POLICY BRIEF. Civil Society Participation Determines The Success of Health Promotion Efforts RECOMMENDATION

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1 RECOMMENDATION Publishing Mayor Regulation on the technical guideline of sub-district health forum management included its purpose, function, financing, membership, mechanism, and explanation about the role of the stakeholders. Providing capacity building to improve health workers' understanding and skills which also supports the performance of the forum. Allocating regular budget for the forum in the Local Budget (APBD) and also encouraging other financings from CSR, for example. Involving city, sub-district, and urban village health forums as the participants of planning and development consultation based on their location and other health planning. POLICY BRIEF Civil Society Participation Determines The Success of Health Promotion Efforts By: Dwi Yunita Prismawati - PATTIRO Semarang Activist Lack of public participation in conducting health promotion results in the ineffective disease prevention efforts. All this time, there are only some small groups involved. Those groups will do this promotion only when they get an instruction and is dominated by women. The government has created a regulation to broaden the civil society space to participate. It is the Health Ministry Regulation Number 75 Year 2014 which regulates public engagement in making the preventive and promotive efforts Urban Village Health Forum (FKK) is a forum established to encourage the preventive and promotive efforts. However, PATTIRO found out that many of them are not well-functioned. One of the causes is the absence of technical regulations to manage the forum. Accordingly, the members of the forum failed in interpreting their roles. The existing forums are not well-managed and the main goal to realize the standby-urban village cannot be achieved. The civil society remains passive hence the health promotion efforts do not run as expected. Civil society participation and collaboration with other stakeholders need to be encouraged to stimulate the effectiveness of THE preventive and promotive program.

2 BACKGROUND Health promotion is a strategic step we can do to improve civil society health status. FKK has an important role in promoting this initiative by coordinating the civil society organization and government institutions to work together as it is not only the Health Department and Community Health Center responsibility, but also the civil society's. The government of Semarang City must take this health promotion effort seriously as in 2013 maternal mortality rate (MMR) in their city was pretty high. It was per births, higher than the 2012 MMR. Not much different from the MMR, Semarang City mordibity rate is still high particularly in some diseases such as respiratory infections, heart disease and hypertension, as well as pharyngitis. Indonesian maternal mortality rate in 2007 was 228 per births. Instead of decreasing, this rate increased to 359 in Furthermore, in 2006 until 2013, the Incidence Rate (IR) of Semarang City dengue hemorrhagic fever was much higher than Central Java s and even the nationwide average. In 2013, Semarang City dengue hemorrhagic fever Incidence Rate remained high. It was two times higher than the incidence rate of Central Java. Trying to address the problem, since October 2014, PATTIRO Semarang has been trying to test the management of each district health forum to find out the effectiveness of the coordination between the stakeholders and public engagement in implementing health promotion at district level. This trial is done by conducting regular focus group discussion. In this forum, not only map the problems and the potential, the participant also composing some recommendations regarding the health promotion to be passed to the stakeholders at the district level. 15.0% Diagram-1 Health Promotion Budget Compared to Semarang City Direct Expenditure for Health ( ) 12.7% 10.0% 6.7% 8.0% 6.6% 5.0% 0.0%

3 SOME FINDINGS Insufficient Human Resource for Conducting Health Promotion The total number of health workers who specialize in health promotion is not sufficient. In one Community Health Center there is only one health cadre working on this health promotion issue. Furthermore, each Community Health Center covers 2 until 8 urban village. It means, one health promotion cadre has to take care of more than a thousand of people at average (see table 2). Semarang City government has tried to address this problem by recruiting extension workers or surveillance workers on a contractually basis. These officers worked at the urban village level, one officer for one urban village. Nevertheless, this effort is still not able to solve this matter. Tabel-2. Health Promotion Cadres in Semarang City, 2013 No Worker The Condition in Target of Healthy Resources 2013 Indonesia 1 Nutrient 7 : : Public Health 6 : : Sanitation 3,1 : : Source: Health Department of Semarang City, 2014 The Target of Health Promotion is not Gender Responsive Biased against women. Health promotion dissemination and activity conducted by the Community Health Center and the Health Department do not the men because there is an assumption that health problem is women s domestic problem. Moreover, people still consider that woman is part of vulnerable group. One hundred percent of health workers are women who works in Guidance for Family Welfare (PKK) from the urban village level to the city level. Accordingly, health promotion tends to target the women and does not reach the men whose role in promoting health in the society is as important as the women s. For example, there is a perception in the society that it is unnecessary for the health workers to tell the information on pregnancy to the men or the husbands and surroundings of pregnant women. Until now, the health workers tell the information on pregnancy only to the expectant women while in fact the problem regarding pregnant women safety and health are also the responsibility of the family as well as the society. People needs regarding health knowledge is different from Health Department and Community Health Center programs and agenda. Consequently, the socialization and health promotion activities only become Community Health Center and Health Department regular program without considering and paying more attention to what people really need. The health promotion media campaign which are not able to deliver the message to the people properly makes this situation even worse. Various props and other socialization media are not utilized properly and put in the Community Health Center. Accordingly, only those who come to visit the Health Center can access those equipment. WHY DOES NOT THE HEALTH FORUM WORK EFFECTIVELY? The health forum function does not run effectively because of the homogenous participant. District and Urban Village Health Forum (FKK) has not involved other important stakeholders like the Local Technical Implementation Unit of Education Department, Department of Water Resources Management, universities, hospitals, and civil society organizations.

