Bill and Melinda Gates Institute for Population and Reproductive Health INDONESIA FAMILY PLANNING LANDSCAPE ASSESSMENT

Transcription

1 Bill and Melinda Gates Institute for Population and Reproductive Health INDONESIA FAMILY PLANNING LANDSCAPE ASSESSMENT MAY 2010

2 TABLE OF CONTENTS 1.0 Background Methodology Recent Developments in Demography and Family Planning Services Recent Trends in Family Planning and Significant Differentials Total Fertility Rate Contraceptive Prevalence Rate Unmet Need Quality of Family Planning Services Map of FP-Related Services Maternal Mortality Abortion Main FP-Related Issues Knowledge about Family Planning Adolescent Knowledge of Family Planning and Reproductive Health Reproductive Health Information Family Planning Information Funding for Family Planning National Budget Local Government Budget Specific Allocation Budget Partners and Actors in Family Planning Government BKKBN Ministry of Health National Development of Planning and Budgeting Agency Ministry of Home Affairs Non-Governmental Organzations PKBI Faith-Based Organizations Muhamaddiyah and Aisyiah Nahdlatul Ulama and Muslimat, Fatayat Professional Organizations Indonesian Midwife Association Indonesian Obstetics and Gynecology Association Indonesian Doctor Association Private Companies. 17 Chart: Development of District Planning and Budgeting Process.. 18 Acknowledgements.. 19

3 LIST OF ACRONYMS AND ABBREVIATIONS AFP APBD APBN BPS CPR DAK DPA SKPD FP GP IBI IDHS IDI IYRHS KUA MDGs MMR MR Musrenbangdes Musrenbangcam Musrenbangkab NAD NGO NU PANGAR PPAS PKBI PKBA POGI PPH Renstra SKPD RKA SKPD RKPD SKPD TAPD TFR TWG WRA Advance Family Planning Anggaran Penerimaan dan Belanja Daerah (District Budget) National Budget Statistic Central Bureau Contraceptive Prevalence Rate Specific Allocation Funding Dokumen Pelaksanaan Anggaran Satuan Kerja Perangkat Daerah (Document of District Budget Unit) Family Planning General Practitioner Ikatan Bidan Indonesia (Indonesian Midwife Association) Indonesian Demography Health Survey Ikatan Dokter Indonesia (Indonesian Doctor Association) Indonesia Youth Reproductive Health Survey Kebijakan Umum Anggaran (Budget Policy) Millennium Development Goals Maternal Mortality Ratio/Rate Menstrual regulation Musyawarah perencanaan dan pembangunan desa (Deliberative forum at village level) Musyawarah perencanaan dan pembangunan kecamatan (Deliberative forum at sub district level) Musyawarah perencanaan dan pembangunan Kabupaten (Deliberative forum at district level) Nangroe Aceh Darussalam Non-Governmental Organization Nahdlathul Ulama Panitia Anggaran (Budget Committee) Prioritas Plafon Anggaran Sementara (Temporary of Budget Ceiling Priority) Retrospective Study on Menstruation Regulation in 9 Cities in Indonesia Indonesia Planned Parenthood Association (IPPA) Indonesian Obstetrics and Gynecology Association Postpartum hemmorage Rencana Strategis Satuan Kerja Perangkat Daerah (Strategic Planning of District Working Unit) Rencana Kerja dan Anggaran Satuan Kerja Perangkat Daerah (Work Plan and District Budget Unit) Rencana Kerja Pemerintah Daerah (government unit work annual planning) Local Government Plan of Action Tim Anggaran Pemerintah Daerah (District Government Budget Team) Total Fertility Rate Technical Working Group Women of Reproductive Age

