contraceptive use among married women at the time was essentially zero. Fertility rose slightly during this period, from an average of 5.5 in the early 1950s to 5.6 children per woman a decade later. However, in 1965, Sukarno was overthrown, and the next year, a military general named Suharto assumed power in an uprising that left as many as half a million people dead.
Suharto’s regime would last until 1998. Though he operated with a “heavy hand” amidst personal corruption, Suharto also aggressively pursued economic development and brought about a policy shift towards promoting family planning. Despite initial reservations – Suharto believed that the people would oppose family planning on religious grounds – various domestic and international advisers convinced him otherwise.
General Ali Sadikin, the governor of Jakarta – a city of three million even then – was particularly influential in convincing Suharto. According to Australian demographer Terence H. Hull, who has written extensively about population issues in Indonesia, Sadikin was “quickly learning demographic lessons in his attempts to renovate a city with poor housing, schooling, transport, and basic services,” and he began to regularly speak out about the challenges that rapid population growth posed to his goals of urban development.
Indonesian Planned Parenthood Association, which had a network of clinics offering family planning, but lacked the funding to meet more than a small amount of demand. With the public support of Sadikin, a Jakarta-wide pilot program was operational in 1967.
Hull reports that a second integral event in the early years was a 1967 meeting between government officials and Muslim, Protestant, Catholic, and Hindu leaders representing four of the country’s major religions. Following the meeting, a pamphlet called “Views of Religions on Family Planning” was published, representing “a tipping point when national consensus around the morality of birth control was turning from strongly negative to strongly positive.”
A Strong Coordinating Board Reaches out to Communities
By late 1968, efforts were in place to scale up the family planning program in Jakarta to the national level. The National Family Planning Coordinating Board (BKKBN in Indonesian) was created and quickly became entrenched throughout the country thanks to generous funding, including from international donors.
The BKKBN’s emphasis on the community level, which ensured that family planning services and awareness-generating activities were reaching people around the country through multiple channels, was a key factor in the program’s achievements. The organizations involved in promoting family planning messages at the community level included youth, women’s and religious groups, employers, and schools, with high-level support reiterated regularly by the president. Hull described the BKKBN’s efforts as “a true collaboration because the program emphasized institutions not normally associated with family planning, but did so in a way that was both socially acceptable and socially invigorating.”
In the program’s first two decades, the contraceptive prevalence rate for modern methods rose from almost nonexistent to 44 percent, and fertility subsequently fell from 5.5 to 3.3 children per woman. These changes are widely attributed to robust government sponsorship from the highest levels, together with effective grassroots implementation that fostered support from nearly all sectors of society.
In subsequent years, Indonesia experienced rapid economic and social development. Per capita income increased more than 20 times over between 1966 and 1996, with initial growth largely due to oil revenues. Other development indicators also improved dramatically. The literacy rate is now over 90 percent, nearly all girls attend school, and half of women are members of the labor force. However, Hull cautions against proclaiming the family planning program the primary causal factor in these successes. Family planning and other development programs would not have been as effective, he says, without changes in the political structure, which steadily became more centralized and stable in its oversight of a very heterogeneous society.
A Recent Plateau
In the early 2000s, the family planning program was decentralized to district and municipal levels, in line with political reforms aimed at diminishing the role of central hierarchy nationwide. District leaders were charged with planning, budgeting, and implementing family planning and other primary health services. In accordance, BKKBN modified its strategies to become even more community-oriented. Still, observers judge the family planning program to have “weakened” following decentralization.
With strong logistics, popular support, and donor assistance, contraceptive use continued rising during the years of political transition. By 2002-2003, 57 percent of married women were using a modern contraceptive method and the fertility rate had reached 2.6 children per woman. However, these indicators remained unchanged in the next national survey, conducted in 2007. Fertility in Indonesia is at the median for Southeast Asia – higher than Thailand and Vietnam and lower than Cambodia and the Philippines.
The Program Moves Forward
As democracy became more secure in the early 2000s, the country’s next generation of leaders kept sight of demographic issues. In 2005, President Susilo Bambang Yudhoyono stated, “High population growth without rapid economic growth will result in poverty and setbacks … Large numbers of children and high populations will only bring advantages if they are skilled.” BKKBN and the Ministry of Health worked with USAID, public health researchers, NGOs and others to develop national family planning standards for quality of care, which were devised and implemented in the early 2000s.
Judging the program’s achievements to have been substantial and its momentum sustainable, USAID graduated Indonesia from population assistance in 2006, after 35 years. Though gaps remain, women’s fertility preferences are largely being met.