4 Because of this, the health problems cannot be solved properly and the potentials of the stakeholders cannot be utilized to optimizing the health promotion program. As an example, public health risk caused by the flood increases because the FKK is not able to harmonize the work of the Water Resources Management Department with the civil society organization s in keeping the drainage clean from the garbage that often become the source of disease. The implementation of health promotion for students are not well coordinated with the Local Technical Implementation Unit of Education Department while in fact they already have the Immunization Month Program for Student (BIAS) whose functions can be expanded, not only to organize immunization activity but also an activity to introduce reproduction health. The forum is established but the stakeholders does not know how to manage it. Every year the urban village office publish a Statement Letter of FKK appointment to push the performance of this forum. Nevertheless, the activity conducted by the health forum is nothing more than just a formal discussion with the community health central. There is no interactive discussion held. After the meeting with the community health center there is no regular evaluation related to the health forum performance. In the pilot area we find out that the meeting between the health forum and the stakeholders is held once in a year. The members of the health forum in the pilot area stated that they have not acquired any capacity building to manage a participative forum both in terms of general knowledge and methods. Actually, the health forum is a space that has been provided for the citizens to participate in improving the quality of health service. However, this forum is yet to run effectively because they do not have the operational guideline and the people will only participate only if the government asks them to. A forum to overcome the shortage of health promotion workers. The health department and Community Health Center stated that they do not have enough workers to conduct the health promotion. This problem can be solved by the effectiveness of the health forum implementation because the health promotion effort will be done by many institutions. The Agency for Community Empowerment and Family Planning is responsible for establishing a forum on Adolescent Reproductive Health Information Promotion in every urban village. This establishment is intended to be the early prevention of HIV/AIDS infection and free sex among teenagers. Based on our findings in two pilot areas, there is no forum on adolescent reproductive health established at the urban village level because the Agency for Community Empowerment and Family Planning is not able to enforce the youth organization in their areas to work. There is no regular budget support for the Forum. Nowadays, the Urban Village Forum operational budget is less than Rp1 million. The forum uses the money to buy some foods and drinks for the meeting and to reimburse the participant local transport fee. This operational budget all this time is used for only one time forum meeting while according to the health promotion workers this kind of meeting should be held at least 3 times in a month. This is much different from the budget allocation for the Health Department which increases every year.

5 Box-1: Does the Forum Financing Burden the Local Budget? 14,000 12,000 10,000 8,000 6,000 4,000 2,000 - Diagram-3 Semarang City Health Budget Allocation ( ) IDR 4,436 IDR 9,239 IDR 7,679 Source: Local Budget (APDB) Book IDR 12, The health budget allocation of Semarang City has been increasing in this last four years. This indicates their ability to finance the District Health Forum implementation. THE FORUM IS YET TO FUNCTION AS A BRIDGE The member of the Urban Village Health Forum is the representatives of the community who are active in their neighborhood. Based on our findings, there is no regulation which requires the forum to conduct coordination meeting at district level attended by the stakeholders from the city level. The forum has not yet succeeded in becoming the bridge for the community to deliver their problems to the city level stakeholders. POLICY OPTION The existence of the Multi-Stakeholder Forum answers the needs of public participation mandated in Home Affairs Minister Regulation Number 34 Year 2005 and Health Minister Regulation Number 1138/Health Minister/PB/VIII/2005. The effectiveness of this forum is one of main indicators in Health City assessment at the national level in The major has already published a circular letter regulating the establishment of healthy district forum but the letter is yet included operational technical guidance of the forum. Expanding City Health Multi-Stakeholder Forum, District Health Forum, and Urban Village Health Forum. Stakeholders at the city level needs to be involved in city health forum. Those stakeholders are Regional Work Units (SKPD) related to Health City implementation, Organizations for Civil Society Empowerment at the Urban Village Level (LPMK), Coordinators of City Forum on Information and Promotion regarding Adolescent Reproductive Health, universities, hospitals, NGOs, Press, State-Owned Enterprises (SOEs), private sector, the Indonesian Midwives Association, and other stakeholders at the city level. In the district health forum, the stakeholders involved should be the heads of districts, the regional work unit who has technical team at district level, Family Welfare Guidance (PKK), private midwives, health workers, Organizations for Civil Society Empowerment at the Urban Village Level (LPMK), NGOs, hospitals, universities and other stakeholders at district level. In the urban village health forum, the stakeholders involved should be the head of urban village, health workers, Family Welfare Guidance (PKK), and other stakeholders at urban village level.