4 1.0 Background Advance Family Planning (AFP) is an evidence-based, three-year effort designed to help developing countries achieve universal access to reproductive health (Millennium Development Goal MDG target 5b). AFP s goal is to increase funding and improve policy commitments at all levels of national governments, among bilateral and multilateral donors, and in the private sector. It builds on past investments and ongoing activities in reproductive health advocacy, leadership development, knowledge generation, and innovative service delivery projects. The success of AFP will very much depend on effectively working with established reproductive health organizations in Indonesia such as BKKBN, Ministry of Health and other government institutions, Ikatan Bidan Indonesia (IBI), Ikatan Dokter Indonesia (IDI) and other professional organizations, USAID, UNFPA, and other donors, parties and individuals. AFP-Indonesia formed a Technical Working Group (TWG) that consists of key stakeholders in family planning (FP) and will lead the process of developing a national family planning strategy. In this process, the TWG will need a document that captures the current family planning situation in Indonesia. This landscape assessment was commissioned to fill this need. 2.0 Methodology This landscape document was developed by reviewing available data and documents, as well as interviewing key resource persons at the district, province, and national levels. Sources Reviewed: Indonesia Demography Health Survey (IDHS) (2003), Statistic Central Bureau (BPS) Indonesia Demography Health Survey (IDHS) (2007), Statistic Central Bureau (BPS) Adolescent Reproductive Health Survey (ARHS) (2007), Statistic Central Bureau (BPS), BKKBN, Ministry of Health, Macro International Basic Health Survey Riskesdas (2007) National Census (2005) National Socio Economic Survey (2008) Retrospective Study on Menstruation Regulation in 9 Cities in Indonesia ( ), PKBI Technical Guidelines Specific Allocation Funding (DAK) Usage for Family Planning (2009) BKKBN Population Law UU 52 (2009) Health Minister Regulation (2010) Roles and Practice Permission of Midwife Persons Interviewed: Sri Moertiningsih, Researcher of University of Indonesia for demography, Economy Faculty Harni, the Head of Indonesian Midwife Ascociation Inne, the executive director of PKBI Bambang Mursidi, The head of division of planning bereau at BKKBN Destri Fitriyani, Bappenas 3.0 Recent Developments in Demography and Family Planning (National and Provincial) Based on the National Socio-Economic Survey (2008), the estimated population of Indonesia is over 228 million people. Generally, the female population (50.13%) is larger than the male population (49.87%). In rural areas, the female to male ratio is 50.39% and 49.61%, respectively. In urban areas, however, the ratio is reversed, with 50.11% of the urban population being male and only 49.89% female. The population growth annually is 1.30% (SUPAS, 2005). The area with highest population growth is Riau Island, at 4.99%. The area with the lowest population growth is West Kalimantan at 0.18%. The highest proportion of youth was found in West Papua (38.43%), while the lowest was found in DI Yogjakarta (20.84%). The highest percentage of elderly persons was found in DI Jogjakarta (10.32%), while the lowest was found in Papua (1.11%). 1

5 Population composition with respect to marital status shows that the percentage of unmarried males was higher than that of unmarried females, 38.15% compared with 29.36%. 3.1 Recent Trends in Family Planning and Significant Differentials Total Fertility Rate (TFR) Comparing the results of the IDHS with the 2007 IDHS shows that the TFR in urban areas was lower in 2007 than in (2.3 compared with 2.4 births per woman, respectively). However, the TFR in rural areas was higher in 2007 than in (2.8 compared with 2.7 births per woman, respectively). TFR IDHS IDHS IDHS IDHS IDHS 2007 TFR Trends in fertility can be assessed by comparing the current TFR with estimates from previous DHS surveys. The graph above shows the TFRs for IDHS surveys carried out in 1991, 1994, 1997, , and The table below lists the provinces with the highest and lowest TFRs. No. Province TFR National East Nusa Tenggara Maluku North Sumatera DI Yogjakarta Bali DI Jakarta West Kalimantan Contraceptive Prevalence Rate (CPR) A woman s age at first marriage is an important factor influencing risks related to pregnancy and childbirth. Overall, first marriages most commonly take place during the ages of 19 and 24 (39.90%). This increase over past figures denotes that women are now more conscious about the high health risks associated with young marriage. However, 15.06% (18.58% in rural areas, 11.08% in urban areas) of ever-married women were younger than 16 at the time of marriage. Contraceptive prevalence is defined as the proportion of currently married women aged that reported using a method of family planning at the time of the survey. The survey indicated that 58% of ever-married women and 61% of currently married women are using contraception. Furthermore, 54% of ever-married women and 57.4% of currently married women are using modern methods (IDHS, 2007). 2

6 Injectable contraceptives (31.8%), the oral contraceptive pill (13.2%) and IUD (4.9%) were the most commonly used methods. According to Susenas (2008), 56.62% of women of reproductive age (WRA) were currently using contraceptive methods. Compared to other methods, injectable contraceptives (58.74%), the oral contraceptive pill (23.95%), and IUD (7.07%) were used most often by married women years of age. The CPR varies widely between provinces, from 24.5% to 70.4%. The table below lists the provinces with the highest and lowest CPRs. No. Province CPR Method Injection Pill IUD National 57.4% 31.8% 13.2% 4.2% 1 Bengkulu 70.4% 46.9% 13.0% 1.7% 2 Bali 65.4% 26.7% 7.7% 23.8% 3 Jambi 62.5% 34.3% 18.4% 1.5% 4 Papua 24.5% 11.5% 5.9% 1.2% 5 Maluku 29.4% 18.5% 4.2% 1.3% 6 West Papua 37.5% 23.9% 6.8% 1.3% 7 West Kalimantan 61.2% 38.5% 15.5% 2.2% Unmet Need for Family Planning The 2007 IDHS data showed that the total demand for family planning in Indonesia is 71%, of which 87% has been satisfied leaving a 9% unmet need. Of that 9%, 4% is unmet need for spacing pregnancies and 5% is for limiting pregnancy and childbirth altogether. These levels of unmet need have remained constant since No. Province Unmet Need National 9.1% 1 Maluku 22.4% 2 East Nusa Tenggara 17.4% 3 West Sulawesi 17.4% 4 Bangka Belitung 3.2% 5 Lampung 5.5% 6 Bengkulu 6.1% 7 West Kalimantan 7.7% CPR and unmet needs are two of four indicators for MDG 5b. Below, the figure shows the current level of achievement compared with the MDG5b target levels. 3

7 4.0 Quality of Family Planning Services Currently, most clients seek private family planning services and contraceptives. The IDHS (2007) shows that private midwives provide 28% of family planning services. Midwives not only provide services, but also counseling and community mobilization. Their role in community mobilization is especially important because of the lack of field worker outreach. 4

8 Distribu,on of Current Users of Modern Contracep,ve Method by source and Supply (IDHS, 2007) Other medical sector 21% Others 1% Other Source 8% Public Sector 22% Private Vilage Midwife 19% Private Midwife 29% The poor quality of family planning services is a major obstacle for women who wish to use modern contraceptives. Studies show low compliance of healthcare provider to standards. The STARH Program, funded by USAID, conducted a Quick Investigation of Quality (2005) 1. This study was conducted in 12 districts in Indonesia. The highlights of the study showed that: Only 75% of the healthcare facilities studied had guidelines for family planning. Infection prevention needs improvement. Only 80% of providers washed their hands before IUD insertions. 91% of clients received a speculum exam for sexually transmitted infections (STIs). 55% of the facilities services complied with standards for clinical procedures for injectables. Puskesmas Punggur Raya at West Kalimantan shows the low quality of family planning services: No counseling room with privacy, no skilled midwife for providing family planning services, no equipment. No budget allocation from district health offices for improving the capacity of health providers. Unskilled providers still provide family planning services without any supervision. Although health providers distribute information about sterilization, because most clients could not get the desired services when they needed them, many no longer desire sterilization. Several factors influenced these conditions, including: Lack of knowledge and skill. The commitment of key stakeholders needs to be strengthened and the quality of family planning services needs to be improved. Most institutions mentioned the importance of midwives in providing family planning services, but there is insufficient support for midwife training. More than 50% of midwives were unskilled. Lack of adequate equipment. Lack of supervision. Lack of strong, clear policy. Lack of a reference manual. 1 The Quick Investigation of Quality (QIQ) is a practical tool to measure quality of care (QC) in family planning services. 5

9 120% Data of Trained Midwife 100% Percentage 80% 60% 40% Untrained Trained 20% 0% IUD InserMon Implant insermon InformaMon, EducaMon and CommunicaMon (IEC) ReporMng and Recording Source : Indonesian Midwife Ascociation (IBI), 2009 Training Type 5.0 Map of Family Planning-Related Programs 5.1 Maternal Mortality Analysis of the 1994 IDHS shows that, for the five-year period spanning from , the maternal mortality ratio (MMR) was 390 deaths per 100,000 births. An unpublished analysis of data from the 1997 IDHS implied a slight decline in the MMR for the period of , to 334 deaths per 100,000 births. The MMR estimates of 307 deaths per 100,000 births in the IDHS and 228 deaths per 100,000 births in the 2007 IDHS appear to confirm the downward trend in maternal mortality in Indonesia. Postpartum hemorrhage (PPH) is the leading cause of maternal mortality, causing 24% of maternal deaths. The second greatest factor is unsafe abortion, which accounts for 13% of maternal deaths 2. The primary intervention shown to reduce the incidence of PPH is active management of complications. Improving the manner of care during delivery and pregnancy can reduce maternal mortality. With improved care in the social, cultural, economic, and educational sectors, maternal mortality could be reduced by 64%.(Prevention or Postpartum Hemorriage Initiative (POPPHI), active management of the third stage of labor (AMTSL), 2007) This intervention depends on the readiness of health facilities to provide delivery services and the level of skill and knowledge of health providers. The number of home deliveries and deliveries with unskilled providers in Indonesia is still high. Province % deliveries at health facilities % deliveries with skilled provider National Bali DI Jogjakarta East Nusatenggara POPPHI, Prevention of Postpartum Hemorrhage Initiative, USAID 6

10 Province % deliveries at health facilities % deliveries with skilled provider Maluku West Kalimantan National Source: IDHS (2007) 5.2 Induced Abortion Abortion data were obtained from a survey with relatively limited coverage, as comprehensive data on induced abortion in Indonesia is not available. However, it is estimated that there are between million abortions in Indonesia annually, or 43 abortions per 100 pregnancies, according to Dr. Titik Kuntari, a lecturer on the medical faculty of the Indonesian Islamic University (UII).Approximately 30% of abortions were sought by women between the ages of 15 and 24. Based on PKBI (Indonesian Planned Parenthood Association, IPPA) data from , drawing from 37,685 client records collected from nine clinics in nine cities in Indonesia, the highest number of clients sought menstrual regulation (MR) service for abortion in Denpasar (Bali) (14,965 or 39.7%) and in Jogyakarta, (10,056 or 26.7%). Women seeking MR services who were younger than 20 years of age is only 12% of the total. The table below shows that the number of MR requests is relatively equal for clients aged years old and those over 30. Clients ranged from years of age. Client Age Frequency % < 21 4, , >30 16, Total 37, Most of the clients (73%) surveyed were married, while 27% were unmarried. The remaining 1% had a marital status of other, including widowed women and those living with a partner. Before providing MR services, the PKBI Clinic required unmarried young people to obtain a parent s permission. Married women needed to present written approval from their husband. Clients reported many different reasons for terminating their pregnancies. The table below show that of the 71.3% clients who were married, 31% asked for MR services due to a family planning failure. In this study, the failure of family planning refers to not only clients who got pregnant while using a contraceptive method, but also those who forgot to take their oral contraceptive pills, delayed the use of an IUD or injectable contraceptive, or miscalculated their ovulation time. Marital Status Family planning failure Have enough children Reason for seeking MR service Still in school Unmarried Other reason Subtotal Married 8,327 5, ,471 19, Unmarried ,736 4,016 7,830 7, Subtotal 8,468 5,906 1,986 4,147 27,301 27, % One factor in the maternal mortality rate is unsafe abortion, which is likely to be underreported. The low number of reported abortions could be due to inability to trace where a woman requested abortion services or first tried to end her pregnancy. Some women with unwanted pregnancies have tried to terminate their pregnancies using unsafe methods (e.g., traditional herbs, drugs, massage) before visiting a clinic. % 7

11 Efforts to terminate pregnancy before visiting clinic (%) Type of efforts Year Not Traditional Doctor/ Subtotal Massage Drugs Other Disclosed Herbs Midwife Subtotal Total Clients: 27,608 Unsafe abortions were estimated to contribute to 11% of maternal deaths in Indonesia. In comparison, the average rate globally is 13%. According to the IDHS (2007), the proportion of unwanted pregnancies increases as birth order increases. Almost all first births (93%) were wanted at the time of conception. For those fourth-born or higher, only 75% of births were wanted at the time of conception. Mother s age Percent distribution of birth to women by mother's age at birth (IDHS, 2007) Wanted Then Wanted Later Wanted No More Missing Total Number of Births < , , , , , Total ,168 These data show that many married women years old are highly likely to want no more children and that the older she is, the less likely her pregnancy is to be wanted. Family planning failures could be a contributing factor. 6.0 Main Family Planning-Related Issues 6.1 Knowledge About Family Planning The IDHS (2007) studies knowledge of contraceptive methods for ever-married and currently married women, as well as for currently married men.the results indicate widespread knowledge of contraceptive methods among both women and men. Almost all ever-married and currently married women (98% and 99%, respectively) know at least one method of family planning. Knowledge of modern methods for evermarried and currently married women is as high as knowledge of any method. Knowledge of traditional or modern contraceptive methods is almost universal among currently married men. Almost half of women and men know at least one traditional method. The most widely known methods for both ever-married and currently married women are contraceptive injectables and the oral contraceptive pill (96% and 97%, respectively). 8

12 Percentage of currently married woman who know Modern Contraceptive Male SterilizaMon Female SterilizaMon Male Condom IUD Implant Pill Injectable The figure above shows that knowledge of contraceptive methods among married women has continued to increase since Knowledge of implants increased significantly during the last decade, from 68% to the current level of 86%. Knowledge of the male condom and female sterilization has also increased since Knowledge of Currently Married Women by Province Source: IDHS (2007) Province Knowledge of contraceptives DI Jakarta West Java 99.9% Central Kalimantan 99.8% Papua 61.9% West Kalimantan 97% Adolescent s Knowledge of Family Planning and Reproductive Health According to Indonesia Youth Reproductive Health Survey (IYRHS) (2007) data, 15% of young women and 29% of young men who responded had never discussed sex with anyone. Some had discussed reproductive health issues within their group (71% of young women and 58% of young men). 9

13 Percentage Most Young of People Unmarried Do Not Young Discuss Women Reproductive and Men who Health had with Disccused Adult Reproduc,ve Health with Someone Friend Mother Father Sibling Family Teacher Health Provider Religious Religion Leader 29 No Discussion Young Woman Young Man Family Planning Information Knowledge about contraceptive methods among young women and young men has increased since Young women s knowledge about contraceptive methods increased from 95% in to 96% in 2007, and the knowledge of young men increased from 91% to 93%. Method FP method Modern method Knowledge about contraceptive method by marital status 3 Young Women Young Men Unmarried Married Unmarried Married Unmarried Married Unmarried Married Data indicate that unmarried young women and men know less about contraceptive methods than the married group surveyed. 7. Funding for Family Planning 7.1 National Budget (APBN) National Budget allocation goes through BKKBN Central and is distributed to the provinces and districts. This budget is for providing contraceptives and operational costs of certain services, such as sterilization. National regulation states that free contraceptive methods are to be provided to the poor, but condoms and IUDs are provided free to all. The APBN plan for family planning began in February 2010 at the national meeting, and BKKBN centrally developed the plan based on target indicator criteria, including the estimated number of new clients and community need. Community need is based on the number of citizens classified as poor. This process will continue from February through August, a year before implementation. 3 Adolescent Reproductive Health Survey (2007) 10

14 To determine the number of those who are poor, BKKBN uses criteria such as the existence of permanent housing or steady income. But in practice, there are difficulties in determining who qualifies as poor in the field. Central BKKBN provides free contraceptive to all citizens of specific provinces (Papua, East Nusatenggara, and Nangroe Aceh Darussalam (NAD). The reasons of these three provinces are very specific, such as very low CPR, high TFR and recovery effort after tsunami disaster. BKKBN has already developed a five-year plan ( ), and the budget has increased by approximately 100%. BKKBN proposes that the increased budget will revitalize the program by providing the resources necessary to revitalize field workers, build capacity of family planning/population staff, and provide partnership mobilization activities. The national budget for family planning in 2009 was 1.2 trillion Rupiahs and nearly doubled in 2010, increasing to 2.3 trillion Rupiahs in Local Government Budget Each district is required to allocate 20% of its total budget for health, but in practice, most districts are only able to allocate 10% or less. According to Law Number 25 Year 2004 and Law Number 17 Year 2003, there are three main processes in the planning and budgeting cycle in each district: the planning process, the budgeting process, and the political decision-making process. The planning process focuses on identifying problems, identifying needs, and defining programs. This process uses a participatory approach and the forum is to be attended by multiple stakeholders. The planning process itself is delivered in four phases: a deliberative forum at the village level, a deliberative forum at the sub-district level, a deliberative forum at the district level, and deliberative forum in the local government unit. The budgeting process focuses on the development of a district budget ceilling, based on the deliberative forum proposal and the Local Government Plan of Action (SKPD) program. The political decision-making process is defined by two perspectives: first, the institutionalization process of the Bupati, or executive commitment, which is reflected in the local government midterm planning development document, and second, the political process between the Local Government Budgeting Team and the Parliament Budget Committee, which reconciles local budget decisions (see matrix below). Key dates of local government budget development process Type of activity Planning Process Deliberative forum at village level (Musrenbangdes) Deliberative forum at sub-district level (Musrenbangcam) Deliberative forum at district level (Musrenbangkab) Deliberative forum local government unit Budgeting Process Develop local government unit work annual planning Develop district annual planning Develop budgeting Develop budget ceiling Political decision-making process Decision on Local Government Unit Work Annual Planning Decision of General Policy of Budgeting Decision of Initial Ceiling and Priority of Budgeting Decision on local government budget Timeframe January February 2 nd and 3 rd week of March 2 nd and 3 rd week of March 2 nd week of April 4 th week of May 1 st week of June 2 nd week of July 3 rd and 4 th week of May 1 st and 2 nd week of June 1 st of July 4 th of July 11

15 After decentralization, the district-level BBKN offices were merged with other institutions. Thus, the development of the family planning budget at the district level is related to the core institution in each district. Budget allocation for family planning is not always included under health funding, depending on which institution the district BKKBN office was merged with. In some districts, the responsibility for family planning comes under the offices of health, population, civil registration, women s empowerment, or some combination of the four. These budget and planning processes are also influenced by situational factors in each district, such as: The Bupati/major s interest in family planning. The Local Autonomy Directorate, the directorate under Ministry of Home Affairs, plays an important role in influencing the local government s budget allocation. In Cianjur District West Java, the local BKKBN was merged with Women s Empowerment and named BKKPP Badan Keluarga Berencana dan Pemberdayaan Perempuan, or the Family Planning and Women s Empowerment Institution. BKBPP has four divisions: Information, Family Welfare, Family Planning and Reproductive Health, and Women s Empowerment. The percentage of the budget allocated for family planning is 30% of the total BKBPP budget. In 2009, BKKBN Central provided contraceptives. The province allocated 500 million Rupiah and local government allocated 286 million Rupiah. The political agenda at the district level, which influences the district s budget allocation. If the district has a plan for elections, budget allocations may be prioritized for this kind of activity. 7.3 Specific Allocation Budget National Development Planning Agency (Bappenas) Specific allocation funding (DAK) is allocated in the National Budget (APBN) to fund a variety of specific development activities at the district level. The objective is to minimize the gap in public services within districts and to improve the ability of the local government to mobilize its own resources. This budget is added to the local budget. The local government has the option to actively propose budget allocations, but in reality most local governments simply receive DAK passively. Until now, the role of the local government budget has been to provide data regarding the facilities and infrastructure conditions within the sectors that will receive DAK. The central government, particularly the Ministry of Finance, will then allocate funds by sector and by district. The Ministry of Finance also uses development priorities to define DAK. After receiving information from the central government about the total funds available for DAK, the local government distributes the funds to certain activities or projects based on central government regulations. The local government must add a contribution equal to 10% of the total DAK for management. The Ministry of Finance uses the fiscal index to determine which districts will receive DAK, and BKKBN provides technical data for consideration. The technical indicators are: Low CPR; High CWR Child-woman ratio (number of children under age 5 compared with women of reproductive age (WRA); High percentage of people pre welfare; High TFR; High number or density of citizens. Due to the lack of transparency in the system of DAK allocation, the local governments need to approach the central government to ensure DAK allocation for their region. Since 2003, the priorities of the central government in defining DAK are public services, such as education, health, and infrastructure. The DAK allocated for family planning went to the procurement of motorcycles for field workers, mobile services, mobile information, clinic facilities, and IEC materials. The 12

16 total DAK has increased year by year. In 2005, the percentage of DAK was less than 1% of the national budget, and by 2006 it was 1.7%. Coordination and communication in fund usage needs to be improved. Currently, local governments must report on the progress of fund usage every three months. The government plans to expand DAK usage, not only for facility and infrastructure development, but also for things such as capacity-building. The plan to change DAK usage will be included in the National Middle Term of Development Plan ( ). In the National Budget, the 2009 DAK was used to fund health, environment, facilities, infrastructure initiatives in the rural and remote areas, family planning, irrigation, roads, naval projects and fisheries. DAK can also be used for water sanitation, education, forestry, agriculture, trade facilities, and government infrastructure. The central government also plans to base future DAK levels on performance. Thus, local governments must report on not only the spending of DAK, but also the corresponding benefits that resulted in the community. The total amount of DAK in 2010 is 20 trillion rupiahs, compared with 24.8 trillion rupiahs in The total budget for family planning in 2010 is 241 billion rupiahs, a decrease of 27% compared to DAK levels in 2009 (329 billion rupiahs). 13