Today, 80 percent of all births are intended, and unmet need for family planning – the share of married women who wish to delay or prevent pregnancy but are not using contraception – stands at nine percent, two percentage points below the average for Southeast Asia and all developing countries. Meanwhile, Indonesia’s demographic profile looks much different than it might have. At the time of graduation, USAID reported that without its long-standing and well administered family planning program, Indonesia’s 2006 population would have been larger by 80 million people, or 35 percent.
Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.
Sources: Demographic and Health Surveys; Hull (2007); Management Sciences for Health; New York Times; UN Population Division; USAID.
Photo Credit: “Jakarta,” courtesy of flickr user frostnova.
Richard Black: Future Climate-Migration Interactions Will Stress Cities, “Trap” Vulnerable Populations›
“In a 50-year time span, climate change, in particular, is likely to have a quite a strong impact on the drivers of migration,” said Richard Black, professor of human geography at University of Sussex and lead author of Migration and Global Environmental Change: Future Challenges and Opportunities. “But in a way that is different to what has been understood until now.”
›The Woodrow Wilson Center’s Comparative Urban Studies Project, USAID, the International Housing Coalition, the World Bank, and Cities Alliance are teaming up a third time to co-sponsor an academic paper competition for graduate- and PhD-level students focused on challenges facing urban centers in the developing world.
The themes of this year’s competition are land markets, global climate change, and youth.
Land Markets: The absence of efficient land and housing markets and lack of secure tenure for both renters and owners are impediments to urban and economic development in developing cities. Papers on this topic should explore strategies and approaches that would enable property markets to function better and would provide increased security of tenure and strengthened property ownership rights.
Global Climate Change: Papers should examine how urban populations, especially the poor, are coping with the impacts of climate change, and provide strategic policy analysis to better understand how cities can become more resilient to climate change impacts.
Youth: Most of the youth of the developing world are now or will soon be living in urban areas. Unfortunately, they are often growing up in the poorest urban areas – informal settlements and slum communities where their opportunities for advancement are limited by a variety of negative factors. Papers focused on youth should explore ways to build capacity so that you can develop knowledge and skills, find gainful employment, and participate more fully in society to advance economic growth and social development.
Winning papers from each category will be published and the authors invited to Washington, D.C. in the fall of 2012 for a policy workshop with subject matter experts. Additionally, one grand prize winner will be asked to present his or her work at the World Urban Forum (WUF). WUF was established by the United Nations to examine rapid urbanization and its impact on communities, cities, economies, climate change, and policies. The sixth WUF will be held from September 1-7, 2012 in Naples, Italy and will be focused on “The Urban Future.” In addition to the Washington conference and publication of his or her paper, the grand-prize winner will be invited to present his or her winning paper on a panel at the World Urban Youth Assembly at WUF on September 1st and 2nd.
The deadline for the submission of abstracts is February 20, 2012.
For detailed competition guidelines and requirements, and further information on the sub-topics, please see the full call for papers.
Image Credit: “Split by yelowcap,” courtesy of flickr user yelowcap (Vladimir Kaštier).
›January 26, 2012 // By Wilson Center Staff
ECSP’s Sean Peoples, Meaghan Parker, and Schuyler Null accepted the Population Institute’s Global Media Award for Best Online Commentary at a January 12 ceremony in New York City.
Five years ago, in January 2007, we launched New Security Beat. Since then we’ve established a strong editorial focus on a key but neglected niche: where population, environment, and security meet.
›January 26, 2012 // By Schuyler Null
One of the best talks of last week’s NCSE Environment and Security Conference was thewater security plenary on Friday. Moderator Aaron Salzberg, who is the special coordinator for water resources at the Department of State, led with a provocative question: how many in attendance think there will be war over water in the future?
›A new set of maps from the United Nations Environment Programme (UNEP) identifies “climate hotspots” – areas vulnerable to instability exacerbated by climate change – in 17 sub-Saharan countries in and bordering the Sahel region. The maps reflect the fact that, more often than not, the impact of climate change on local populations is compounded by changes in migration, conflict, or both. According to Livelihood Security: Climate Change, Migration and Conflict in the Sahel, the UNEP report accompanying the maps, understanding “the exacerbating effect of changes in climate on population dynamics and conflict in the region” will be essential to developing successful adaptation strategies throughout the region.
UNEP’s maps analyze 40 years of data to pinpoint where the region’s most at-risk populations are located based on environmental, population, and conflict trends dating back to 1970. In a single map pinpointing the Sahel’s 19 hotspots, UNEP synthesizes subnational data from four environmental indicators over time – rainfall (from 1970 to 2006), temperature changes (1970 to 2006), drought (1982 to 2009), and flooding (1985 to 2009) – which are then layered on top of population trends (1970 to 2010) and conflict data (1970 to 2005) in order to identify the region’s most insecure areas.
At first glance, the map can appear hard to decipher; it is flooded with different colors and symbols, each indicating something different about the extent of climate change, migration, and conflict in the region. A Google Earth version of the map (available for download here) makes all this information easier to process by allowing users to select which indicators they want to see mapped out, cutting back on the number of lines, dots, colors, and pie charts the user has to decode.
Given the vast amount of the information being condensed into these maps, the report is a helpful and worthwhile read. For instance, eight hotspots are in places with growing populations and another seven are located in places that have experienced conflict; altogether, 4 of the 19 hotspots have both past conflict and growing populations. The report digs deeper into the confluence of climate, conflict, and migration by discussing case studies that highlight how the three intersect in local communities (at the same time, the report is careful to avoid suggesting that there is a causal relationship between the three issues.). In Niger, Nigeria, and Chad, for example, tensions have been mounting between northern pastoralists and southern farmers as each group has moved further and further afield in search of water and arable land to sustain their livelihoods.
Holes In the Data
While the hotspot maps include a wealth of information, the report makes clear that it is by no means exhaustive. Rising sea levels are, for instance, a major impending threat to coastal populations in the Sahel, but only the downloadable Google Earth map – not the hotspot map in the report or the Google Earth map as presented online – incorporates this factor. Compounded with a skyrocketing population in the coastal areas – the coast between Accra and the Niger delta is expected to be “an urban megalopolis of 50 million people” by 2020, according to the report – an increase in sea levels could have a huge impact on the region’s stability.
The report also readily admits that the datasets for population trends and conflict have shortcomings. Population data is largely based on censuses, which both the report and its data sources (UNEP’s African Population Database and the Gridded Population of the World, version 3) acknowledge can be inconsistent in their accuracy. Additionally, after 2000, population data is based on projections rather than estimates, which, as last year’s update from the UN Population Division showed, have often proven inaccurate, particularly in sub-Saharan Africa.
Regarding conflict, the UNEP report is straightforward in admitting its limits. The report lacks data on small-scale conflict (fewer than 25 battle deaths, following the Uppsala Conflict Data Program’s threshold that separates conflicts from lower-level violence), even as it acknowledges that such conflict is “often the first to occur” when climate change threatens communities’ access to resources and livelihoods.
Ultimately, however, these maps give valuable data on specific locations that are uniquely vulnerable to trends in population, climate, migration, and conflict. They add focus to the conventional wisdom that climate change will impact the region’s stability, and, taken together, the maps and the report provide a valuable resource for scholars and policymakers attempting to craft adaptation policies that take into consideration these complex links.
Sources: Socioeconomic Data and Applications Center at Columbia University’s Earth Institute, UNEP, Uppsala Conflict Data Program.
Image Credit: UNEP.
›January 25, 2012 // By Wilson Center StaffThe original version of this article, by Ethan Goffman, appeared on the Sustainability: Science, Practice, and Policy blog.
In a time of polarized politics in the United States, over the environment and just about everything else, an overlooked development is how much the military, as well as the national security apparatus, has taken on climate change and other environmental challenges. “Environment and Security” was thus a profoundly important choice of theme for the 2012 National Conference on Science, Policy, and the Environment, held last week in Washington, DC. With the early effects of climate change apparently already occurring, notably in an increase in natural disasters and in a new northwest passage through the Arctic, those responsible for our security can’t afford to sit around and engage in speculation that climate change is caused by sunspots or isn’t really occurring. It is the military’s job, after all, to take action against potential threats rather than getting immersed in domestic politics.
The concern with climate change is the next step in a widening of the concept of security from strict military matters, to include such interrelated strands as food and water access, public health, and the environment. Much of the military has already acknowledged that armed force alone won’t make us safe. “Energy security, economic security, environmental security, and national security are all inextricably linked. Address one and you need to think of the others,” explained Vice-Admiral Dennis McGinn at the conference.
One obvious linkage is the connection of our oil dependency with security risks that can easily draw us into conflict in politically unstable parts of the world. Just how much the recent wars in the Middle East are about oil, and how much about a clash of civilizations, is a matter of considerable debate, although undoubtedly both factors play a part. The Iranian threat to close the Strait of Hormuz, choking outgoing oil deliveries, underscores vulnerability on the energy issue. From another angle, in Afghanistan, the military experienced the fragility of supply lines for a force strongly dependent on large quantities of oil. The Air Force, in particular, is working on algal jet fuel to free us from such reliance. And the Navy’s need for more icebreakers and other capacity shows concern regarding shipping and resource exploitation enabled by the melting of Arctic ice and the new passage.
Continue reading on the SSPP blog.
Photo Credit: Sherri Goodman and Rear Admiral Neil Morisetti, courtesy of Sean Peoples/Wilson Center.
›“Throughout the 2009-2011 Advancing Dialogue on Maternal Health lecture series, we always heard the same good news: we know how to save the lives of women and girls. But more political will is needed,” said Calyn Ostrowksi, program associate for the Wilson Center’s Global Health Initiative on December 15 for the launch of the series’ culminating report, Delivering Solutions: Advancing Dialogue To Improve Maternal Health.
Joining Ostrowski were co-author Margaret Greene, director of GreeneWorks; Luc de Bernis, senior advisor on maternal health at the UN Population Fund; Tim Thomas, interim director for the Maternal Health Task Force; and Chaacha Mwita, director of communications at the African Population and Health Research Center.
One of the few forums dedicated to maternal health, the series brought together senior-level policymakers, academic researchers, members of the media, and NGO workers from the United States and abroad. The series consisted of 21 separate events, with hundreds of experts sharing their experiences and thousands of participants and stakeholders providing their expertise. The final report captures, analyzes, and synthesizes the strategies and recommendations that emerged from the series.
Promoting Social Change
Unlike other health issues, said Green during her presentation on the findings of Delivering Solutions, the field of maternal health requires a holistic and multi-faceted approach; that is, an approach that looks not only at health systems, but also at underlying social factors. The report divides maternal health into three broad categories: social, economic, and cultural factors; health systems factors; and research/data demands.
Looking first at the social, cultural, and economic issues, Greene highlighted the need to improve nutrition and educational opportunities for young women in developing countries. Policymakers must be convinced that investing in women is not just good for women but good for families and children, she said. The participation of male partners and other male family members is also needed to increase access to maternal health services, such as family planning, and promote gender equality. The report pointed to a number of recommendations to promote male engagement:
- Target interventions that educate men about danger signs and pregnancy complications.
- Address pressures that many young married men feel to prove their fertility.
- Inform men about sexual rights and how they relate to the health and wellbeing of their partners.
Health systems and medical resources play an equally pivotal role in reducing maternal mortality as social factors. The report highlights several key areas for strengthening the health system including the expansion of healthcare workers, health finance schemes, technology, and commodity distribution.
One key recommendation is to integrate reproductive health and maternal health supply chains. Four key medicines, oxytocin misoprostol, magnesium sulfate, and manual vacuum aspirators, target the three leading causes of maternal mortality (post-partum hemorrhage, obstructed labor, and unsafe abortion). Efforts to improve the distribution of these commodities should be more widely dispersed in developing countries and supported by community-based interventions. Women in urban slums, for example, face unique challenges that are not being adequately addressed.
Additionally, new technologies should be more creatively and effectively used, in particular the use of mobile phones in rural communities.
Many of the policy recommendations offered by the report, as Greene pointed out, are low-cost and highly effective. Yet three significant challenges remain for the field in general:
- Six countries – Afghanistan, Democratic Republic of Congo, Ethiopia, India, Nigeria, and Pakistan – account for over half of the maternal deaths worldwide. The unique problems of each of these countries must be addressed and solved.
- Integration of maternal health with existing health services along with an over-reliance on community health workers can overburden weak infrastructure.
- Unnecessary cesarean births are on the rise as more women deliver in private sector facilities. These births cost 2 to 18 times as much as vaginal births and create unnecessary risks for mothers.
Chaacha Mwita of the African Population and Health Research Center (APHRC), located in Nairobi has seen firsthand the result of an overburdened and inadequate maternal health system in both his personal and professional life. Mwita endorsed the findings of the series report, emphasizing in particular the focus on transportation systems, male involvement, stakeholder dialogue, and education.
Mwita said that collaboration at all levels is the key to improving maternal health. Policymakers must communicate with researchers, who, in turn, must communicate with doctors, nurses, and hospital administrators in the field. The collaborative in-country dialogue series between the Wilson Center and APHRC, he believes, was a highly useful and easily replicable way of encouraging dialogue among relevant stakeholders in the field.
The Big Picture
”Our hope is that we’ve been able to seed discussions,” said Tim Thomas of the Maternal Health Task Force, one of the co-sponsors of the maternal health series. “We hope those seeds will take root and flourish.” Luc de Bernis, senior maternal health advisor of UNFPA, echoed Thomas’ sentiments, emphasizing the need for continued dialogue.
While maternal health has drawn increased international attention, creating political agreement among policymakers is a complex and often difficult process. There has been marked, though uneven, progress in improving maternal health across the globe, but more must be done. The Delivering Solutions report provides a state of the field assessment as well recommendations for existing, easy-to-implement solutions.
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