6 POLICY OPTION Forum management reorientation, starting from the general knowledge, methods, to skills. To strengthen the existing forum, it is necessary to improve the capacity of its members in understanding the purpose of forum, its functions, and the roles of the members. In addition, it is important to also improve their communication and lobbying skills, as well as the skill to be a good facilitator. Providing those capacity buildings is the responsibility of the government adjusted to each regional work unit s duties. Provide budget support for forum management. The existing health forum must be supported in regard of proper budgeting for the operational of the forum. Budget support can be obtained from the Local Budget (APBD) as well as other financing like CSR fund. The involvement of private sector is very strategic as it can also increase budget resource. By giving CSR funds to the forum, private sector has shown their concern to the community as their consumer. Integrating the forum to the annual planning and budgeting process. The results of the health forum, from the lowest level (the urban village level) to the highest level (the city level) need to be delivered during the development planning processes in order to encourage its implementation, for example in planning and development forum (Musrenbang). It is expected that the implementation of the recommendation generated can be pushed through the health forum as well as the planning and development forum. CLOSING REMARKS All this time, civil society participation which is limited to the women group and tends to be instructive does not give a significant effect to the health promotion achievement. Another problem PATTIRO finds out is there is no synergy between each stakeholders in encouraging health promotion as there is no space for coordinating with each other. The result of Multi-Stakeholders Forum (MSF) PATTIRO conducted in Candisari and East Semarang Sub District shows that the involvement of multi-stakeholders at sub district level can be used as a strategic effort to improve the health promotion achievement. The MSF serves as a mean to unite the multi-stakeholders in generating some recommendations regarding the health problems based on the conditions of each area. The government of Semarang City can replicate the Sub District MSF on Health Issue by creating a major regulation on guidelines or technical instruction to manage the forum. With the existence of operational guidance, we hope the forum will be able to solve the problem of health promotion in the future.

7 REFERENCES 1. PATTIRO Semarang (2015). Report on Promoting Community Health Center Service Improvement Policy through a Multistakeholder Forum Program Activities. 2. The Government of Semarang City (2013). Semarang City Health Profile Book year The Government of Semarang City (2014). Semarang City Health Profile Book year The Government of Semarang City Local Budget (APBD) Documents of Semarang City 5. The Government of Semarang City Local Budget (APBD) Documents of Semarang City 6. The Government of Semarang City Local Budget (APBD) Documents of Semarang City 7. The Government of Semarang City Local Budget (APBD) Documents of Semarang City Additional Information Urban Village Health Forum (FKK) is a forum established as a realization of Standby Urban Village, an effort to actualize a social community whose people are caring, responsive, and capable of identifying, preventing, as well as addressing the health problems autonomously in order to improve their health status. The function of the Urban Village Health Forum (FKK) are to conduct society based monitoring, promote health and clean lifestyle, and respond the health emergency condition such as emergency in giving birth as well as in disaster management. Semarang City is the capital city of Central Java Province and one of metropolitan cities in Indonesia. It is located in the North Coast of Java Island in the middle of Jakarta and Surabaya. It has an area of kilometers and consists of 16 sub districts and 117 urban villages. In March 2015, it has approximately 1.7 million of people, making it Indonesia s sixth most populous city. Its population is very diverse; there are Javanese, Chinese, Arabian, and other ethnics. Topographically, the City is hilly yet it also has plains and beaches. The low land areas are often flooded during the rainy season while the ones near to the beach are often flooded caused by the tide, and the hill sides often suffer from draught during the dry season.

8 PATTIRO CENTER FOR REGIONAL INFORMATION AND STUDIES PATTIRO (Center for Regional Information and Studies), which was established on April 17, 1999, is a research and advocacy institution based in Jakarta, Indonesia. By focusing on three main sectors: improvement on public services; improvement on public finance management; and the reform of public policy, our activities have been dedicated to the actualization of good governance and improvement of public participation in Indonesia. PATTIRO conducts research, workshop and training; provides technical assistance, community organizing and publications; as well as develops models in order to improve the quality of public service management across Indonesia. Through the network of PATTIRO Raya spreading out in 15 regions, PATTIRO operates in 17 provinces and more than 70 districts/regencies and/or cities in Indonesia. In , PATTIRO has been implementing a program to promote bureaucratic reform, accountability in education service, and civil society involvement to improve the quality of health service. Regarding this matter, PATTIRO is now working together with Program Representasi (ProRep) to promote health service quality improvement by conducting a multi-stakeholder forum trial in Semarang City and Semarang District to increase the health promotion efforts. PATTIRO POLICY BRIEF SERIES Civil Society Participation Determines the Success of Health Promotion Efforts 2015, PATTIRO Office Jalan Mawar, Komplek Kejaksaan Agung Blok G35, Pasar Minggu Jakarta Selatan, Indonesia Phone No: